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A    SYSTEM    OF    MEDICINE 


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A 

SYSTEM    OF   MEDICINE 


BY   MANY   WRITERS 


EDITED  BY 

THOMAS   CLIFFORD   ALLBUTT 

M.A.,  M.D.,  LL.D.,  F.R.C.P.,  F.R.S.,  F.L.S.,  F.S.A. 
EEGrcrS   PROFESSOR  OF  PHYSIC   IN   THE   UNIVERSITY   OF   CAMBRIDGE,    ETC.,    ETC. 


VOLUME   I 


THE   MACMILLAN   COMPANY 

LONDON:  MACMILLAN  &  CO.,  Ltd. 
1901 

All  rightu  refierved 


Copyright.  1896, 
By  MACMILLAN  AND  CO. 


Set  up  and  electrotyped  May,  1896.      Reprinted  February, 
1898 ;  October,  1899 ;  May,  December,  1900. 


NorfajoolJ  ^«as 

J.  S.  Cushing  &  Co.  —  Berwick  &  Smith 
Norwood  Mass.  U.S.A. 


TO 

SIR   J.    RUSSELL   REYNOLDS,   BART.,  M.D.,   F.R.S. 

PRESIDENT    OF    THE    ROYAL    COLLEGE    OF    PHYSICIANS 

THIS    WORK    IS    DEDICATED 

IN   MEMORY    OF    THIRTY    YEARS    OF    FRIENDSHIP 

BY  THE  EDITOR 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/systemofmedicin01allb 


PREFACE 

The  latterday  Editor  of  a  System  of  Medicine  is  met  on  the  thresh- 
old by  a  vast  increase  of  the  matter  with  which  he  has  to  deal. 
In  the  Introduction  some  fuller  reference  is  made  to  this  increase; 
at  present  it  is  sufficient  to  point  out  that  to  aetiology  alone  the 
whole  chapter  of  bacteriology  has  been  added.  Contributors  speak 
of  the  difficulty  of  keeping  the  matter  within  anything  like  the 
limits  assigned  to  them;  for  what  is  true  of  aetiology  is  true  more 
or  less  for  every  section  of  every  chapter. 

When  nothing  more  than  opinions  were  needed  as  support  for 
opinions  teaching  was  easily  made  dogmatic  and  compact.  In 
modern  Medicine,  however,  every  statement  must  not  only  be  sub- 
mitted to  verification,  but  submitted  again  and  again.  The  methods 
of  verification  must  also  be  punctually  given,  and  all  statements  as 
accurately  reported  as  if  for  cross-examining  counsel.  We  cannot 
be  any  longer  content  to  state  that  "  the  soldier  said "  such  and 
such  a  thing,  but  we  must  give  our  testimony  at  first  hand,  or  from 
carefully  accredited  and  recent  sources. 

Again,  pathology  has  not  only  become  intolerant  of  second  hand 
evidence,  but  is  irresistibly  leading  us  to  the  study  of  origins  — 
to  the  study  of  processes  in  a  disinterested  way  as  an  aspect  of 
natural  history.  It  is  impressed  upon  us  in  the  field  of  Medicine, 
as  in  all  other  fields  of  knowledge,  that  to  pursue  knowledge  with  a 
consciously  utilitarian  end  before  us  is  to  fail  even  in  our  immediate 
ends.  It  is  as  true  now  as  it  was  two  thousand  years  ago  that  Wisdom 
must  be  sought  with  a  single  heart  devoted  to  her  love  and  service; 


viii  SYSTEM   OF  MEDICINE 

and  that  even  the  relief  of  humanity  cannot  stand  always  first  in 
our  sight.^  The  ultimate  use  of  thought,  no  doubt,  is  to  guide  our 
conduct;  but  biology  must  be  studied  as  an  end  in  itself  before  we 
can  hope  to  apply  biology  successfully  in  the  conduct  of  living 
processes. 

On  the  other  hand,  were  an  Editor  to  rule  out  of  his  treatises 
all  formulated  thought  on  things  not  measured  or  comprehended 
he  would  err  in  the  opposite  direction.  To  speak  or  act  as 
if  things  seen  imperfectly  or  confusedly  do  not  exist  were  worse 
than  pedantry;  all  that  lore  which  has  the  approximate  truth  of  a 
large  number  of  observations  —  of  a  number  large  enough  to  reduce 
the  margin  of  error,  if  not  to  expel  it,  —  would  be  rejected, 
and  mth  it  much  useful  art.  Many  a  bridge  was  built  before 
engineers  learnt  to  calculate  stress ;  and  although  traditional 
medical  lore  may  prescribe  for  evils  wastefully,  yet  in  a  more  or 
less  cumbrous  or  roundabout  fashion  it  often  attains  or  approaches 
the  desired  purpose.  In  a  strange  land  a  tedious,  painful  and 
circuitous  route  is  better  than  no  route  at  all.  It  has  been 
our  endeavour  to  preserve  these  traditional  practices  and  these  hazy 
views,  where  we  cannot  replace  them  by  more  definite  measure- 
ments, lest  we  pull  up  wheat  with  tares,  and,  waiting  for  more  light 
deprive  sufferers  meanwhile  of  some  kind  of  aid  however  rude.- 
The  acquired  tact  and  patient  study  of  individual  physicians,  as  I 
have  indicated  under  the  head  of  Prognosis  in  the  Introduction, 
must  pilot  them  through  these  uncharted  waters. 

It  has  been  my  duty  to  consider  in  what  way  the  large  mass  of 
new  matter  may  be  accepted  without  an  enormous  expansion  of  the 
limits  of  this  work.  Contributors  have  done  their  best  to  be  con- 
cise, and  have  not  in  any  instance  resented  editorial  co-operation 
to  this  end.  Footnotes  as  a  rule  have  been  excluded,  and  references 
in  the  text  have  been  replaced  by  very  select  "bibliographies." 

Perhaps  all  "  overlapping "  parts  ought  to  have  been   ruthlessly 

1  "That  knowledge  may  not  be  as  a  curtesan,  for  pleasure  and  vanity  only,  or  as  a 
bondwoman,  to  acquire  and  gain  to  her  master's  use ;  but  as  a  spouse,  for  generation, 
fruit,  and  comfort."  —  Adv.  of  L.,  lib.  i. 

2  No  better  examples  could  be  given  to  illustrate  this  argument  than  the  revival  of 
counter-irritation  and  of  bleeding  on  reasonable  grounds  and  discriminating  methods. 


PREFACE  ix 

excised,  but  I  have  often  held  my  hand ;  and  this  for  several 
reasons.  Continual  cross-references  tease  the  reader;  the  same  matter 
may  take  on  different  meanings  with  changes  in  its  context,  and 
various  writers  may  put  the  same  substance  in  very  different  lights. 
For  example,  the  repetitions  involved  in  Sir  Joseph  Fayrer's  review 
of  ''Fevers"  from  the  stand-point  of  an  Indian  physician  have  been 
accepted;  and  I  am  bold  to  think  that  my  readers  will  thank  me, 
even  at  the  cost  of  some  additional  pages,  for  presenting  to  them 
the  uncurtailed  opinions  of  this  distinguished  member  of  our 
profession,  particularly  those  of  them  who  practise  in  this  vast 
possession  of  the  Empire.  To  have  given  cross-references  to  the 
respective  specific  fevers  at  every  division  of  so  important  a  chapter 
would  neither  have  been  fair  to  the  writer  nor  tolerable  hj  the 
reader. 

Historical  matter  has  been  for  the  most  part  omitted:  this 
relieved  the  System  of  some  burden,  and  at  little  loss  to  the 
reader.  During  nearly  two  millenniums  of  time  and  over  broad 
domains  of  the  world  the  story  of  Medicine  has  been  but  a  melan- 
choly study.  To  the  curious  scholar  the  "  pseud-ideas "  of 
sophists,  the  dreams  of  mystics,  the  quaint  conceits  of  monkish 
craft,  the  devices  of  magicians,  the  grotesque  or  brutal  records  of 
folk-lore  may  be  entertaining,  or  even  instructive;  far  be  it  from 
us  to  find  any  human  things  alien.  Primus  sapientice  gradus  est 
falsa  intelligere.  Here  may  be  some  felicity  of  observation ;  there 
some  shrewdness  of  opinion:  yet  after  all  we  read  the  history 
of  medicine  rather  for  the  honour  of  a  certain  few  of  our  ancestors 
than  for  our  own  instruction.  To  enter  into  this  subject  fully 
would  occupy  much  of  the  very  pages  which  I  am  trying  to 
economise;  but  I  may  briefly  say  that  the  only  period  of  the  past 
history  of  our  profession  which  can  interest  the  medical  student 
directly  is  the  Medicine  of  Ancient  Greece,  which  came  to  life 
again  on  contact  with  our  own.  Greek  medicine  of  the  fifth 
century  b.c.  seems  to  be  almost  of  yesterday;  English  medicine 
of  the  twelfth  century  of  our  era  seems  more  alien  to  our  thought 
than  the  Galenical  treatises  of  the  Arabs,  and  almost  as  grotesque 
as  the  demonology  of  the  Chaldeans.     No  modern  book  of  Chemistry 


SYSTEM  OF  MEDICINE 


deals  with,  the  stories  of  Alchemy,  nor  of  Astronomy  with  those  of 
Astrology. 

The  great  profession  of  the  Law  may  feel  a  just  pride  in  the 
growth  of  its  reasonable  and  gradual  dominion;  Medicine,  after  the 
decay  of  the  school  of  Hippocrates,  and  in  countries  which  knew 
not  that  master,  became  the  tool  of  priests,  slaves,  charlatans,  or 
literary  men.  To  trace  the  living  waters  of  the  healing  art  and 
the  auxiliary  sciences .  in  their  secret  channels  under  the  foundations 
of  the  Temple,  of  the  Gymnasium,  of  the  Museum,  or  of  the 
Marketplace,  until  they  burst  forth  once  more  in  the  time  of 
Vesalius,  of  Harvey,  of  Morgagni,  of  Haller,  of  Hunter,  of  Bichat, 
of  Bernard,  of  Laennec,  is  not  a  pursuit  for  these  pages. 

The  Prolegomena  which  open  this  volume,  and  others  which 
will  appear  occasionally  hereafter,  are  in  part  to  enlarge  the  concep- 
tions of  the  student,  to  lead  him  to  see  the  domains  of  Medicine 
from  points  of  advantage :  in  part,'  by  means  of  these  broader 
surveys  of  General  Pathology,  of  Statistics,  or  of  Dietetics  and 
Therapeutics,  to  avoid  some  repetitions,  otherwise  necessarily  fre- 
quent, in  the  several  articles  of  the  work. 

The  pleasant  duty  remains  of  thanking  my  contributors  for 
the  kindliness,  good  faith,  and  intelligent  support  which  they  have 
manifested  throughout  this  undertaking,  which,  although  now  pub- 
lished in  small  part,  is  in  a  fair  way  of  completion.  If  all  be  as 
well  as  the  promise  of  it  the  future  volumes  will  be  published 
without  long  delay.  The  first  volume  of  such  a  co-operative  work  is 
the  most  arduous :  the  time  allotted  to  the  several  contributors  is 
shorter  than  to  those  whose  treatises  come  in  later.  Moreover,  the 
heavy  sickness  of  the  two  past  winters  played  havoc  with  my  staff. 
Some  of  these,  prostrated  with  one  plague  or  another,  have  striven 
hard  on  their  imperfect  convalescence  to  perform  their  task.  Others, 
such .  as  the  late  Dr.  Sturges,  Dr.  Beaven  Eake,  and  Prof.  Walley, 
had  finished  their  work,  but  not  for  us.  My  cordial  thanks  are  due 
to  Dr.  Cheadle,  to  Dr.  Phineas  Abraham,  and  to  Dr.  M'Fadyean,  for 
generously  taking  up  the  labours  of  those  who  had  passed  away.  Pro- 
fessor Burdon-Sanderson  took  up  the  chapter  on  Fever  at  very  short 
notice,  and  wrote  it  under  severe  pressure  of  time  and  other  engage- 


PREP  A  CE  XI 

meiits.     Dr.  Eolleston    has    given   me   invaluable    aid   throughout    in 

the  reading  of  proofs;  in  advising  me  continually,  in  forwarding  my 

arrangements  with  contributors  in  London,  and  in  many  other  ways. 

Finally,  I  have  to  thank  those  kind  and  able  friends  who  have 

not  only  given  me  the  advantage  of  their  articles  on  special  subjects, 

but  have  spent  much  time  and  pains,  which  they  could  ill  spare,  in 

the    arrangement    of    certain    sections    of    the    System    or    in    proof 

reading.     Invaluable  help  of  this  kind  has  been  ungrudgingly  given 

to    me    by   Dr.   Terrier    (Cerebral    Diseases),   Dr.    Manson    (Tropical 

Diseases),  Dr.  Payne  (Skin  Diseases),  Dr.  Savage  (Mental  Diseases), 

and   Dr.   Felix    Semon    (Laryngeal    Diseases).      Dr.   Venn    and   Mr. 

Thomas    Marshall,  of    Leeds,  have   given   me   valuable  help   in   the 

revision  of  the  Introduction,  for  the  contents  of  which,  however,  I 

am  wholly  responsible. 

T.  C.  A. 


CONTENTS 


Introduction  .........    xix 

DIVISION   I.— PEOLEGOMENA 

Medical  Statistics.     Dr.  Billings  ......        3 

Anthropology  and  Medicine.     Dr.  Beddoe       .  .  .  .  .21 

On  Temperament.     Dr.  Rivers      .  .  .  .  .  .  .36 

On  the  Laws  or  Inheritance  in  Disease.     Mr.  Hutchinson  .  .  .      39 

Medical  Geography  of  Great  Britain.     Mr.  Haviland        .  .  .46 

Inflammation.    Dr.  Adami  .  .  .  .  .  .  .54 

The  Doctrine  of  Fever.     Dr.  Burdon-Sanderson        ....     139 

The  General  Pathology  of  Nutrition.     Dr.  Mott    ....     161 

General  Pathology  of  New  Growths.     Mr.  Shattock  and  Mr.  Ballance    .     201 
Principles  of  Drug  Therapeutics.     Dr.  Leech  ....     217 

Climate  in  the   Treatment  of   Disease.     Dr.   Hermann  Weber,  and  Dr. 

Michael  G.  Foster     .  .  .  .  .  .  .  .247 

Artificial  Aerotherapeutics.     Dr.  Theodore  Williams         .  .  .     300 

Balneology  and  Hydrotherapeutics.     Dr.  Hermann  Weber  and  Dr.  Parkes 

Weber  .  .  .  .  .  .  .  .  .    318 

The  Medical  Applications  of  Electricity.     Dr.  Lewis  Jones       .  .     349 

Massage:    Technique,   Physiology,    and  Therapeutic   Indications.     Dr. 

Kearsley  Mitchell      .  .  .  ...  .  .  .373 

The  General  Principles  of  Dietetics  in  Disease  ;  or,  the  Feeding  of 

the  Sick.     Sir  Dyce  Duckworth    ......     385 

The  Diet  and  Therapeutics  of  Children.     Dr.  Eustace  Smith       .  .     412 

Nursing.     Miss  Amy  Hughes        .......    423 

The  Hygienk  ok  YocTir.     Dr.  Dukes     ....  .  .    457 

Life  Assurance.     Dr.  Symes  Thompson  .  .  .  .  .    476 


XIV 


SYSTEM   OF  MEDICINE 


DIVISION   II.— FEVERS 
Pakt  I. 

Insolation  or  Sunstroke.     Sir  Joseph  Fayrer 


PAGE 

.    491 


Part  II.  —  The  Infections 

The  General  Pathology  of  Infection.     Dr.  Kanthack        .            .            .  504 

Septicaemia  and  Py^smia.     Mr.  Watson  Cheyne            ....  586 

Erysipelas.     Mr.  Watson  Cheyne            ......  613 

Infective  Endocarditis.     Dr.  Dreschfeld           .....  626 

Puerperal  Septic  Disease.     Dr.  Playfair          .....  635 

Furuncle  ;  Carbuncles.     Dr.  Melsome              ......  651 

Epidemic  Pneumonia.     Dr.  Whitelegge  ......  655 

Epidemic  Cerebro-Spinal  Meningitis.     Dr.  Ormerod              .            .            ,  659 

Influenza.     Dr.   Goodhart              .......  679 

Diphtheria.   Dr.  Gee,  Dr.  Thorne  Thome,  Dr.  Kanthack,  and  Dr.  Herringham.  701 

Tetanus.     Sir  George  M.  Humphry  and  Dr.  Sims  Woodhead            .            .  758 

Enteric  Fever.     Dr.  Dreschfeld              ......  791 

Cholera  Asiatica.     Dr.  MacLeod,  Mr.  Ernest  Hart,  Dr.  S.  C.  Smith,  Dr. 

Kanthack,  and  Mr.  J.  W.  W.  Stephens    .  .  .  .  .864 

Plague.    Dr.  J.  F.  Payne  .  .  .  .  .  .  .917 

Relapsing  Fever,  or  Famine  Fever.     Dr.  Rabagliati  and  Dr.  Wesbrook  .  940 

Index             ..........  961 


ILLUSTRATIONS 

FIG. 

1.  Spleen  Pulp  of  Monkey  ...... 

2.  Two  Giant  Cells  from  a  Rodent        ..... 

3.  Fhagocytes  from  Spleen  and  Eye  of  White  Rat     . 

4.  Anthrax  of  Pigeon        ....... 

5.  Cortical  Pyramidal  Cell  ...... 

6.  Microphotograph  of  Pyramidal  Cell  from  a  Case  of  General  Paralysis  of 

the  Insane      ........ 

7.  Microphotograph  of  Pyramidal  Cell  undergoing  Atrophic  Degeneration 

8.  Atrophic  Liver  Cells  from  Cyanotic  Atrophy  of  Liver 

9.  Microphotograph  of  Heart,  showing  early  Fatty  Degeneration     . 

10.  ,,  ,,  11       ^  few  Fibres  more  highly  magnified 

11.  Microphotograph  of  Liver  from  a  Case  of  Pernicious  Anaemia     . 

12.  ,,  ,,         showing  a  few  Cells  more  highly  magnified 

13.  Cloudy  Swelling  of  Liver  Cells  treated  with  Acetic  Acid 
14. 

15.  Oertel's  Steam  Nebuliser 

16.  Waldenburg's  Apparatus  for  condensing  and  rarefying  Air 

17.  Fraenkel's  Apparatus  for  condensing  and  rarefying  Air   . 

18.  The  Pneumatic  Cabinet  ...... 

19.  Compressed  Air  Bath  ....... 

20.  Tracing  showing  Depth  of  Respiration  in  Compressed  Air 
21-25.   Sphygmographic  Tracings  showing  Pulse-rate    . 

«26.   Motor  Points  of  the  Head  and  Neck  .... 

27.  Motor  Points  of  Extensor  Aspect  of  Upper  Limb  . 

28.  Motor  Points  of  Flexor  Aspect  of  Upper  Limb 


82 
83 
84 
84 
182 

183 
183 
185 
190 
190 
191 
191 
192 
192 
305 
307 
308 
309 
311 
318 
314 
357 
358 
359 


SYSTEM  OF  MEDICINE 


29.  Motor  Points  of  Front  of  Thigh 

30.  Motor  Points  of  Posterior  Aspect  of  Lower  Limb 

31.  Motor  Points  of  Leg  and  Foot 

32.  Feeding-Cup       ...... 

33.  Apparatus  for  Nasal  Feeding  .  .  , 


PAGE 

360 
361 

362 
387 
387 


CHAETS 
1.  Death-rates  in  New  York,  etc.  ..... 

2-8.  Variations  in  Temperature  of  Puerperal  Fever    . 

9.   Enteric  Fever     ........ 

10.  Temperature  of  an  Acute  Case  of  Plague,  with  Temperature  in 

Eectum  after  Death  ...... 

11.  Temperature  of  a  less  rapid  Case  of  Plague 

12.  Temperature  and  Pulse  in  Relapsing  Fever 
13 


6 

642-648 

To 

face  791 

.  930 

.  931 

.  946 

.  947 

PLATE 

Hsematoidin,  Melanin,  and  Carbon  Pigmentation 


.  To  face  197 


LIST   OF   AUTHORS 

Adami,  George  Johu,  M.D.,  Professor  of  Pathology,  M'Gill  University  of  Montreal. 
Ballance,  Charles  Alfred,   M.S.,  F.R.C.S.,  Surgeon  to  the  National  Hospital  for  the 

Paralysed  and  Epileptic;  Assistant  Surgeon  to  St.  Thomas's  Hospital,  and  to  the 

Hospital  for  Sick  Children,  Great  Ormond  Street. 
Beddoe,  John,  M.D.,  LL.D.,  F.R.C.P.,  F.R.S.,  Late  Physician  to  the  Royal  Infirmary, 

Bristol;  Ex-President  of  the  Anthroi^ological  Institute. 
Billings,  John  S.,  M.D.,  LL.D.,  D.C.L.  Oxon.,  F.C.P.  Phil.,  Surgeon  U.S.  Army;  Libra- 
rian to  the  Surgeon-General's  Library,  and  Professor  of  Hygiene  in  the  University 

of  Pennsylvania. 
Burdon-Sanderson,  John,  M.D.,  D.C.L.,  D.Sc,  LL.D.,  F.R.S. ,  Regius  Professor  of  Medicine 

in  the  University  of  Oxford,  Fellow  of  Magdalen  College. 
Cheyne,  William  Watson,  M.B.,   CM.,   F.R.C.S.,  F.R.S.,   Surgeon  to  King's  College 

Hospital,  and  Professor  of  Surgery  at  King's  College. 
Dreschfeld,  Julius,  M.D.,  B.Sc,  F.R.C.P.,  Physician  to  the  Manchester  Royal  Infirmary, 

and  Professor  of  Medicine  in  the  Owens  College,  Victoria  University. 
Duckworth,  Sir  Dyce,  M.D.,  LL.D.,  F.R.C.P.,  Physician  to  and  Lecturer  on  Medicine  at 

St.  Bartholomew's  Hospital. 
Dukes,  Clement,  M.D.,  M.R.C.P.,  Physician  to  Rugby  School,  and  Senior  Physician  to 

Rugby  Hospital. 
Fayrer,   Sir  Joseph,  Surgeon-General,  K.C.S.I.,  LL.D.,  M.D.,  F.R.S.,  F.R.C.P.,  Late 

President  Medical  Board,  India  Office. 
Foster,  Michael  George,  M.A.,  M.D.,  L.R.C.P.,  M.R.C.S.,  San  Remo. 
Gee,  Samuel  Jones,  M.D.,  F.R.C.P.,  Physician  to  St.  Bartholomew's  Hospital. 
Goodhart,  James  Frederick,  M.D.,  CM.,  F.R.C.P.,  Physician  to  Guy's  Hospital,  and 

Consulting  Physician  to  the  Evelina  Hospital. 
Hart,  Ernest,  D.C.L.,  M.R.C.S.,  Editor  of  the  British  Medical  Journal. 
Haviland,  Alfred,  M.R.CS.,  Late  Lecturer  on  the  Geography  of  Disease  at  St.  Thomas's 

Hospital. 
Herringham,  Wilmot  Parker,  M.D.,  F.R.CP.,  Assistant  Physician  St.  Bartholomew's 

Hospital,  Physician  Paddington  Green  Children's  Hospital. 
Hughes,  Miss  Amy,  Superintendent  of  Nurses,  Bolton  Union  Workhouse ;  Late  Superin- 
tendent Central  Training  Home,  Queen  Victoria  Jubilee  Institute  for  Nurses  for  the 

Sick  Poor. 
Humphry,  Sir  George  Murray,  M.D.,  F.R.C.S.,  D.Sc,  LL.D.,  F.R.S.,  Honorary  Fellow 

of  Downing  College,  and  Fellow  of  King's  College,  Cambridge ;  Professor  of  Surgery 

in  the  University ;  Consulting  Surgeon  to  Addenbrooke's  Hospital. 
Hutchinson,  Jonathan,  M.D.,  LL.D.,  F.R.C.S.,  F.R.S.,  Consulting  Surgeon  to  the  London 

Hospital,  Senior  Surgeon  to  the  Hospital  for  Diseases  of  the  Skin,  Late  President 

of  the  Royal  College  of  Surgeons. 


SYSTEM  OF  MEDICINE 


Jones,  Henry  Lewis,  M.D.,  F.R.C.P.,  M.R.C.S.,  Medical  Officer  in  charge  of  the  Electrical 

Department  of  St.  Bartholomew's  Hospital. 
Kanthack,  A.  A.,  M.D.,  M.R.C.P.,  F.R.C.S.,  Lecturer  on  Pathology  and  Pathologist  at 

St.  Bartholomew's  Hospital. 
Leech,  Daniel  John,  M.D.,  F.R.C.P.,  Senior  Physician  to  the  Manchester  Infirmary,  and 

Professor  of  Materia  Medica  and  Therapeutics  in  the  Victoria  University. 
MacLeod,  Kenneth,  Brigade  Surgeon  Lieutenant-Colonel,  M.D.,  LL.D.,  F.R.C.S.E.,  Late 

Professor  of  Surgery  in  the  Medical  College  of  Calcutta. 
Melsome,  William  Stanley,  M.D.,  Fellow  of  Queen's  College,  Cambridge,  and  Senior 

Demonstrator  of  Anatomy  in  the  University. 
Mitchell,  John  Kearsley,  M.D.,  F.C.P.  Phil.,  Physician  to  St.  Agnes's  Hospital,  Assistant 

Physician  to  the  Orthopaedic  Hospital  and  Infirmary  for  Nervous  Diseases,  Lecturer 

on  General  Symptomatology,  University  of  Pennsylvania. 
Mott,  Francis  Walker,  M.D.,  F.R.C.P.,  M.R.C.S.,  Assistant  Physician  to  Cliaring  Cross 

Hospital,  and  Pathologist  to  the  Asylums  Board  of  the  London  County  Council. 
Ormerod,  Joseph  Arderne,  M.D.,  F.R.C.P.,  Assistant  Physician  to  St.  Bartholomew's 

Hospital,  and  Physician  to  the  National  Hospital  for  the  Paralysed  and  Epileptic. 
Payne,  Joseph  Frank,   M.D.,   F.R.C.P.,   Late  Fellow  of    Magdalen  College,  Oxford  ; 

Physician  and  Lecturer  on  Medicine  at  St.  Thomas's  Hospital. 
Playfair,  William  Smoult,  M.D.,  LL.D.  F.R.C.P.,  Professor  of  Obstetric  Medicine  at 

King's  College,  and  Physician  to  Women  and  Cliildren  at  King's  College  Hospital. 
Rabagliati,   Andrea  Carlo  Francisco,   M.D.,  F.R.C.S.E.,  Late   Senior  Surgeon  to  the 

Bradford  Infirmary  and  to  the  Bradford  Fever  Hospital. 
Rivers,  William,  H.R.,  M.D.,  M.R.C.P.,  Lecturer  on  Moral  Science  in  the  University 

of  Cambridge. 
Shattock,  Samuel  G.,  F.R.C.S.,  Joint  Lecturer  on  Pathology ;  Curator  of  the  Pathological 

Museum,  St.  Thomas's  Medical  School. 
Smith,  Eustace,  M.D.,  F.R.C.P.,  F.R.C.S.,  Physician  to  the  East  London  Hospital  for 

Children,  and  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest. 
Smith,  Solomon  Charles,  M.D.,  M.R.C.P.,  M.R.C.S.,  Consulting  Surgeon  Halifax  Infirmary, 

Physician  Westminster  General  Dispensary. 
Stephens,  J.  W.  W.,   M.B.,   B.C.,   The  Treasurer's  Student  in  Pathology  at  St.  Bar- 
tholomew's Hospital. 
Thompson,  Edmund  Symes,  M.D.,  F.R.C.P.,  Consulting  Physician  to  the  Consumption 

Hospital,  Brompton;  and  Gresham  Professor  of  Medicine. 
Thorne,  R.  Thorne,  C.B.,  M.B.,  F.R.C.P.,  F.R.S.,  Medical  Officer  to  the  Local  Government 

Board,  and  Lecturer  on  Public  Health  at  St.  Bartholomew's  Hospital. 
Weber,  Hermann,  M.D.,  F.R.C.P.,  Consulting  Phj'sician  to  the  German  Hospital,  London, 

and  to  the  Royal  Hospital  for  Diseases  of  the  Chest,  Ventnor. 
Weber,  Frederick  Parkes,  M.D.,  M.R.C.P.,  M.R.C.S.,  Physician  to  the  German  Hospital, 

Loudon. 
Wesbrook,   Frank  Fairchild,   M.D.,   Professor  of    Bacteriology  in  the  University  of 

Minneapolis,  U.S.A. 
Whitelegge,  Benjamin  Arthur,  M.D.,  B.Sc,  M.R.C.P.,  M.R.C.S.,  County  Medical  Officer 

for  the  West  Riding  of  York. 
Williams,  Charles  Theodore,  M.D.,  F.R.C.P.,  Consulting  Physician  to  the  Consumption 

Hospital,  Brompton. 
Woodhead,  German  Sims,  M.D.,  CM.,  F.R.C.P.E.,  F.R.S.E.,  Director  of  the  Research 

Laboratories  of   the  Conjoint   Board   of   the   Royal  Colleges  of   Physicians  and 

Surgeons. 


INTRODUCTION 

Medicine  as  a  System.  —  The  title  which  has  been  chosen  for  this  work 
is  one  which  may  be  necessary  for  present  purposes,  but  one  which  on 
logical  grounds  cannot  be  defended :  a  System  of  Medicine  cannot  now 
be  written,  either  by  one  man  or  by  many,  and  this  state  of  things  is 
by  no  means  to  be  regretted.  Of  a  body  of  empirical  knowledge  a 
system  may  be  made,  and  in  such  a  system  place  may  be  found  for  new 
accretions  or  elaborations ;  before  the  days  of  Bacon,  for  example,  and 
even  after  the  publication  of  the  Novum  Organon,  it  was  the  ambition 
of  learned  men  to  attain  to  encyclopasdic  knowledge,  to  spread  them- 
selves over  the  whole  realm  of  it,  and  laboriously  to  gather  all  its  prod- 
ucts into  a  Corpus  or  System :  this  was  their  end.  To  construct  such 
an  "Orbis  Doctrinse"  seemed  to  them  to  be  a  mere  matter  of  time, 
ability  and  capacity;  and  to  its  attainment  many  noble  lives  were 
devoted.  It  seems  probable  that  even  Bacon  himself  had  little  idea  of 
the  remote  consequences  of  his  own  method :  it  seems  probable  that  he 
believed  the  new  Organon  to  be  a  key  to  the  discovery  of  natural 
knowledge  which  at  no  distant  time  would  reveal  that  realm  to  us  as  a 
band  of  scouts,  armed  with  other  weapons,  might  reveal  to  us,  let  us  say, 
the  parts  of  Central  Africa.  A  system  of  natural  knowledge  would 
thus  have  completed  the  encyclopaedia  —  the  "  Institutio  in  circulo  "  — 
already  fairly  sufficient  for  the  student  of  discovered  subjects  such  as 
theology  and  philosophy.  That  his  method,  as  afterwards  interpreted 
and  extended  by  Newton  and  later  thinkers,  had  an  application  correla- 
tive in  depth  and  extent  with  the  perceptible  universe,  and  that,  this 
depth  and  extent  being  infinite  in  all  dimensions,  its  analysis  must  be 
inexhaustible.  Bacon  perhaps  never  apprehended.^  The  complexity  and 
the  infinity  of  nature  were  not  and  could  not  be  realised  in  the  infancy 
of  the  investigation  of  it.  As  later  generations  learned  that  natural 
knowledge  cannot  be  held  in  categories,  but  must  be  conceived  as  a  classi- 

1  Glanvil  (Vanity  of  Dof/matisinc/)  says:  "And  'tis  the  observation  of  the  noble 
St.  Alban,  that  philosophy  is  built  upon  a  few  vulgar  experiments."  The  noble  St.  Alban 
thought  more  wisely  than  this,  but  not  altogether  out  of  this  fashion.  In  saying  this  I  do 
not  forget  the  well-known  127th  Aph.  of  N.  0.,  lib.  1.  My  view  is  founded  upon  Bacon's 
own  way  of  going  about  to  apply  his  method,  which  indeed  he  drew  almost  entirely  from 
Aristotle. 


SYSTEM  OF  MEDICINE 


fication  by  kinds  ^  whose  similarities  and  dissimilarities  are  inexhausti- 
ble, it  became  obvious  that  a  system  uniform  in  its  proportions  and  parts 
is  impossible ;  or  that,  so  far  as  possible,  such  a  system  would  indicate 
not  progress,  but  arrest  of  development  —  in  a  word,  a  stereotype. 

In  times  when  knowledge  is  almost  stationary,  as  was  approximately 
the  case,  for  instance,  in  the  Arabian  schools,  a  System  of  Medicine  may 
be  thus  made;  its  parts  will  be  classified  by  means  of  resemblances 
only  as  deep  as  the  foundations  of  contemporary  knowledge :  thus,  for 
example,  a  specious  group  or  class  of  pulmonary  diseases  may  be  made. 
At  no  time,  however,  is  knowledge  quite  stationary ;  and,  even  at  its 
most  stable  moments,  some  deeper  resemblances,  truer  explanations  that 
is,  are  hit  upon  by  this  man  or  the  other,  and  the  fixity  of  the  system 
and  of  its  categories  is  disturbed.  On  the  revelation  of  profounder 
resemblances  objects  hitherto  set  near  each  other  are  detached,  and 
objects  far  apart  in  the  system  are  approximated.  Thus,  in  respect  of 
the  pulmonary  diseases,  kinds  of  pulmonary  phthisis  or  of  pneumonia 
may  be  carried  away  to  the  class  of  Infectious  Diseases,  and  so  forth ; 
every  new  explanation  bringing  about  a  change  of  the  order. 

Moreover,  in  seeking  and  verifying  explanations,  we  find  that  pio- 
neers in  natural  researches  do  not  rule  themselves  as  an  army  in  the 
field,  pressing  forward  on  a  uniform  plan  and  upon  all  faces  of  the  enemy 
at  once ;  but  attacks  are  made  upon  certain  quarters,  and  individuals  or 
companies  penetrate  particular  parts  regardless  of  the  advance  of  others. 
At  one  time  morbid  anatomy,  at  another  bacteriology,  at  another  phar- 
macolog}^,  or  several  quarters  of  each  of  these  respectively,  are  the 
chief  subjects  of  inquiry ;  progress  in  one  direction  thus  passes  out  of 
immediate  relation  to  progress  in  another.  Individual  tastes,  again, 
occasional  facilities,  and  the  advances  of  ancillary  sciences  or  arts, 
modify  the  rates  of  progress  in  the  several  sections  of  each  department 
of  natural  knowledge.  It  is  then  characteristic  of  natural  knowledge, 
if  not  strictly  pertinent  to  it,  that  its  progress  should  be  largely  unsys- 
tematic ;  although  from  time  to  time  generalisations  are  made,  such  as 
the  classification  by  genetic  affinities,  which  break  up  older  systems, 
and  bring  some  method  into  large  groups  of  things  which  before  had 
appeared  to  be  unrelated.  Thus  no  doubt,  as  generations  of  men  pass, 
the  subjects  of  knowledge  are  more  and  more  co-ordinated ;  but,  if  prog- 
ress continue,  we  shall  observe  still  that  new  and  irregular  adits  are 
driven  into  the  unknown  before  the  older  winnings  are  completely 
surveyed  and  classified. 

The  reader  will,  therefore,  be  disappointed  if,  on  opening  the  follow- 
ing pages,  he  expects  to  find  a  System  of  Medicine  formally  so  called : 

1  The  logician  may  remind  me  that  to  put  matter  in  natural  groups  and  to  classify  it 
are  the  same  thing ;  and  that  as  "  natural  groups  "  do  not  exist,  such  a  classification,  like 
any  other,  is  hut  a  convenient  de\'ice  for  a  particular  purpose,  a  way  of  looking  at  things 
from  a  certain  point  of  ^aew.  In  the  biological  sciences,  however,  classification,  since  it 
has  become  an  expression  of  affinities,  —  that  is,  since  the  publication  of  the  Origin  of 
Species,  —  has  taken  a  larger  meaning,  and  is  a  conceptional  summary  of  permanent  and 
universal  convenience. 


INTRODUCTION 


he  will  rather  find  our  knowledge  set  forth  on  the  whole  as  immediate 
convenience  and  the  exigencies  of  contemporary  learning  may  dictate. 
The  arrangement  which  may  seem  good  to  one  editor  m.ay  be  displeas- 
ing to  another:  in  biological  subjects  all  editors  desire  to  place  their 
matter  in  groups  as  natural  as  possible  —  to  classify  its  parts  by  the  tie 
of  kind,  so  that  the  classification  may  become  explanatory  of  the  matter ; 
on  the  other  hand,  orders  of  convenience  are  no  less  imperative,  and  a 
treatise  of  Medicine  must  be  based  upon  a  compromise.  If  herein  the 
formal  mind  occasionally  feel  pain,  I  trust  it  will  be  remembered,  as  I 
have  said,  that  irregular  expansions  which  burst  the  limits  of  a  "  System" 
are  signs  of  life  and  progress. 

Some  endeavour  I  have  made  to  recompose  my  matter  in  accordance 
with  the  latest  advances  of  science ;  yet  when  faced  on  one  side  by  a 
large  block  of  ignorance,  or  diverted  on  another  by  some  dictate  of  con- 
venience, I  have  not  hesitated  to  regard  rather  the  habit  and  convenience 
of  the  ordinary  reader  than  the  doctrines  of  the  systematic  thinker :  I 
have  endeavoured  to  make  provisions  for  the  former  and  for  the  latter 
necessities,  yet,  systematising  where  I  can,  and  "distributing  our  igno- 
rance" as  equally  as  I  can,  I  have  had  to  present  much  of  the  matter  in 
the  unconnected  way  in  which  it  was  discovered. 

Science  and  Practice.  —  No  thoughtful  man  versed  in  the  methods  of 
natural  inquiry  can  fail  to  be  reminded  at  every  moment  of  the  ultimate 
and  universal  dependence  of  every  one  group  of  phenomena  upon  every 
other.  Too  often  we  regard  causation  as  a  pedigree  drawn  up  on  the 
plan  of  primogeniture  in  the  male  line  —  as  a  series  of  linear  sequences, 
each  result  owning  a  parent,  and  so  on  until  a  primal  cause  is  reached. 
I  need  not  say  that  such  a  conception,  and  the  use  of  such  metaphors  as 
"  the  chain  of  causation,"  are  so  narrow  as  to  be  false.  So  incalculable 
are  the  properties  of  things,  so  contingent  is  each  event  upon  every  other, 
that  anything  like  a  final  presentment  of  causation  is  impossible,  nay, 
inconceivable  by  our  limited  faculties ;  and  our  propositions  are  but  pro- 
visional formulae  which,  if  permitted  to  harden  into  aphorisms,  become 
fetters  of  thought.  Our  formulae,  then,  should  be  in  a  state  of  continual 
flux :  fresh  exceptions  are  continually  turning  up,  and  fresh  qualifications 
are  incessantly  made.  On  the  other  hand,  without  provisional  formulae 
we  cannot  act,  and  in  action  lie  the  purpose  and  end  of  medical  studies. 
The' "  merely  scientific  "  physician  is  apt  to  be  blind  to  useful  mancBuvres 
which  rest  rather  upon  the  accidental  than  upon  the  more  permanent 
qualities  of  things :  indeed,  the  practical  man  often  sees  more  of  the 
surface  of  things  than  does  the  analytical  man,  and  thus  keeps  more 
sense  of  proportion,  more  of  the  sense  called  "  common."  So  it  comes 
about  that  in  practice  personal  tact  and  character  are  as  important  to 
the  operations  of  a  physician  as  scientific  equipment.  He  has  to  deal 
with  men  of  limited  vision,  full  of  accidental  qualities,  and  subject  to 
accidental  disturbances ;  and  the  tact  which  deals  with  these  confused 
and  conflicting  attributes  is  born  rather  of  a  wide  survey  of  the  outsides 
of  things,  and  of  transitory  conventions,  than  of  a  penetrating  insight 


xxii  SYSTEM   OF  MEDICINE 

into  causation.  Excessive  concentration,  if  it  fit  a  man  for  analytical 
study,  may  unfit  him  for  the  world.  Moreover,  the  purely  scientific 
physician  tend^  to  undervalue  opinion,  as  the  man  of  the  world  to  over- 
value it.  Now,  prevalent  opinions,  though  not  formal  truth,  generally 
contain  truth,  and  this  the  practical  physician  does  not  fail  to  perceive; 
nor  does  he  forget  that  the  observations  of  any  one  person,  however  pro- 
found, being  the  observations  of  an  individual  of  brief  life  and  limited 
faculties,  need  some  tempering  by  traditional  lore  —  by  the  embodied 
opinions  of  a  vast  number  of  observers  over  a  long  period  of  time; 
opinions  which,  individually  inaccurate  as  they  may  be,  yet  make  collec- 
tively an  approximation  to  truth  of  no  small  value  to  the  man,  be  he 
statesman  or  physician,  who  has  usually  "  to  act  on  a  choice  of  second 
best  courses"  {vide  paragraphs  on  Prognosis]. 

Methods.  —  We  are  met  at  the  outset  of  our  study  by  the  questions 
—  ^Yhat  is  health;  and  ivhat  is  disease  ?  The  man  who  lives  to  the  age 
of  a  hundred  years,  and  who  during  that  time  suffers  no  pain,  and  is 
continually  able  to  make  use  of  the  powers  proper  to  his  age,  would  by 
universal  testimony  be  regarded  as  an  example  of  health :  yet  even  the 
life  of  such  an  one  would  not  always  be  at  its  best ;  and  health,  like 
every  other  such  name,  is  to  be  used  in  a  relative  sense.  Into  the  life 
of  the  healthiest  man  disorder  must  frequently  enter.  Absolute  health 
is  an  ideal  conception,  as  the  line  of  the  mathematician,  the  ether  of  the 
physicist,  and  the  atom  of  the  chemist ;  it  is  a  positive  conception  of  a 
perfect  balance  of  the  moving  equilibrium  which  we  call  systemic  life: 
disease  is  a  negative  conception,  and  signifies  something  less  than  this 
perfect  balance. 

In  other  times,  nay,  even  in  our  own,  there  has  been  a  disposition  to 
regard  disease  as  something  imported  into  the  system,  as  a  possession  of 
it  by  a  malign  agent  which  may  be  expelled  by  some  sorcery  or  virtuous 
herb ;  in  this  sense  health  and  disease  are  not  different  attitudes  of  one 
thing,  but  a  binary  combination.  Insensibly  this  personification  of  dis- 
ease falls  by  a  sort  of  refinement  into  the  "  principle  "  of  the  vitalists, 
as  in  the  phrase  of  a  distinguished  physician  who  describes  a  patient  as 
"  saturated  with  insanity  " ;  or  it  becomes  the  peccant  humour  of  a  less 
unscientific  pathology ;  or,  again,  it  may  be  identified  with  a  microbe  or 
a  virus.  Yet  to  speak  thus  is  to  confound  disease  with  the  causes  of 
disease,  and  to  use  figurative  language  to  our  confusion — the  "perilous 
stuff  "  from  which  the  bosom  must  be  cleansed  is  no  more  a  disease 
than  a  blackthorn  staff  is  a  broken  head.  The  blackthorn  may  be  the 
cause  of  a  green  wound ;  by  this  gate  other  bacilli,  less  gross  in  kind, 
may  enter  the  body,  and  cause  the  oscillations  in  its  system  which 
we  call  fever;  the  consequent  dislocations  and  disturbances  in  the 
body  are  properly  called  diseases.  A  cancer  is  no  more  a  disease  than 
the  hyssop  on  the  wall :  a  cause  of  disease  it  may  be,  but  the  disease 
is  in  the  damaged  tissues,  which  are  irritated,  invaded,  or  choked  by 
the  growth. 

Again,  whether  the  causes  be  prevented  inside  the  body  or  outside  it. 


INTRODUCTION 


are  matters  of  no  essential  difference.  To  kill  Laveraa's  microbe^  within 
the  body  by  eating  quinine  is  not  to  cure  an  ague,  but  to  prevent  the 
cause  of  a  future  ague  :  the  ague  itself  is  a  perturbation  of  the  systemic 
balance  which  will  usually  yield  to  the  vis  medicatrix  natanje,;  that  is 
to  say,  to  the  tendency  of  all  stable  equilibriums  to  maintain  them- 
selves— the  vis  medicatrix  naturce,  being  an  aspect  of  inertia. 

If  we  keep  clearly  before  us  this  distinction  between  the  causes  of 
disease  and  disease  itself,  we  shall  use  our  remedies  more  intelligently; 
we  shall  see  how  dominant  is  the  sphere  of  preventive  medicine,  and 
that  curative  medicine  is  often  but  the  ancillary  mouse  Avhich  liberates 
the  body  for  its  own  work  of  recovery. 

To  know  disease,  then,  we  must  first  know  the  latitudes  of  health ; 
we  must  study  the  balance  of  forces  in  their  normal  play  before  we  can 
comprehend  and  neutralise  the  disturbances  to  which  this  balance  is  sub- 
ject. The  corporeal  system  of  man  is  one  of  vast  multiplication  and  differ- 
entiation of  members ;  in  him,  therefore,  comprehension  of  the  system  is 
most  difficult.  As  we  descend  the  scale  of  life,  and  study  simpler  sys- 
tems and  simpler  functions,  description  becomes  easier ;  and  physiol- 
ogists, building  up  our  knowledge  of  the  normal  by  the  comparative 
method,  take  pathologists  with  them,  who,  in  their  turn,  working  upwards 
from  the  lowest  forms  of  life,  or  the  embryos  of  the  higher  or  the  embryonic 
tissues  of  the  higher,  are  revealing  to  us  day  by  day  the  secret  ways  of 
the  earliest  and  simplest  deviations  from  the  normal  —  that  is  to  say, 
the  elements  of  disease  \yide  arts,  on  '^  Inflammation,"  "  Fever,"  and 
"Pathology  of  Infection"  in  this  volume].  Again,  as  the  building  up 
of  an  organism  is  not  by  permanent  accretion  like  the  building  of  a  house, 
but  by  an  incessant  repair  of  decay,  the  student  of  the  normal,  that  is  the 
physiologist,  is  constantly  in  the  presence  of  pathological  features.  As 
the  healthy,  so  the  normal  is  but  a  relative  term  ;  that  which  is  normal 
in  one  series  may  be  abnormal  in  another,  and  thus  the  physiologist  and 
the  pathologist  are  intimately  one :  physiology  as  well  as  pathology  is 
concerned  with  decay.  The  comparative  method  necessarily  embraces 
the  work  of  both,  pathology  being  one  aspect  of  physiology ;  to  speak 
metaphorically,  it  is  the  reverse  view  of  physiology,  the  study  of  accel- 
erated or  irregular  rates  of  decay.     Disease  is  a  matter  of  time  relations. 

What,  then,  is  the  nosologist  ?  The  nosologist  bears  the  relation  to 
the  pathologist  that  the  naturalist  or  morphologist  does  to  the  physi- 
ologist ;  as  the  pathologist  classifies  the  morbid  variations  of  plants  and 
animals,  so  the  nosologist  describes  the  natural  history  of  diseases :  the 
nosologist,  as  such,  has  no  concern  with  curative  means ;  he  has  his  views 
of  the  balance  of  forces,  but  has  no  concern  in  the  promotion  of  them. 
Cure  is  an  art ;  it  is  the  application  of  these  sciences,  and  is  the  concern 
of  the  physician :  a  physician  is  an  engineer  who  cannot  construct,  but 
is  skilled  in  conservation  and  repair. 

Classification.  —  The  nosologist  or  clinician,  describing  and  comparing 

J  The  use  of  the  word  "  microbe  "  is  not  to  be  limited  to  bacteria.  A  g;eneral  term  for 
minute  living  things  is  required,  and  "  micro-organism  "  is  too  cumbrous. 


SYSTEM  OF  MEDICINE 


organisms  which  have  deviated  from  the  normal  balance  of  function,  finds 
that,  infinite  as  are  the  gradations  between  health  and  disease  and  be- 
tween one  mode  of  perturbation  and  another,  yet  these  perturbations  tend 
to  resolve  themselves  in  certain  ways,  to  fall  into  certain  morphological 
groups  which  present  some  Ioav  degrees  of  constancy.  By  these  recurrent 
characters  he  is  enabled  to  classify  them ;  and  this  he  tries  to  do  after 
the  method  of  a  naturalist,  that  is,  on  an  explanatory  arrangement  based 
upon  degrees  of  genetic  aflB.nity.  As  the  naturalist  cannot,  however,  go 
far  without  the  anatomist,  so  the  nosologist,  soon  finding  that  a  study 
of  superficial  features  leads  to  classifications  which,  however  convenient 
for  the  time,  are  but  provisional,  has  to  classify  by  likenesses  of  a 
deeper  and  a  deeper  kind ;  and  as  he  does  so  he  becomes  a  pathologist. 
As  the  naturalist  without  the  help  of  the  comparative  anatomist  might 
classify,  let  us  say,  the  swift  with  the  swallow,  so  the  nosologist  with- 
out the  comparative  pathologist  might,  as  he  has  done,  classify  leprosy 
with  psoriasis,  tubercular  with  typhoid  enteritis,  sarcoma  with  car- 
cinoma, and  so  forth. 

Here,  however,  we  are  led  to  the  reflexion  that  to  regard  and  name 
diseases  as  species,  or  even  as  varieties,  in  a  biological  sense,  is  an  error 
of  the  same  kind  as  to  regard  them  as  entities.  A  disease  is  a  particular 
state  of  an  individual;  and,  although  certain  families  show  persistent 
bents  to  certain  kinds  of  morbid  variation,  yet  the  constancy  of  this 
fashion  bears  a  very  small  proportion  to  that  of  the  characters  of  a 
variety  in  a  biological  sense.  Moreover,  although  careless  clinical 
teachers  will  continue  to  speak  of  the  ''  development "  of  this  or  that 
disease,  yet  disease  is  no  new  advance,  but  a  retreat,  a  stage  of  decline 
failing  in  relative  stability,  a  state  which  must  end  either  in  a  recovery 
of  the  normal  balance  or  in  dissolution.  All  attempts  to  describe 
diseases  in  terms  equivalent  to  the  genera,  species,  or  natural  varieties 
of  plants  or  animals  are  then  erroneous ;  they  lead  to  mistakes  both  of 
theory  and  of  practice,  and  to  ignorance  of  the  underlying  unity  in  the 
various  forms  of  disease.  A  sick  plant  or  animal  is  but  itself  in  another 
state,  a  state  more  transient  and  less  useful. 

■  On  the  other  hand,  amid  the  instabilities  and  the  frequent  and  rapid 
changes  of  natural  perturbation,  nosologists  in  early  times  —  times  earlier 
than  our  records  —  observed,  nevertheless,  that  symptoms  do  not  occur 
haphazard,  or  congregate  pell-mell,  but  that  they  tend  to  arrange  them- 
selves in  recurrent  groups  of  some  likeness,  so  that  a  medical  mor- 
phology is  possible.  We  should  anticipate  perhaps  that,  inasmuch  as 
in  animals  of  the  same  kind  the  several  systems  of  the  body  are  ap- 
proximately alike,  so  their  disorders,  like  autumn  leaves,  would  appear 
with  fairly  uniform  features  within  the  kind.  We  do  find,  accordingly, 
in  man  that  diseases,  or  symptom  groups,  present  broad  features  of 
resemblance,  diversified  in  subordinate  detail  as  individuals  are  diverse. 
No  two  men  are  alike  at  all  points,  and  no  two  cases  of  disease  are 
identical ;  but  comparative  nosologists  tell  us  that,  so  far  as  observation 
has  gone,  each  kind  of  plant  and  each  kind  of  animal  seems  on  the  whole 


INTRODUCTION 


to  have  certain  sets  of  morbid  characters  more  or  less  jjeculiar  to 
itself. 

That  symptoms  do  not  occur  in  disorderly  jumbles,  but  tend  to  form 
groups  of  certain  degrees  of  constancy  varying  with  various  organisms, 
may  receive  some  explanation  not  only  by  the  set  of  the  lines  of  least 
resistance  in  the  several  anatomical  systems  of  which  the  higher  organ- 
isms consist,  but  also  by  a  study  of  certain  other  facts  in  biology  lying 
as  deep  as  diseases  or  anatomical  systems. 

Biologists  ^  tell  us  that  there  may  often  or  generally  be  "  discon- 
tinuity" between  the  arrangements,  or  related  compounds,  mechanically 
stable  under  various  conditions.  Either  of  two  arrangements  may  be 
relatively  stable,  but  nothing  between  them;  so  that  the  transition 
between  them  can  only  take  place  by  a  swift  passage.  If  this  be  a  true 
view  of  biological  variations  it  may  have  truth  likewise  in  respect  of 
disease.  The  most  stable  attitude  of  the  bodily  functions  is  no  doubt 
the  position  we  call  "  health " ;  but  there  are,  we  may  suppose,  several 
other  positions  in  which  component  functions  have  degrees  of  stability, 
and  these  may  be  the  sundry  kinds  of  disease.  It  may  well  be,  again, 
that  interferences  reinforce  or  neutralise  each  other  along  certain  lines, 
so  that,  wheresoever  the  disturbance,  the  set  of  functional  balance,  after 
a  brief  oscillation,  would  tend  to  resolve  itself  in  a  particular  direction ; 
thence,  after  a  time  of  moderate  steadiness  it  may  recover  the  more 
perfect  balance  of  health  or  fall  into  dissolution. 

These  opinions  seem  likely  to  illuminate  some  nosological  riddles. 
We  have  heard  a  little,  too  much  of  the  proverb,  Natura  nihil  facit  per 
saltum,  and  have  been  led  to  forget  that,  however  gradual  transitions 
may  be,  intermediate  phases  between  positions  of  relative  stability  may 
be  so  rapid  as  to  be  elusive ;  or  again,  that  retrocession  may  take  place 
to  a  certain  point,  whence  a  new  position  is  reached. 

In  this  light  such  a  saw  as  "We  are,  all  of  us,  more  or  less  insane  " 
takes  on  a  new  untruth,  and  we  see  how  it  comes  that,  in  respect  of 
mental  and  other  disease,  there  is  not  in  practice  the  difficulty  which 
laymen  assume  of  definitely  recognising  perversions  from  the  normal. 
Theoretically,  of  course,  "borderland  phases"  must  occur,  but  they 
may  not  be  persistent  or  frequent  enough  to  embarrass  us,  and  a  new 
position  of  relative  equilibrium  may  be  reached  so  quickly  that  inter- 
mediate positions,  like  the  flap  of  the  wing  of  the  albatross,  are  unper- 
ceived.  Even  thought  runs,  no  doubt,  in  certain  grooves.  It  is  not  to 
be  supposed  that  our  senses  have  continual  cognisance  of  every  property 
of  things,  or  exhaust  every  possible  combination  of  them.  We  are,  as 
artists,  consciously  or  unconsciously  ever  selecting.  Moreover,  in  our 
development  our  thoughts  have  probably  followed  certain  lines  of 
balance,  cohesion,  cleavage,  or  what  not,  consisting  either  in  the  physical 
basis  of  life  or  in  the  conditions  of  the  medium.  Thus  every  old  fancy 
may  be  said  to  have  some  quality  of  science  in  it.     But  whether  the 

1  Mr.  Galton  and  Mr.  Bateson  {Materials  for  the  Study  of  Variation,  Macmillan  &  Co., 
London,  1894)  have  dealt  with  this  subject  before  me,  but  with  other  aspects  of  it. 


SYSTEM   OF  MEDICINE 


inclination  to  particular  attitudes  be  inherent  in  the  structure  of  living 
molecules,  or  arise  in  the  same  way  as  the  differentiation  of  the  several 
anatomical  systems,  or  be  impressed  upon  the  organism  by  the  preva- 
lences of  certain  combinations  of  parts  in  the  medium,  or  be  again  but 
an  aspect  of  inertia,  is  not  important  to  my  argument,  nor  are  these, 
indeed,  soluble  questions  at  present. 

These  considerations  indicate  the  factors  which  make  classification 
and  diagnosis  possible ;  perturbations  tend  to  fall  into  groups  which 
can  be  arranged  in  classes  by  likenesses  and  separated  by  unlikenesses. 
In  the  earlier  stages  of  pathological  knowledge,  stages  Ave  have  scarcely 
left  behind,  classification  of  symptom  groups  could  only  be  made  by 
reference  to  superficial  and  obvious  features ;  for  instance,  scarlatina 
was  confounded  with  measles,  typhus  fever  with  typhoid ;  all  eruptions 
on  the  skin  were  classed  together,  —  small-pox  and  impetigo,  psoriasis 
and  leprosy,  and  so  forth.  Even  yet  we  put  together  certain  syphilides 
and  certain  tubercular  eruptions,  and  these  again  with  other  skin 
affections,  and  so  on ;  and  convenience,  as  I  have  said,  may  often  con- 
tinue for  a  while  an  arrangement  which  began  in  ignorance. 

As  our  insight,  however,  becomes  more  penetrating,  we  detect  re- 
semblances more  and  more  profound,  and  very  commonly  profound 
resemblances  between  diseases  so  unlike  on  the  surface  that  we  may 
hesitate  at  first  which  signs  to  follow.  In  the  biological  sciences,  how- 
ever, classification  consists  in  the  discovery  of  the  profounder  resem- 
blances which  have  a  wider  bearing  and  indicate  the  remoter  genetic 
origins.  Clinical  diagnosis,  hoAvever,  is  not  investigation  —  a  distinction 
some  practitioners  forget ;  diagnosis  depends  not  upon  all  facts,  but 
upon  crucial  facts.  Indeed  we  may  go  farther  and  say  that  accumula- 
tion of  facts  is  not  science  ;  science  is  our  conception  of  the  facts  :  the 
act  of  judgment,  perhaps  of  imagination,  by  which  we  connect  the 
unknown  Avith  the  knoAvn.^  As  pathology  advances  we  detect  still 
deeper  affinities,  still  more  permanent  qualities  in  disease,  and  we  form 
more  natural  classifications  —  classifications,  that  is,  Avhich  depend  less 
and  less  upon  those  superficial  characters  which  are  more  likely  to  be 
products  of  accidents  ;  diagnosis  is  the  art  of  placing  any  given  morbid 
group  in  the  class  to  which  at  bottom  it  is  most  akin. 

An  explanatory  classification  of  disease  must  rest,  then,  upon  such 
an  analysis  of  all  life,  whether  animal  or  vegetable,  as  may  enable  us 
to  trace  the  more  intimate  processes  of  disease,  beginning  with  those 
of  widest  generality  and  moving  onwards  to  the  more  complex.  Fever, 
for  example,  is  a  symptom  group  of  wide  generality,  and  may  be  found 
in  its  degree  no  doubt  in  all  warm-blooded  animals,  possibly  in 
all  animals  which  possess  a  nervous  system ;  biologists  have,  indeed, 
inquired  Avhether  even  in  plants,  or  parts  of  plants,  oscillations  of 

1  "  AiVe  cannot  describe  a  fact  without  implying  more  than  the  fact "  (J.  S.  Mill,  S.  of 
L.,  vol.  ii.  p.  189,  ed.  1872).  Whewell  repeatedly  enforced  the  same  truth,  saying  that 
comparison  precedes  induction,  and  that  every  record  of  an  observation  implies  a  com- 
parison {Phil.  Ind.  Sci.). 


INTRODUCTION  xxvii 


temperature  inco-ordinate  with  that  of  the  surrounding  medium  may  be 
detected  during  rapid  changes  of  the  tissues.  A  local  disengagement  of 
heat  is  a  factor  of  inflammation  rather  than  of  fever,  which  latter  term 
is  more  properly  applied  to  the  irregular  propagation  of  heat  waves  in  a 
system  integrated  by  blood-vessels  and  nerves.  There  is  a  point  where 
differentiation  of  fever  from  inflammation  has  not  begun  —  where  destruc- 
tive changes  for  lack  of  integrating  machinery  cannot  maintain  their 
balance  by  diffusing  their  vibrations;  when  component  parts  fight  as 
individual  members  or  clans,  and  not  yet  as  a  national  regiment.  In- 
flammation, then,  is  even  a  more  general  term  than  fever. 

Proceeding  farther  we  find  that  fever  forms  part  of  a  large  group  of 
maladies  within  which  sub-groups  are  made  according  to  more  and  more 
special  differences.  Broussais,  deplorable  as  was  his  teaching  on  its 
therapeutical  side,  destroyed  the  idea  of  Fevers  as  several  morbid  enti- 
ties :  an  immense  service  to  nosology.  We  now  know  that  cow-pox  and 
small-pox,  widely  different  as  they  superficially  appear,  must  be  classed 
together,  because  the  processes  in  the  cow  and  in  men  follow  like  initial 
causes ;  although,  owing  to  differences  in  the  media,  they  reach  the  sur- 
face in  widely  different  forms.  Within  the  memory  of  living  physicians 
Mr.  Hutchinson  and  others  have  impressed  upon  us  that  syphilis,  widely 
eccentric  in  its  superficial  aspects,  profoundly  resembles  such  febrile 
diseases  as  scarlet  fever  and  its  kin,  and  is  to  be  classified  with  these. 
The  various  phases  of  tuberculosis  have  still  more  recently  been  fitted 
into  a  serial  order  {vide  art.  "  Tuberculosis "],  and  the  malady  as  a 
whole  carried  into  the  same  class  of  syphilis,  small-pox,  scarlet  fever, 
leprosy,  and  so  forth,  —  a  class  presenting  the  widest  differences  in  the 
superficial  features  of  its  members.  Tuberculosis  and  syphilis  are  now 
indeed  recognised  as  the  most  exemplary  instances  of  a  nosological 
"  series  "  of  which  we  have  cognisance. 

When  we  turn  to  consider  the  forms  in  which  diseases  present  them- 
selves to  the  eye,  we  shall  find  that,  even  within  the  limits  of  the  most 
definite  kinds  such  as  small-pox,  no  two  cases  are  identical ;  and  in  kinds 
of  more  aberrant  habit,  such  as  syphilis,  the  unlikeness  of  cases  is  so 
marked  that  many  of  the  various  phases  of  this  protean  malady  have 
been  fitted  into  the  series  within  the  last  few  years.  We  must  not 
suppose,  indeed,  that  our  observation  of  this  series  is  even  yet  complete. 
For  not  only  may  corresponding  members  of  two  or  more  series  of  morbid 
phases  differ  in  degree,  but  one  or  more  members  of  the  series  may  be 
absent  —  scarlatina  may  occur  without  rash,  whooping-cough  without 
whoop,  angina  pectoris  without  pain,  migraine  without  headache,  and 
so  forth.  Only  by  a  study  of  genetic  affinities  can  we  dispose  such 
cases  in  proper  serial  order;  and  some  symptom  groups,  no  doubt,  are  yet 
undistinguished,  or  if  distinguished,  are  not  yet  placed  in  a  series.  The 
obscure  series  which  we  call  gout  may  yet  receive  many  more  affections 
within  its  limits  —  attributions  perhaps  as  unexpected  as  was  that  of 
"  pathologists'  warts,"  when  this  deformity  appeared  in  the  series  we  call 
tuberculosis.   Many  skin  diseases  have  yet  to  find  their  places  in  series  of 


SYSTEM  OF  MEDICINE 


affinity,  places  which,  will  be  found  for  them  when  their  causation,  im- 
mediate and  remote,  is  better  comprehended.  A  description  cannot,  of 
course,  be  complete  until  our  knowledge  of  morbid  processes  is  complete, 
indeed,  classification  by  genesis,  being  the  expression  of  the  order  of  our 
thoughts,  is  but  the  form  of  such  knowledge,  and  it  is  by  the  study  of 
aberrant  processes  that  we  may  often  detect  the  more  intimate  kinships. 
When  morbid  affections  are  all  plotted  out  in  serial  order  the  number 
of  such  series  may  turn  out  not  to  be  large,  and  the  fashions  of  disease 
may  indicate  the  several  lines  of  cleavage  or  paths  of  least  resistance  in 
each  organism  or  class  of  organisms. 

If  I  may  convert  Whewell's  fine  figure  to  my  present  purpose,  I  will 
compare  the  field  of  disease  to  a  large  woodland  country  in  which  woods 
are  seen  of  various  sizes  and  kinds  occupying  hills  or  valleys  in  several 
masses;  in  places  the  confines  are  definite,  in  other  directions  smaller 
tufts  of  trees  and  scattered  trees  so  diversify  the  intermediate  tracts 
that  Ave  cannot  precisely  say  where  one  wood  ends  and  another  begins. 
So  again  in  respect  of  the  kind  of  trees :  on  the  limestone  uplands  we 
may  see  beech,  fir  on  sandy  knolls,  elm  and  oak  in  the  loam  or  clay  of 
the  lowlands,  yet  even  of  these  kinds  it  may  be  hard  to  mark  the  limits, 
so  gradually  may  clay  pass  into  sand,  or  sandy  clay  blend  with  the  lime 
into  marl.  So  likewise  with  the  various  distribution  of  the  waters  we 
find  other  changes  in  the  character  of  the  vegetation,  whether  of  the 
trees,  of  the  shrubs,  or  of  the  herbs,  which  again  confound  the  superficial 
observer  by  apparent  caprice.  Yet  to  one  who  has  penetrated  to  the 
underlying  facts  of  causation  that  which  seemed  confusion  falls  into 
order. 

Once  more;  as  these  underlying  and  antecedent  conditions  of  land 
and  water  do  not  fall  apart  or  together  by  haphazard,  but  are  likewise 
obedient  in  their  turn  to  yet  profounder  series  of  antecedent  changes, 
so  oak,  elm,  beech,  pine,  and  the  rest  are  not  flung  together  pell-mell, 
but  grow  in  divers  groups,  which  are  repeated  again  and  again  wher- 
ever the  underlying  conditions  repeat  themselves,  though  never  perhaps 
with  identical  repetitions :  so  the  groups  of  symptoms  which  we  call 
disease,  if  never  identically  repeated,  because  their  antecedents  may 
never  be  identically  repeated,  yet  tend,  as  I  have  said,  to  manifest  themT 
selves  in  sets  or  in  recurrent  series  of  approximate  resemblance.  Now 
the  forester,  if  ignorant  of  causation,  yet  learns  to  note  the  recurrence-of 
these  patterns,  and  the  discovery  is  valuable  to  him  for  many  practical 
reasons.  By  his  practised  eye  the  various  contents  of  a  group  of  trees 
would  be  thus  recognised  at  once  from  previous  experience,  and  he  would 
be  disposed  to  set  up  types  in  his  mind,  types  of  the  natural  associa- 
tions of  trees  and  plants  with  which  he  is  already  familiar.  He  might 
give  names  to  these  recurrent  groups,  as  we  name  our  symptom  groups, 
and  would  speak  approvingly  or  disapprovingly  of  individual  groups  as 
his  convenience  was  favoured  by  the  sura  and  qualities  of  the  several 
kinds  of  trees  which  enter  into  them.  Aberrant  and  defective  groups 
would  offend  his  practical  mind,  and  he  would  gladly  have  all  conform- 


INTRODUCTION 


able  to  his  main  patterns,  that  descriptions  and  recognitions  might  for 
practical  purposes  be  more  easy. 

Thus  nosologists  have  been  disposed  to  set  up  "Types, ' '  and  to  look  for 
the  repetition  of  these  types  for  purposes  of  recognition  and  practical  uses. 

If  by  the  word  "  type "  we  mean  no  more  than  a  prevalent  and 
recurrent  group,  a  common  order  of  symptoms,  we  may  thus  refer 
diseases  to  types.  But  we  run  into  two  dangers  by  so  doing :  we  tend 
to  undervalue  diversities  and  the  teachings  of  diversity,  fixing  our  eyes 
on  the  nuggets  and  forgetting  to  test  the  "tailings";  moreover  we 
keep  up  the  error  connoted  in  the  word  "  type,"  which  comes  down  to 
us  from  the  Platonist  schools  of  philosophy.  Diseases  are  not  cast 
in  a  mould;  nor  would  any  one  now  affirm  that  behind  phenomenal 
groups  there  exists  a  transcendental  type  towards  which  any  par- 
ticular embodiment  is  an  approximation ;  although  biologists  of 
the  school  of  Owen  used  language  very  like  it  not  long  ago,  and 
the  language  of  some  of  us,  even  if  we  do  not  talk  of  the  "archi-" 
or  "  schematic  mollusc,"  implies  the  same  thing  still.  We  use  the 
words  "  type  "  and  "  typical "  too  often,  and  bring  with  them  something 
more  than  the  notion  of  a  mean — some  sense  of  approximation  to  or 
falling  away  from  a  standard  or  conceptual  model.  Teachers  who  would 
deny  that  they  apply  the  term  "  scarlet  fever"  to  a  type  in  the  sense  of 
an  ideal  standard,  yet  themselves  use  and  allow  their  disciples  to  use 
the  word  "type"  in  such  a  sense.  On  every  page  of  a  student's 
note-book  we  see  the  phrases  "  a  typical  case  "  or  a  "  non-typical " ;  by  the 
former  some  students  seem  to  indicate  a  complete  case,  one,  that  is,  which 
presents  every  symptom  ever  seen  in  the  disease,  others  a  case  presenting 
a  mean  of  them,  and  better  called  an  ordinary  case ;  others  such  a  case 
as  their  teacher  or  their  book  sets  forth ;  and  lurking  in  the  minds  of 
most  of  them  is  the  notion  that  there  are  real  standards,  or  architypes, 
to  which  disease  ought  to  conform,  a  notion  which  tends  to  blind  them 
to  the  continuity  of  nature  and  the  modes  of  causation.  Description 
by  "type"  lends  itself,  then,  rather  to  the  epic  of  disease  as  presented 
in  those  "  systematic  "  lectures  on  medicine  which  are  mischievous  to 
beginners,  and  except  in  the  hands  of  teachers  of  fresh  and  original 
gifts,  do  on  the  whole  more  harm  than  good,  preferring  academic 
reasoning  and  pictorial  description  to  the  place  of  immediate  observation 
and  measurement  at  the  bedside  or  in  the  laboratory.^ 

Of  the  confusion  which  this  term  brings  into  our  thought  the  dis- 
cussion on  "  change  of  type  in  disease  "  is  an  example.  Physicians  try 
to  conceive  some  standard  to  which  a  disease  approximates,  so  that  a 
change  of  type  means  generally  a  change  of  the  features  of  this  figment 
in  the  mind  of  the  speaker.  Thus  there  are  as  many  types  of  disease 
as  there  are  varieties  of  individual  imagination.  A  change  of  type  in  a 
scientific  sense  is  a  "  pseud-idea  "  —  one  which  eludes  analysis  and  defini- 
tion.    If  we  thoroughly  realise  that  diseases  are  but  so  many  attitudes 

'  Vid".  excellent  remarks  on  systematic  lectures  on  medicine  by  Sir  J.  Russell  Reynolds 
in  his  Address  to  the  British  Medical  Association  iu  London  in  1895. 


XXX  SYSTEM  OF  MEDICINE 

of  men  we  realise  the  correlative  of  this  that  there  can  no  more  be  a 
standard  pattern  of  disease  than  a  standard  pattern  of  man.  That  the 
functions  even  of  a  peculiar  sort  of  man  —  Englishmen  or  Frenchmen, 
let  us  say  —  preserve  a  constant  centre  of  gravity  is  highly  improbable, 
as  improbable  as  that  circumstances  should  be  permanently  uniform,  or 
that  differential  evolution  should  bring  about  no  changes  in  the  relative 
values  of  component  organs  inter  se}  Man,  even  the  most  secluded  and 
protected  of  mankind,  has  advanced  or  retrograded,  and  at  various  rates 
of  acceleration ;  it  has  never  been  alleged,  even  of  an  Andaman  islander, 
that  he  has  stood  still.  I  conceive  that  in  the  minds  of  the  able  and 
accomplished  physicians  who  somewhat  polemically  declare  that "  disease 
has  not  changed  its  type  "  there  survives  still  —  if  unconsciously  to  them- 
selves —  a  belief  that  disease  is  an  entity  which  so  dominates  mankind 
and  its  circumstances  as  to  impress  a  large  measure  of  uniformity  upon 
the  phenomena  of  their  interaction.  Otherwise  it  seems  to  me  they 
would  hesitate  to  assert  that  every  perturbation  preserves  a  constant 
mean  rate,  and  every  deflected  molecule  a  constant  mean  distance  from 
a  centre  of  gravity  which  never  shifts. 

Yet,  if  we  teach  ourselves  to  regard  diseases  as  oscillations  of  actual 
men  and  women,  to  assume  a  constancy  of  these  attitudes  is  to  assume 
a  constancy  of  the  kinds  and  generations  of  men,  and  a  constancy  of 
the  circumstances  uuder  which  they  live.  If  the  whole  argument  be 
not  a  dispute  with  windmills,  at  any  rate  it  will  not  do  in  the  same 
breath  to  denounce  the  mischief  of  *'  modern  civilisation." 

What  ought  physicians  to  mean,  then,  when  they  speak  of  types ; 
and  what  shall  we  lack  if  this  term  be  denied  to  us  ? 

Now,  in  any  disease,  the  more  closely  a  particular  symptom  is  con- 
cerned with  the  functions  of  the  organ  affected,  the  more  frequent  will 
be  its  occurrence.  In  other  words,  if  a  large  number  of  cases  in  which 
a  certain  organ  is  affected  were  arranged  in  order  of  the  intensity  with 
which  the  direct  functions  of  the  organism  are  affected,  it  would  be  found 
that  in  the  more  intense  cases  certain  symptoms  were  universal  or  very 
frequent,  and  that  as  the  intensity  of  the  infection  fell  off,  so  also  did  the 
frequency  of  the  occurrence  of  the  symptom  noted. 

The  organisms  of  individuals  are  variable  in  themselves,  and  are 
subject  to  disturbances  which  are  not  identical  in  each  instance ;  but  a 
large  number  of  observed  cases  of  any  disease  may  be  grouped  about  a 
certain  ''morbid  mean," and  any  particular  case  of  disease  will  naturally 
be  compared  with  the  "morbid  mean."  Any  symptom  may  vary  in 
excess  of  or  defect  from  this  morbid  mean,  and  thus  the  morbid  mean 
forms  a  convenient  standard  for  expressing  to  our  minds  the  set  or  bent 
of  the  phenomena. 

By  a  typical  case,  then,  we  ought  to  signify  (for  Ave  use  the  word 
very  inconsistently)  a  case  in  which  the  symptoms  do  not  differ  largely 
from  those  occurring  in  the  ''  morbid  mean."     As  parallel  instances,  we 

1  Vide  art.  on  "Typhus,"  in  which  Dr.  Moore  tells  us  that  this  symptom  group 
varies  with  intellectual  cultivation.    This  is  certainly  my  experience  also. 


INTRODUCTION  xxxi 


may  take  the  variation  of  the  stature  of  the  men  of  a  nation  about  a 
mean,  or  the  distribution  of  bullet  marks  on  a  target. 

Not  only  this  question  but  many  others  also  might  be  explained  if  by 
plotting  out  measurable  symptoms  in  curves  we  could  get  the  mean 
intensity  of  each  and  the  amount  of  its  variability  ;  and  could  determine 
whether  the  measures  are  symmetrically  arranged  about  this  mean.  To 
form  such  a  curve  the  measurements  would  be  set  out  along  the  abscissa, 
and  the  numbers  of  instances  as  ordinates.  This  is,  however,  too  diificult 
an  undertaking  to  discuss  here,  even  were  I  capable  of  its  discussion.' 
We  have  also  to  bear  in  mind  that  the  treatment  of  statistics  is  somewhat 
dangerous,  unless  carried  out  by  one  who  has  some  acquaintance  with  the 
theory  of  errors ;  the  curves  might  be  constructed  accurately,  but  they 
might  be  made  and  used  on  wrong  principles. 

Again,  a  like  traditional  habit  of  thought  may  be  seen  in  respect 
of  causation  itself.  Students  are  taught  on  the  highest  authority 
to  divide  causes  into  the  categories  of  "  pre-disposing  "  ''  and  exciting  "  — 
the  "  causce  prevenientes^'  and  the  "  causce  efficientes'^  of  the  schoolmen. 
This  habit  is  mischievous  in  two  ways :  to  divide  causes  into  stronger 
and  weaker  kinds  keeps  up  that  obstinate  habit  of  men  to  seek  in  the 
word  "  cause  "  something  more  than  an  indication  of  invariable  ante- 
cedence, something  of  a  community  of  nature  between  cause  and  effect ;  and 
to  associate  with  the  word  "  cause  "  some  notion  of  a  casting  act,  of  effort, 
or  genesis :  moreover,  being  a  confusion  of  thought  it  breeds  confusion. 
Need  I  say  that  by  the  causation  of  a  thing  we  mean  those  events  of 
the  infinite  past  which  preceded  it  —  events  which  have  no  degree  of 
rank  or  affinity,  either  within  themselves  or  in  respect  of  the  thing 
under  observation,  and  whose  invariable  precedence  is  a  mere  matter  of 
routine  experience,  and  not  of  generation,  enforcement,  or  even  of  col- 
ligation. Some  of  the  antecedent  events  are  nearer,  others  are  more 
remote ;  some  vast  sections  of  the  system  we  take  for  granted,  others 
which  immediately  concern  us  we  quote ;  but  there  is  no  difference  of 
quality  —  indeed,  the  same  event  may  be  called  a  "  predisposing  cause  " 
at  one  moment  and  an  "  exciting  cause "  at  another :  a  certain  coccus 
on  one  day  harmlessly  traverses  the  lung,  on  the  next  a  chill  and  the 
coccus  together  precede  a  pneumonia ;  which  of  the  two  is  the  exciting 
cause  ?  Whichsoever  comes  first,  some  one  may  say  ;  but  what  if  they 
arrive  at  the  same  moment  ?  The  distinction  is  of  course  absurd.  We 
sometimes  even  hear  of  a  "  plurality  of  causes,"  or  that  one  of  two  or 
three  "  causes  "  might  have  produced  a  particular  result.  This  is  loose 
thinking ;  a  certain  general  result  —  such  as  fever  —  might  have  been 
caused  in  this  way  or  in  that,  but  a  "case,"  with  all  its  individual 
characters,  could  have  had  but  one  set  of  antecedent  phenomena  and  no 
other.  Why  this  is  we  know  not;  that  so  it  is,  experience  hitherto  has 
taught  us ;  and  upon  this  experience  we  make  our  forecasts. 

1 1  may  refer  the  inquiring  reader  to  a  paper  by  Prof.  Karl  Pearson  in  the  Proc.  Royal 
Soc,  January  24, 1895,  entitled  "  Mathematical  Contributions  to  the  Theory  of  Evolution  ;  " 
although  this  paper  is  not  written  with  a  view  to  medical  applications,  yet  the  principles 
set  forth  in  it  underlie  all  applications  of  the  method. 


XXXii  SYSTEM  OF  MEDICINE 

Another  otiose  distinction  is  made  in  the  formal  separation  of  signs 
and  symptoms  —  signs  being  matters  rather  of  direct,  symptoms  of 
inferential  notation.  The  adjective  "  physical "  makes  matters  worse, 
and  yet  I  have  heard  many  a  student  worried  by  such  distinctions,  and 
have  even  seen  questions  on  the  distinctions  in  an  examination  paper ! 
A  cough  or  a  pale  cheek  is  of  course  as  much  a  "  physical  sign  "  as  a 
mitral  murmur ;  everything  that  befalls  a  patient  is  a  "  symptom,"  and 
his  symptoms  are  the  signs  of  his  malady.  Strictly  speaking,  health  is  a 
symptom  group  as  well  as  disease,  and  this  we  must  remember  although 
common  usage  restricts  the  word  to  morbid  incidents. 

From  what  has  gone  before  it  becomes  evident  that  all  efforts  to 
define  diseases  fully  are  in  vain.  The  love  of  definition  comes  from  the 
Socratic  School/  and  definition  is  absolutely  necessary  to  settle  a  use  of 
words,  or  of  certain  abstract  conceptions,  such  as  line,  point,  molecule,  and 
the  like,  which  are  used  as  counters  in  reasoning ;  these  words  and  concep- 
tions are  arbitrarily  adopted,  and  their  i;se  must  be  made  precise  by  the 
logician.  But  to  define  a  disease  is  to  build  the  wall  round  the  cuckoo : 
natural  processes  will  not  be  thus  impounded;  they  are  infinite 
and  elusive.  To  define  is  to  pretend  to  sum  up  knowledge,  or  at  any 
rate  to  enumerate  likenesses  and  unlikenesses  which  are  inexhaustible ; 
we  are  no  more  in  a  position  to  define  diseases  than  to  define  dogs  and 
cats.  The  use  of  "  definitions,"  like  the  use  of  "  types,"  leads  the 
student  to  form  conceptions  which  interfere  with  his  appreciation  of  the 
infinite  variety  and  gradation  of  natural  processes ;  like  the  use  of 
"types,"  it  leads  to  contemplation  of  Kranliheitshegriffen  rather  than 
of  Krayikheitszustande  —  of  entia  rather  than  of  Jientia.  The  aspects 
of  disease  are  not  to  be  likened  to  a  picture  gallery  in  which  every  set  of 
impressions  is  contained  within  its  own  frame.  The  "  definitions  "  of 
systematic  writers  on  disease  are  of  course  no  more  than  brief  descriptions, 
and  as  such  are  no  doubt  useful  as  mere  indications  of  subject  matter. 

To  sum  up :  disease  is  a  state  of  a  living  organism,  a  balance  of 
function  more  unstable  than  that  which  we  call  health ;  its  causes  may 
be  imported,  or  the  system  may  "  rock  "  from  some  implicit  defect,  but 
the  disease  itself  is  a  perturbation  which  contains  no  elements  essentially 
different  from  those  of  health,  but  elements  presented  in  a  different 
and  less  useful  order.  Diseases,  therefore,  have  no  analogy  with  the 
genera  and  species  of  the  biologist.  They  may  be  arranged  for  con- 
venience of  reference  by  any  external  character,  such,  for  example,  as 
locality;  but  a  natural  classification  of  diseases  is  an  arrangement 
of  them  in  order  of  genetic  affinity,  and  is  a  description  of  their 
causation.  Diagnosis  is  the  recognition  of  a  disease  already  classified 
and  the  reference  of  it  to  its  place,  and  thus  differs  from  research 
or  discovery.  Classification  is  a  measure  of  our  knowledge  of  the 
pathology  of  all  organisms,  and  a  pathology  limited  to  man,  like  a 
geocentric  astronomy,  is,  or  ought  to  be,  a  notion  of  the  past. 

1  8vo  5'  oiv  airbSoiiv  tis  Sw/cpdret  diKal<i)s '  roi/s  S'  iiraKTtKoiis  \byov^  kolI  t6  6pl^e(T0ai, 
Kad6\ov.  —  Arist.  Met.  xii. 


INTR  OD  UCTION  xxxiii 


The  causes  of  diseases  cannot  be  divided  into  categories ;  causes  are 
merely  the  antecedent  phenomena  —  the  routine  found  by  experience  to 
be  invariable.  Although  symptom  groups  tend  to  run  in  sets,  yet  it 
is  with  much  inconstancy,  infinite  variety,  and  manifold  transition ;  so 
that  although  a  disease  may  be  summarily  indicated  by  some  prominent 
features,  yet  to  define  it  is  a  bootless  quest;  a  definition  cannot  be 
regarded  as  a  schedule. 

Are  then  symptom  groups  so  fluid  that  we  can  have  no  nomen- 
clature? In  so  far  as  organisms  are  differentiated  into  systems,  and 
their  functions  into  departments,  their  perturbations  will  have  some  corre- 
sponding orders,  and  appear  in  groups  which  more  or  less  repeat  each 
other ;  in  other  words,  the  more  complex  the  organism  the  more  differ- 
entiated its  symptom  groups.  For  instance,  a  blow  upon  the  head  of  a 
man  is  followed  by  a  group  of  changes  different  from  that  which  follows 
a  blow  upon  his  spine  or  abdomen ;  indeed,  if  the  violence  of  the  blow  be 
given,  the  main  characters  of  the  resulting  group  in  each  case  may  be 
foretold  with  some  approach  to  accuracy.  As  we  descend  from  man  to 
lower  animals,  these  results  will  have  a  more  general  character  and  their 
groups  be  less  definite. 

Again,  symptom  groups  can  be  arranged  in  an  order  beginning  with 
the  most  general  and  ending  with  the  most  special.  Fever,  for  example, 
is  a  group  of  wide  generality,  and  is  found  at  any  rate  in  all  warm 
blooded  animals ;  probably  heat-regulation  or  tissue  stability  is  inherent 
in  and  conditioned  by  the  very  existence  of  a  nervous  system.  The 
extraordinary  manifestation  of  electric  control  in  certain  fishes  also 
indicates  to  us  that  even  cold  blooded  vertebrates  have  in  electric 
regulation  an  analogous  faculty.  So  far  as  I  am  aware,  however,  no 
experiments  have  been  made  upon  local  and  general  fluctuations  of 
temperature  in  cold  blooded  animals  subjected  to  catabolising  agents, 
though  tissue  changes  which  occur  under  such  influences  are  described 
by  Professor  Adami  in  his  article  on  Inflammation  in  this  volume.  If 
fever  be  a  member  of  the  ^ass  of  most  general  symptom  groups,  the 
elaborate  automatic  actions  of  certain  human  epileptics  might  be  taken 
as  instances  of  highly  special  groups  of  disordered  functions,  and 
between  these  extremes  we  may  distinguish  multitudes  of  groups  of 
various  stages  of  complexity,  not  by  any  means,  as  I  have  said,  "feharply 
defined  one  from  the  other,  insensibly  rather  melting  at  their  limits 
one  into  another,  yet  having  uniformity  enough  on  the  whole  to  admit  of 
naming  in  sets.  "  Well-marked  cases  "  are  probably  those  in  which  a  like 
perturbation  is  felt  especially  by  one  organ,  or  by  one  set  of  organs ;  a 
uniform  irritant  falling  precisely  upon  the  same  spot  in  the  body  must 
produce  a  group  of  events  only  not  invariable  in  so  far  as  the  organism 
may  be  inconstant.  Differences  of,  conditions,  however,  which  to  our 
eyes  are  apparently  very  small,  or  even  elusive,  may  and  often  do 
impress  so  great  a  change  upon  the  features  of  definite  perturbations  in 
definite  spots  as  to  blind  us  to  the  underlying  similarity  of  causation. 


XxxiV  SYSTEM   OF  MEDICINE 


Not  only,  for  example,  may  a  morbific  agent  set  up  in  one  kind  of  mam- 
malian animal  a  group  of  symptoms  bearing  little  superficial  resemblance 
to  the  group  set  up  by  the  same  agent  in  another  kind;  but,  as  the 
instance  of  the  tsetze  fly,  among  many  others,  shows  us,  the  resulting 
syndroma  may  have  widely  different  characters  in  the  several  varieties 
even  of  the  same  species  —  nay,  in  individuals  of  the  same  variety 
reared  under  different  conditions.  The  so-called  protective  inoculations 
may  be  cases  of  the  same  order,  though  the  relations  of  artificial  to 
natural  immunity  are  not  yet  made  clear ;  the  former  seems  liitherto  to 
be  of  a  more  temporary  kind  than  the  latter. 

Symptom  groups,  then,  differ  no  doubt  with  the  intimate  form  of 
grosser  or  finer  parts  in  the  various  organisms,  and  every  symptom  in- 
dicates molecular  disarray  somewhere,  could  we  but  detect  it;  chemical 
and  microscopical  discovery,  therefore,  as  they  reveal  more  of  such  dif- 
ferences, will  explain  more  of  the  variations  of  disease  —  for  illustration's 
sake  I  may  refer  to  the  investigations  of  Metschnikoff,  Kanthack,  Hardy, 
and  others  on  the  blood  corpuscles  —  yet  we  have  seen  already  that 
variations  in  morbid  phenomena  bear  no  direct  relation  to  the  lines 
of  obvious  anatomical  structure,  and  may  vary  enormously  with  pecu- 
liarities of  organisation,  chemical  or  other,  which  are  so  latent  as 
hitherto  to  have  escaped  our  analysis.  If,  indeed,  we  may  properly 
appeal  to  protective  inoculations  in  this  place,  the  modified  qualities 
of  the  contrasted  animals,  however  recondite,  may  not  be  very  profound 
or  permanent. 

When  speaking  of  classification,  I  indicated  these  difficulties  and 
the  labour  of  detecting  underlying  similarities  between  groups  of  phe- 
nomena apparently  disparate,  and  I  will  not  enlarge  a^ain  upon  the 
same  difficulties  in  respect  of  naming.  We  cannot  name,  «.  series  until 
we  have  laid  down  the  main  lines  of  it,  and  as  meanwhile  we  must  make 
provisional  classes,  so  we  must  make  provisional  names.  Descriptive 
names  cannot  be  given  until  we  have  relatively  complete  pathological 
explanations ;  but  by  pathological  explanations  I  mean  no  more  than  the 
formulation  of  series ;  or,  in  other  words,  the  discovery  of  the  causation 
—  of  the  ''  antecedent  routine,"  as  Prof.  Karl  Pearson  would  say.^ 

Those  nosologists  are  not  unreasonable  who  now  cry  out  for  names 
which  shall  indicate  pathological  characters,  but  they  anticipate  our 
powers.  Until  we  have  set  forth  the  routine  of  events  such  names  are 
impossible,  or  only  possible  partially  and  in  so  far  as  we  have  made 
out  some  fragments  of  the  ''routine."  To  compare  ethnology  with 
pathology,  let  us  suppose  that  an  ethnologist  of  the  linguistic  school 
had  fifty  years  ago  discovered  the  Basques  and  called  them  Mongolian. 
Later  ethnologists,  putting  language  in  a  much  lower  place  as  a  test  of 
race,  would  supplant  this  name  by  another  —  say  by  the  present  name, 
"  Basque."  No  sooner  is  the  former  name  uprooted,  and  the  new  name 
affixed,  than  comes  the  craniologist  to  tell  us  that  this  people  is  of 
mixed  race,  and  that  distinctive  names  for  at  least  two  stems  are 
1  Grammar  of  Science.    London,  1892. 


INTRODUCTION 


required,  and  so  forth.  Now,  names  are  not  easy  to  attach,  and 
when  attached  are  still  harder  to  get  rid  of;  moreover,  in  the  sup- 
posed instance,  the  name  "Mongolian"  would,  during  its  existence,  not 
only  be  defective  as  an  index  of  quality,  but  positively  mischievous  as 
teaching  some  positive  error  —  the  name  "  Basque,"  on  the  other  hand, 
which  conveys  no  ethnological  meaning,  being  in  this  respect  a  better 
one. 

Thus  it  is  in  the  nomenclature  of  disease ;  to  give  pathological 
names  prematurely  may  be  to  teach  error  immediately  and  persistently. 
By  the  illustrations  I  have  used  above,  I  have  indicated  that  pathology 
has  yet  formulated  but  few  series  or  even  large  segments  of  series  of 
ordinary  morbid  phenomena.  Events  and  startling  features  of  the 
greatest  import  to  us  and  to  our  patients  come  before  us  daily,  and 
many  times  a  day,  and  cannot  be  linked  on  to  any  other  groups  with 
which  we  are  familiar. 

Before  permitting  ourselves,  then,  to  fix  names  significant  of  current 
hypotheses  upon  symptom  groups  not  even  half  understood,  may  it  not 
be  well,  imtil  our  knowledge  is  enlarged,  to  wait  and  be  content  with 
some  name  that  is  but  a  label  ?  Nay,  it  is  undesirable  even  in  our 
merely  provisional  and  descriptive  names  to  connote  too  much ;  in  so 
doing  we  may  combine  parts  of  different  series  the  concurrence  of  which 
is  accidental.  Take,  for  example,  the  disease  often  called  exophthalmic 
goitre  ;  this  name,  given  descriptively,  is  bad  because  as  a  descriptive 
name  it  postulates  two  events,  either  of  which  may  be  absent  from  the 
groiip,  while  it  omits  the  cardiac  events  which  are  at  least  of  equal  im- 
portance. Had  a  pathological  name  been  given  matters  would  have  been 
worse  still,  seeing  that  at  least  three  mutually  exclusive  hypotheses  are  on 
foot.  Is  it  not  really  more  scientific  after  all  to  be  satisfied  for  a  time 
with  such  a  name  as  "  Graves'  disease,"  which  sufiiciently  indicates  the 
inconstant  group  of  events  we  have  in  view,  and  commits  us  neither  to 
a  fixed  order  in  the  group  nor  to  any  premature  classification  ?  Every 
physician,  again,  in  his  tractable  moments  will  admit  the  usefulness  of 
such  a  name  as  "  Bright's  disease  "  which,  until  the  pathology  of  kidney 
disease  is  better  understood,  saves  us  from  tossing  on  the  conflicting 
currents  of  interstitial,  of  glomerular,  or  of  tubular  nephritis.  Dr. 
Dickinson,  in  an  article  in  this  work,  has  deliberately  preferred  the 
name  Lardaceous  Disease  as  one  which  in  the  present  state  of  our 
knowledge  commits  us  to  no  ''notiones  temere  a  rebus  abstractse." 

But,  it  is  argued,  these  names  may  confer  an  immortality  on  the 
wrong  man !  Well,  oblivion  blindly  scattereth  her  poppies :  yet  after 
all,  is  this  often  so  ?  These  names  may  occasionally  violate  the  strict 
order  of  priority  in  discovery,  as  do  the  names  of  capes  and  islands  ;  but 
the  man  who  attaches  his  name  to  a  discovery  usually  deserves  it.  If 
the  NcAV  World  had  been  called  after  Columbus,  neither  Sebastian 
Cabot  nor  Amerigo  Vespucci  would  have  had  reason  to  complain. 
Neptune  had  often  been  observed  before  it  Avas  "  discovered " ;  and  a 
recent  writer  happily  said  concerning  Fraunhofer's  lines,  "Wollaston 


SYSTEM  OF  MEDICINE 


saw  them,  but  did  not  discover  them."  There  were  Brights  before 
Bright,  no  doubt ;  but  the  great  Guy's  physician  worked  out  that  which 
previous  observers  had  not  genius  or  energy  enough  to  reveal  to  mankind. 

And,  after  all,  these  names  are,  as  I  have  said,  but  provisional 
tickets,  and  by  no  means  always  dedicatory  —  as  measles,  shingles, 
epilepsy,  and  the  like.  Such  a  label  as  "  Graves'  disease,"  when  it  has 
served  its  temporary  purpose,  will  give  way  to  a  pathological  name 
when  the  series  is  discovered  in  Avhich  this  malady  has  its  place,  and  its 
position  in  that  series  is  plotted  out.  Are  nosologists  so  ignorant,  then, 
that  as  yet  we  can  have  no  scientific  nomenclature  ?  Can  none  of  our 
names  be  an  intellectual  instrument  ?  By  no  means ;  but  we  must  be 
content  to  give  such  instrumental  names  to  the  simpler  diseases,  and 
thence  cautiously  to  the  more  complex,  remembering  that  to  name 
scientifically  a  disease  of  complex  causation  is  to  suppose  that  pathol- 
ogy has  advanced  far  beyond  its  present  stage. 

Meanwhile,  beside  the  ticket  names,  Ave  have  some,  such  as  chorea, 
which,  although  given  in  ignorance  of  the  nature  of  the  malady,  are 
fairly  well  descriptive ;  paralysis  agitans  is  another  good  name  of  the 
kind ;  anatomical  names  also,  such  as  bulbar  palsy,  disseminated  scle- 
rosis, and  the  like,  are  largely  displacing  those  descriptive  of  symptoms 

—  displacing,  I  say,  and  not  superseding,  because  symptoms  will  prob- 
ably hereafter  be  grouped  under  general  and  special  heads  from  a 
clinical  point  of  view,  such  as  modified  movements,  modified  sensations, 
modified  reflexes,  modified  secretions,  and  so  forth.  But  with  all  this 
we  should  fall  short  of  any  indication  of  general  pathological  characters 

—  for  instance,  mischief  in  one  anatomical  seat,  say  in  a  joint,  may  be 
primarily  of  traumatic,  chemical  or  microbic  causation,  and  yet  at  cer- 
tain stages  produce  similar  modifications  of  motion  and  sensation. 
Identical  or  closely  similar  results  may  be  reached  from  distant,  and 
even  widely  different  starting-points ;  and  we  come  back  to  the  conclu- 
sion that  in  respect  of  most  diseases  we  are  ignorant  of  the  series  to 
which  they  belong.  We  can  give  a  clinically  descriptive  name  to  "  gen- 
eral paralysis  " ;  or  we  can  pathologically  call  it  "  chronic  encephalitis," 
but  we  have  not  learned  to  what  series  —  syphilitic  or  other  —  it  be- 
longs ;  and  until  we  know  this  we  cannot  finally  name  it. 

A  name  is  not  complete,  therefore,  unless  it  indicate  the  tissue  ele- 
ments primarily  engaged,  and  the  series  of  which  the  affection  forms  a 
part.  But  the  subject  is  far  too  extensive  and  various,  and  our  knowl- 
edge too  small  to  make  it  profitable  to  pursue  the  matter  further  in  this 
place;  indeed  it  cannot  be  fully  discussed  without  a  survey  of  that 
field  of  comparative  nosology  —  of  the  symptoms  and  the  causes  of 
them  in  all  organised  beings — the  exploration  of  which  is  scarcely  yet 
begun,  unless  it  be  in  respect  of  certain  diseases  of  animals  and  plants 
which  interfere  with  our  industries.  Pathology  itself  remains  in 
much  the  same  merely  "  anthropocentric "  and  descriptive  stage  as 
was  anatomy  fifty  years  ago;  but  its  morphological  stage  is  already 
initiated. 


INTRODUCTION 


Of  our  Terminology  I  have  little  to  say  —  technical  terms  are  more 
fluid  than  names,  and  are  undergoing  continual  modification  as  our  knowl- 
edge increases.  As  Dr.  Kanthack  incidentally  discusses  some  weak 
points  in  our  terminology  in  his  article  on  the  General  Pathology  of  In- 
fection, I  will  not  speak  so  fully  as  I  had  intended  on  this  subject. 
The  improvement  of  our  terminology  is  much  impeded  by  the  loose 
clinical  slang  which  too  many  teachers  allow  their  pupils  not  only  to  use 
at  the  bedside,  but  to  enter  in  their  case-books  also.  Colloquial  vulgar- 
isms, effete  terms  of  logic,  relics  of  humoralism  and  pseudo-scientific 
phrases,  make  up  a  large  part  of  the  language  of  the  wards,  and  so  long 
as  our  teachers  countenance,  and  even  themselves  use  such  slovenly 
language,  so  long  will  students  be  content  with  it.  It  is  but  fair  to  add 
that  Medicine  is  not  a  subject  in  which  terminology  and  nomenclature 
find  their  best  exemplification :  the  matters  of  our  inquiry,  not  having 
relatively  fixed  specific  characters,  do  not  lend  themselves  as  yet  to  the 
construction  of  an  appropriate  terminology.  If,  for  instance,  we  seek 
to  afiix  a  constant  termination,  such  as  "  itis,"  to  signify  all  kinds  of  in- 
flammation, we  are  met  by  the  inconstancy  of  the  meaning  of  the  term 
"  inflammation,"  and  by  its  possible  confusion  with  the  encroachments 
of  competing  tissues  and  with  acute  degenerations.  We  cannot  yet  say 
when  fibrosis  is  "  inflammatory  "  in  origin,  or  when,  on  the  other  hand, 
it  may  be  relatively  atrophic,  for  we  are  also  uncertain  in  our  use  of  the 
terms  atrophy  or  hypertrophy.  Still  there  is  no  reason  why  in  the  near 
future  these  terms  should  not  be  better  defined.  I  am  not  without  hope 
that  the  work  of  Professor  Adami  and  Dr.  Mott  in  this  volume  may  go 
far  to  help  us  on  our  way. 

To  illustrate  at  length  the  looseness  of  our  terms,  and  the  errors 
which  arise  from  the  equivocal  use  of  any  of  them,  were  an  undertaking 
far  beyond  the  space  at  my  disposal.  The  student  finds  his  notorious 
security  in  terms,^  because  he  has  not  learned  that  one  term  does  not 
always  carry  one  and  the  same  meaning.  As  Mr.  Grote  has  said, 
no  part  of  the  Platonic  writings  is  more  useful  than  those  Dialogues  in 
which  the  disputant  is  forced  to  feel  how  imperfectly  he  understands 
the  phrases  in  common  use.  But  it  was  reserved  for  Aristotle  to 
recognise  "equivocal  terms"  as  a  class,  and  to  assign  to  them  a  par- 
ticular name.  Until  we  are  at  one  in  our  use  of  terms  we  cannot 
formulate  propositions  as  true  or  false ;  we  cannot,  that  is,  combine  our 
terms  as  subject  and  predicate.  As  was  said  of  another  matter,  medi- 
cal discourse  and  medical  literature  are  '^  pervaded  by  assumptions  "  :  I 
would  therefore  earnestly  appeal  to  all  bedside  teachers  to  comjjel  their 
pupils  to  look  every  term  well  over  as  it  comes  to  them  ;  to  scrutinise 
it  obversely,  reversely  and  edgewise  before  using  it  as  currency.  As 
things  a.re,  candidates  for  degrees  use  arguments  based  upon  equivocal 
terms,  shelter  themselves  under  phrases  which  save  them  the  trouble  of 

1  Need  I  quote  from  Faust  the  well-known  lines?  — 
"  Denn  eben  wo  Begriffe  fehlen 
Da  stellt  ein  Wort  zu  rechten  Zeit  sich  ein." 


SYSTEM  OF  MEDICINE 


thought;  and  are  disposed  to  feel  as  injured  as  Tlirasymachus  if  these 
current  phrases  are  chaileuged. 

I  have  spoken  of  the  causation  of  disease ;  I  have  shown  that  diag- 
nosis is  the  practical  aspect  of  classification  ;  I  will  now  conclude  with 
a  few  words  on  Prognosis. 

A  living  being  is  found  in  a  given  abnormal  state  (diagnosis)  ;  we 
have  then  to  find  how  this  came  about  (aetiology)  ;  and,  thirdly,  we  have 
to  foretell  the  state  in  which  the  creature  will  be  at  a  given  future  time. 
Such  forecasts  are  already  possible  when  we  deal  with  large  numbers. 
If  we  wish  to  know  the  mean  duration  of  life  in  a  young  man  of  twenty 
years  of  age  w^e  have  tables  at  hand  which  will  inform  us ;  if  any  par- 
ticular young  man  be  associated  with  a  sufficiently  large  number  of 
others  like  himself,  we  can  deal  with  him  on  a  definite  "curve  of 
frequency." 

But  when  a  particular  patient  comes  to  a  phj^sician  he  is  not  satisfied 
to  know  the  mean  expectation  of  a  thousand  sufferers  in  his  case,  but 
he  will  insist  upon  knowing  the  future  part  of  the  curve  of  his  own  in- 
dividual phases.  If  he  present  himself  before  a  physician  of  large 
experience  he  Avill  get  some  such  estimate  —  an  estimate  fallible,  it  is 
true,  but  in  many  cases  having  sufficient  probability  to  justify  the 
patient  in  laying  out  his  plans  for  the  future  with  some  confidence. 

Now,  how  is  this  attained  ?  Let  us  go  a  step  farther,  and  consider 
a  sub-class  of  the  young  men  aged  twenty,  namely,  young  Englishmen; 
w^e  may  still  find  statistics  for  this  purpose,  and  give  an  estimate  of  the 
mean  duration  of  life  in  this  sub-class.  Suppose  that  we  go  a  step  far- 
ther still,  and  construct  a  class  still  more  subordiiuite,  namely,  of  young 
medical  students,  or  of  young  medical  students  in  a  certain  university, 
or  of  young  medical  students  classed  as  students,  oarsmen,  or  cricketers, 
and  we  may  still  find  something  like  statistics  to  guide  us.  But  in  thus 
subdividing  our  classes,  we  shall  soon  arrive  at  sub-classes  for  which 
registered  statistics  are  no  longer  available  —  the  numbers  are  too  few, 
the  cases  too  special,  or  they  have  not  been  tabulated.  Thus  we 
approach  the  prognosis  of  individual  cases,  and  rely  more  and  more 
upon  the  quality  of  the  observer.  In  discussing  this  matter  with  Dr. 
Venn,  it  appeared  to  us,  nevertheless,  that  the  method  is  still  one  of  sta^- 
tistics  —  one  of  conscious  or  unconscious  abstraction,  based  npon  numeri- 
cal summary.  The  accumulated  experience,  although  not  formulated, 
is  nevertheless  an  accumulation  of  records  of  cases  —  cases  recorded 
imperfectly,  it  may  be,  but  written  upon  the  memory  of  a  skilled 
observer,  and  of  these  the  observer  more  or  less  automatically  strikes  a 
mean  when  called  upon  to  estimate  the  expectation  of  a  given  life,  or 
of  particular  events  in  the  life.  The  observer  may  rely  more  upon  his 
note-books,  and  make  a  calculation  dependent  upon  their  fulness  and 
accuracy;  or  he  may  rely  rather  upon  an  acquired  instinct  bred  of 
accumulated  impressions  upon  his  senses,  and  dependent  upon  the 
tenacity  of  his  memory  and  the  quickness  of  his  observing  faculties: 
still  in  either  case  —  whether  the  judgment  be  more  automatic  or  less 


INTRODUCTION 


automatic  —  it  is  based,  in  the  last  analysis,  upon  statistics,  and  the 
result  has  the  more  validity  as  the  number  of  observed  cases  increases. 
Again,  this  acquired  judgment  does  not  wholly  die  with  the  indi- 
vidual.^ The  instructed  observer  formulates  certain  middle  axioms 
which  he  illustrates  at  the  bedside  before  his  pupils :  using  these  with 
discrimination,  his  pupils  revise,  confirm  or  modify  them;  and  thus 
something  like  a  body  of  quasi-statistical  knowledge  is  handed  down 
from  generation  to  generation.  As  observation  becomes  more  accurate, 
as  the  number  of  observed  cases  increases,  and  as  classes  are  better 
and  better  distinguished,  the  nearer  will  the  physician  be  able  to 
approach  an  accurate  prognosis  —  though  the  time  when  any  suffi- 
cient rule  can  be  applied  to  individual  cases  must  long  be  out  of  our 
sight ;  and  the  application  of  any  approximate  rules  must  long  be  sub- 
ordinate to  the  instinctive  tact  of  the  educated  physician  himself,  who 
alone  can  apprehend  the  sum  of  the  peculiarities  which  must  modify 
their  application  to  individual  instances.  Like  the  so-called  cumulative 
photographic  image  which  results  from  the  blending  of  many  superposed 
faces  of  the  same  kind,  there  grow  up  before  the  mind's  eye  of  the  edu- 
cated physician,  images  of  this  morbid  facies,  and  of  that,  to  which  he 
refers  individual  instances ;  and  he  pronounces  his  opinion  of  the  state 
and  probable  future  phases  of  individuals  as  these  severally  vary  this 
way  or  that  from  the  standards  within  himself. 

T.    CLIFFOED   ALLBUTT. 

1  Dr.  Venn  writes  to  me  on  this  passage  as  follows :  —  "I  think  this  is  very  important. 
I  have  often  been  struck  by  the  way  in  which  an  apparently  subjective  judgment  can 
be  perpetuated,  as  an  almost  objective  standard,  within  some  specially  trained  class  of 
persons,  who  are  in  frequent  communication. 


In  order  to  avoid  frequent  interruption  of  the  text,  the  Editor  has  only  inserted 
the  numbers  indicative  of  items  in  the  lists  of  "  References  "  in  cases  of  emphasis, 
where  two  or  more  references  to  one  author  are  in  the  list,  where  an  author  is  quoted 
from  a  work  published  under  another  name,  or  ichere  an  authoritative  statement  is 
made  loithout  mention  of  the  author's  na<ne.  In  ordinary  cases  an  author's  name  is 
a  sufficient  indication  of  the  corresponding  item  in  the  list. 


DIVISION   I 

PROLEGOMENA 


VOL.    I 


MEDICAL   STATISTICS 

In  this  paper  the  term  "Medical  Statistics"  includes  statistics  of  dis- 
eases in  their  relations  to  etiology,  symptomatology  and  results,  as 
derived  from  comparisons  of  records  of  cases  of  such  diseases.  It  will 
also  be  necessary  to  consider  some  of  the  results  of  mortality  statistics, 
derived  from  a  comparison  of  the  number  of  deaths  in  a  given  time  with 
the  number  of  people  among  whom  such  deaths  occurred ;  and  of  mor- 
bidity statistics,  derived  in  like  manner  from  comparisons  of  the  num- 
ber of  cases  of  disease  occurring  in  a  given  population  in  a  given  time ; 
in  a  broad  sense,  the  term  medical  statistics  no  doubt  includes  both 
mortality  and  morbidity  records. 

The  essential  difference  between  the  methods  of  medical  statistics 
and  those  used  by  the  vital  statistician  is  that  the  former  have  usually 
no  reference  to  population  data.  The  medical  statistician  inquires  how 
many  cases  of  pneumonia,  or  of  consumption,  or  of  Bright's  disease  have 
been  under  observation ;  what  proportion  of  these  have  been  of  certain 
ages,  or  races,  or  occupations;  and  what  proportion  have  recovered  or 
died  under  certain  modes  of  treatment :  but,  as  a  rule,  he  has  no  data  to 
show  the  number  of  cases  of  pneumonia  occurring  among  a  given  num- 
ber of  people  who  are  between  forty-five  and  sixty-five  years  of  age,  he 
cannot  therefore  deal  with  ratios  to  population,  which  are  the  basis  of 
most  of  the  work  of  the  vital  statistician,  who  would  inquire  as  to  the 
relative  probabilities  that  an  Irish  male  between  forty-five  and  sixty-five 
will  have  pneumonia  as  compared  with  a  German  male  of  the  same  age 
group ;  or  that  a  plumber  between  twent}''  and  forty  years  old  will  con- 
tract pulmonary  phthisis  as  compared  with  a  carpenter  of  the  same  age. 

The  physician  finds  from  hospital  records  that  in  each  1000  cases  of 
cancer  in  males  a  greater  number  occur  in  persons  between  the  ages  of 
fifty-five  and  sixty-five  than  in  any  other  age  group ;  while  the  vital 
statistician,  from  the  records  of  deaths,  finds  that  the  mortality  from 
cancer  steadily  increases  with  advancing  years  up  to  the  age  of  ninety, 
and  concludes  that  the  reason  why  there  are  few  cases  of  cancer  in 
people  seventy-five  years  of  age  and  upward  is  simply  because  there 
are  comparatively  few  people  of  that  age.     In  the   tabulation  of  the 


SYSTEM   OF  MEDICINE 


returns  of  cases  of  acute  rheumatism  in  the  Collective  Investigation 
Record  it  is  shown  that  of  the  655  cases  recorded  71  were  in  domestic 
servants,  16  in  agricultural  labourers,  10  in  grocers,  etc.,  and  the  con- 
clusion is  drawn  that  domestic  servants  are  especially  liable  to  rheumar- 
tism,  and  that  this  may  be  due  to  their  greater  use  of  alcoholic  drinks. 

Such  a  conclusion  has  no  basis  in  the  figures,  because  we  know  noth- 
ing of  the  proportion  of  domestic  servants  attended  by  the  physicians 
who  made  the  reports,  to  the  total  number  of  these  servants  in,  exist- 
ence, or  to  the  number  of  servants  who  had  rheumatism.  The  utility 
of  medical  statistics  has  not  been  so  great  as  was  hoped  by  Louis  and 
others.  As  applied  to  the  study  of  a  disease  it  is  necessary  that  the  dif- 
ferent observers  who  furnish  the  records  shall  be  referring  to  substan- 
tially the  same  disorder  of  structure  or  function  —  that  is,  there  must  be 
a  tolerably  definite  series  of  symptoms,  such  as  occur  in  specific  diseases 
and  acute  affections  of  particular  organs.  The  statistical  method  is 
most  applicable,  and  has  proved  most  useful  in  surgical  cases.  With 
improved  methods  of  diagnosis,  the  possible  utilities  of  medical  statis- 
tics are  becoming  greater ;  evidently  little  could  be  done  with  statistics 
of  fevers  before  the  differences  between  typhus,  enteric  and  relapsing 
fevers  were  known ;  but,  on  the  other  hand,  when  we  have  discovered  by 
experiment  that  a  given  result  must  follow  a  given  cause,  a  few  repe- 
titions of  such  experiments  give  as  great  a  degree  of  certainty  as  would 
several  thousand.  Statistics  are  useless  to  prove  that  chalk  will  be  de- 
composed by  sulphuric  acid,  and  they  are  now  of  little  value  in  discussing 
whether  tuberculosis  be  caused  by  a  particular  form  of  bacillus  ;  but  they 
are  the  only  means  yet  available  for  determining  the  varying  degrees  of 
immunity  against  this  bacillus  possessed  by  different  races. 

The  causative  influence  of  a  given  condition  upon  the  results  of  a  dis- 
ease can  only  be  calculated  approximately,  because  we  can  never  be  sure 
that  the  sum  of  all  other  conditions  which  might  influence  the  result  re- 
mains the  same  in  the  different  cases  investigated;  but  much  may  be 
done  to  estimate  the  effects  of  the  different  conditions  of  the  living  body 
and  of  its  environment  upon  disease,  provided  that  we  can  obtain  a  suf- 
ficient amount  of  data  to  enable  us  to  come  within  the  limits  of  the  law 
of  probable  error.  This  matter  of  the  probable  or  possible  error  of 
ratios  in  relation  to  the  magnitude  of  the  figures  from  which  they  are 
derived  should  be  kept  in  mind  in  the  use  of  medical  statistics.  The 
most  convenient  method  to  estimate  it  is  by  what  is  known  as  "Pois- 
son's  formula,"  as  follows  :  — 

:  possible  variation  in  proportion  of  m  to  q. 
q  ■*    g" 

q  =  total  number  of  events. 

m  =  number  in  one  group. 

n  =  number  in  the  other  group,  so  that  m  -\-  n  =  q. 

For  example,  suppose  that  in  1000  cases  of  typhoid  fever  in  whites 


MEDICAL   STATISTICS 


100  die,  while  in  1000  cases  of  the  same  disease  in  negroes  95  die,  what 
is  the  probability  of  the  conclusion  that  this  disease  is  less  fatal  in 
negroes  than  in  whites  ? 

By   the    formula  — For   the    whites,    ^  =  1000,    m  =  100,   w  =  900, 

and  the  possible  variation  in  the  ratio or  0-1  is  plus  or  minus 

_J___  1000  ^ 


X'rOOOliooliOO^  '^^*^^'  ^^  ^^^^^  *^®  death-rate  might  be  from  0-1268 
to  0-0732,  i.e.  from  127  to  73  per  1000.     By  the  formula—  For  the  negroes 

the  possible  variations  in  the  ratio -^  is  2  a/ — -^^"^'^^^ — =  -0262, 

1000  v  1,000,000,000  ' 

so  that  it  might  be  either  0-1212  or  0-0687,  i.e.  from  121  to  69  per 
1000. 

The  figures  are  therefore  too  small  to  answer  the  question  definitely 
as  to  influence  of  race.  But  if  of  1,000,000  cases  in  whites  100,000 
die,  and  of  a  similar  number  in  negroes  95,000  die,  then  the  probable 
error  for  the  whites  becomes  +  or  — -000424  —  or  from  100-424  to 
99-576  per  million  die — ^and  the  probable  error  for  the  coloured  becomes 
+  or  -  -000414,  or  from  95-414  to  94-586  per  million  die. 

Stating  these  in  the  usual  form  of  ratios  per  1000,  it  would  be  that 
among  the  whites  the  death-rate  is  between  99-58  and  100-42,  and 
among  the  coloured  between  94-59  and  95-41  per  1000,  indicating  a 
definite  and  positive  difference  between  the  death-rates  of  the  two  races. 

A  special  application  of  this  law  of  possible  error  in  connection  with 
the  length  of  time  covered  by  the  data  should  be  borne  in  mind  in  com- 
paring medical  and  vital  statistics.  The  death-rates  of  a  city  of  10,000 
inhabitants  for  ten  successive  years  are  much  more  indicative  of  the 
relative  healthfulness  of  the  place  than  is  the  death-rate  of  a  city  of 
100,000  inhabitants  for  a  single  year,  because  the  death-rate  for  a  single 
year  may  be  greatly  influenced  by  epidemics  and  by  meteorological 
peculiarities. 

The  following  table  and  diagram  show  the  relative  magnitude  of  the 
death-rates  in  New  York,  Brooklyn,  Boston,  Philadelphia,  and  Baltimore 
in  each  of  the  sixteen  years  from  1875  to  1890  inclusive :  — 


[Table 


SYSTEM  OF  MEDICINE 


Tear. 


1875 
1876 
1877 
1878 
1879 
1880 
1881 
1882 
1883 
1884 
1885 
1886 
1887 
1888 
1889 
1890 


28-8 
26-6 
23-3 
23-5 
24-0 
26-4 
31-3 
30-0 
26-3 
26-5 
26-3 
27-0 
27-5 
27-7 
26-7 
26-4 


26-3 
25-1 
22-3 
21-0 
21-1 
23-3 
24-7 
24-6 
21-8 
21-6 
22-7 
22-5 
23-5 
24-0 
23-7 
24-5 


Boston. 


30-0 
26-3 
22-5 
22-6 
21-1 
23-5 
24-3 
23-7 
25-1 
24-3 
23-8 
22-4 
23-9 
23-7 
23-3 
23-7 


Philadelphia. 


23-5 
24-4 

20-2 
19-4 
18-6 
20-9 
22-5 
22-7 
22-2 
21-6 
22-7 
20-8 
22-1 
20-3 
20-0 
20-7 


Baltimore. 


24-5 
24-2 
25-4 
21-1 
23-4 
24-2 
25-8 
25-4 
26-0 
22-4 
21-4 
21-3 
20-8 
21-7 
20-5 
23-4 


Bate 

Years 

1875 

187G 

1877 

1878 

1879 

1880 

1881 

1882 

1883 

1884 

31 

K 

30 

/ 

\ 

29 

\ 

/ 

\ 

28 

^ 

1 

\ 

I 

27 

\ 

\^ 

/ 

\ 

26 

\ 

/ 

V- 

— 

25 

^ 

A 

/ 

\ 

24 

-^- 

.-^V 

/ 

/ 
/ 
/ 

y 

/"^ 

^ 

23 

y 

\  ^ 

\  \\      _v 

// 

^ 

V 

\ 
\ 
\ 

22 

\ 

\  \ — ■ 

\^. 

/ 
/ 

// 
// 
// 

/" 

~~--- 

\ 
-A 

\ 
V 

2J 

V 

^-■^ 

20 

\ 
\ 

•v.. 

/ 
/ 
/ 

19 

/ 
/ 

18 

'^./' 

New  York 


Boston 


Baltimore Philadelphia 


Brooklyn 


MEDICAL   STATISTICS 


It  will  be  seen  from  this  table  that  in  all  these  cities  the  death-rates 
fell  from  1875  to  1878-79,  then  rose  until  1881-82,  a.nd  then  again 
declined.  The  influence  which  produced  these  great  variations  could 
not  have  been  a  local  one. 

What  is  the  normal  sickness  rate  of  a  people  ?  That  is  to  say,  in  a 
general  population  of  100,000,  how  many  are  constantly  sick  to  snch  a 
degree  as  to  require  medical  attendance,  or  to  be  incapacitated  from 
pursuing  their  ordinary  avocations  ?  The  only  sources  to  which  we  can 
look  for  the  answer  to  this  question  are  the  records  of  the  army  and 
navy  in  different  countries,  of  certain  benefit  societies  providing  insur- 
ance against  sickness,  of  the  police  force  in  certain  cities,  of  employees  of 
railroads,  and  of  the  last  censuses  of  Ireland,  of  the  Australian  colonies, 
and  of  the  United  States. 

The  following  table  shows  for  various  armies  the  number  of  admis- 
sions to  treatment  for  sickness  and  injury  per  1000  of  mean  strength  in 
a  year,  the  number  constantly  sick,  the  average  number  of  sick  days  to 
each  soldier,  and  the  average  duration  of  each  case  of  sickness :  — 


In  1000  mean  strencth. 

Sick  Days  to 

Averagre 

Armies. 

Periods. 

eacii  Soldier 

Duration  of 

of  mean 

each  case  of 

Admissions. 

Constantly 
sick. 

strength. 

Sickness. 

Belgian  army . 

1880-89 

1407 

28-3 

10-3 

7-3 

Prussian  army 

1883-89 

830 

30-8 

112 

129 

Italian  army  . 

1878-91 

853 

34-7 

12-6 

15-7 

Dutcli  army    . 

1881-89 

906 

37-0 

13-5 

14-1 

United  States  (white)    . 

1881-90 

1337 

43-3 

15-8 

11-0 

Austrian  army 

1879-89 

1185 

45  3 

16-5 

13-4 

British  army  at  home     . 

1881-90 

820 

46-0 

16-7 

20-4 

French  army  . 

1875-84 

2476 

46-8 

17-1 

6-9 

Britisli  in  India 

1881-90 

1458 

730 

26  6 

18-2 

Coloured  Troops. 

United  States  (coloured) 

1881-90 

1577 

44-3 

16-2 

100 

British  troops  (coloured 

in  North  India)    . 

1881-90 

1035 

51-1 

18-6 

18  0 

British  troops  (coloured 

in  North  Africa) . 

1881-90 

1736 

76-5 

27-9 

17-0 

Prom  this  table  it  will  be  seen  that  of  each  1000  soldiers  serving  in 
temperate  climates  about  35  are  constantly  sick,  the  figures  varying  from 
28-3  in  the  Belgian  army  to  46-8  in  the  French  army.  It  must  be 
remembered,  however,  that  these  figures  relate  only  to  males  of  certain 
groups  of  ages,  and  of  a  carefully  selected  class  of  population,  but  of  a  class 
much  more  apt  to  claim  exemption  from  duty  on  account  of  sickness 
than  would  be  the  males  of  corresponding  ages  in  the  general  population. 
Taking  the  male  members  of  friendly  societies  from  the  age  of  fifteen  to 
eighty-five,  Mr.  Finlayson  found  that  about  five  years  of  sickness  occurs 
to  each  man  during  those  seventy  years ;  but  the  sickness  occurring  in 


SYSTEM   OF  MEDICINE 


men  from  forty-two  to  sixty-six  years  of  age  is  almost  double  the  sickness 
occurring  in  men  from  fifteen  to  forty-one  years  of  age.  From  the  com- 
mencement of  the  sixteenth  year  of  age  to  the  close  of  the  sixty-sixth  the 
amount  of  sickness  averages  about  one  and  a  half  weeks  per  man.  (See 
Insurance  Cydopcedia,  vol.  v.  p.  83.) 

In  the  "  Hearts  of  Oak  Benefit  Society,"  Mr.  Ralph  Hardy  reports 
(Journal  of  the  Institute  of  Actuaries,  January  1894,  p.  86)  that  from  1884 
to  1891  the  total  number  of  members  was  940,224,  of  whom  7853  died, 
and  238,787  were  claimants  on  account  of  sickness  or  disability. 

The  following  table  shows  for  each  of  certain  groups  of  ages  the 
number  exposed  to  risk,  the  number  of  weeks  of  actual  sickness  or  dis- 
ability for  which  claims  were  made,  and  the  number  of  weeks  of  sickness 
or  disability  per  member  in  each  group  :  — 


Number  Weeks 

Ages. 

Number  exposed 

Number  Weeks 

Sickness 

to  Kisk. 

actual  Sickness. 

per  Member  in 

each  group. 

19 

2,007 

3,241 

•68 

20-24 

68,637 

69,370 

•75 

25-29 

178,275 

164,740 

•81 

30-34 

235,268 

249,700 

•92 

35-39 

189,502 

261,428 

106 

40-44 

135,164 

239,682 

1-28 

45-49 

75,441 

168,242 

1-65 

50-54 

29,567 

93,373 

2-20 

55-59 

14,054 

67,679 

3-13 

60-64 

7,712 

60,926 

4-74 

65-69 

3,418 

49,278 

7^34 

70-74 

1,001 

20,448 

11-50 

75-79 

169 

3,817 

1619  • 

80 

9 

181 

52  00 

All  ages. 

940,224 

1,452,106 

It  will  be  seen  from  this  table  that  for  those  under  forty  years  of 
age  there  was  less  than  one  week's  sickness  in  each  year,  and  that  after 
this  age  the  amount  of  sickness  nearly  doubled  every  ten  years. 

The  following  table  gives  the  results  observed  in  311  Italian  mutual 
benefit  societies  as  regards  the  sickness  occurring  among  254,193  males. 
{Annali  cli  Statistica,  Tavole  della  frequenza  e  durata  delle  Malattie,  etc. 
Roma,  1892) :  — 


[Table 


MEDICAL   STATISTICS 


Ages. 

Number  taken 

sick  yearly  per 

lOUO  of  Number 

observed. 

Number  of 
cases  of  Sick- 
ness in  a  year 
per lUOU  of 
Number 
observed. 

Number  of 
days'  Sickness 

to  each 

Member  in  a 

year. 

Number  of 

days'  Sickness 

to  each  sick 

Person  in  a 

year. 

Average 

Duration  of 

each  Sickness 

in  days. 

10-15 

191 

235 

3-9 

20-3 

16-5 

15-20 

234 

276 

4-9 

20-9 

17-7 

20-25 

213 

251 

5-0 

23-2 

19-8 

25-30 

229 

266 

5-4 

23-6 

20-3 

30-35 

223 

256 

5-1 

23-0 

20-6 

35-40 

240 

278 

6-0 

24-8 

21-4 

40-45 

232 

273 

6-2 

26-7 

22-7 

45-50 

253 

289 

6'8 

270 

23-7 

50-55 

258 

304 

7-9 

30-7 

26-1 

55-60 

275 

328 

9-2 

33-7 

28-2 

60-65 

299 

361 

11-2 

37-3 

309 

65-70 

322 

404 

13-4 

39-9 

33-4 

70-75 

344 

397 

14-7 

43-0 

37-2 

75-80 

286 

337 

13-4 

41-1 

39-9 

Ave.  over  10 

242 

283 

^■Q 

27-1 

23-2 

The  following  table  shows  the  number  of  sick  and  of  those  suffering 
from  accidents,  per  1000  of  population,  in  certain  sta.tes  and  countries, 
as  found  in  recent  censuses  :  — 


In  1000  Population. 

states  and  Countries. 

Diseases. 

Accidents. 

Maine 

1890 

12-93 

•84 

Connecticut         .... 

1890 

15-23 

-97 

Massachusetts     .... 

1890 

12-31 

•93 

New  Hampshire  .... 

1890 

22-09 

2-41 

Ehode  Island       .... 

1890 

18-36 

1-04 

Vermont 

1890 

28-98 

1-66 

Virginia       .."... 

1890 

16-69 

2-06 

Alabama 

1890 

15-08 

1-36 

District  of  Columbia  . 

1890 

17-08 

1-56 

Delaware 

1890 

13-18 

1-45 

Victoria 

1890 

11-36 

1-97 

South  Australia  .... 

1890 

10-98 

1-46 

New  South  Wales 

1890 

9-00 

1-34 

Tasmania 

1890 

8-00 

1-29 

New  Zealand       .... 

1890 

7-81 

123 

Queensland          .... 

1890 

7-51 

1-21 

Western  Australia 

1890 

4-85 

1-03 

Ireland 

1891 

712 

•47 

SYSTEM  OF  MEDICINE 


Including  women  and  children,  it  is  probable  that  for  each  1000  of 
population  under  ordinary  circumstances,  400  are  taken  sick  or  laid  up 
by  accidents  during  the  year,  and  that  about  thirty  are  constantly  sick, 
the  average  duration  of  illness  being  about  four  weeks. 

It  is  usually  estimated  that  for  every  case  of  death  in  a  community 
there  are  two  persons  constantly  sick  —  that  is  to  say,  there  is  an  aver- 
age of  two  years'  sickness  to  each  death ;  or  with  an  annual  death-rate 
of  18  per  1000,  the  average  number  constantly  sick  is  about  thirty-six 
per  1000 :  but  this  estimate  is  probably  somewha.t  in  excess  of  the  true 
hgures  under  ordinary  circumstances,  and  it  should  be  distinctly  under- 
stood that  it  does  not  apply  to  individual  diseases,  but  only  to  the  whole 
mass  of  diseases  and  injuries.  The  proportion  of  "cases  constantly 
sick  "  to  "  deaths  "  is  very  different  for  consumption,  diabetes  and  can- 
cer, from  that  which  exists  in  diphtheria,  typhoid  fever  and  tetanus. 
The  sickness  ratios  derivable  from  the  data  of  those  censuses  in  which 
an  attempt  has  been  made  to  enumerate  all  the  sick  living  on  the  day  of 
the  census  are  evidently  too  small;  but  it  is  probable  that  they  repre- 
sent very  fairly  the  different  proportions  of  sickness  existing  in  males 
and  females  of  certain  groups  of  ages.  According  to  the  census  of  1880 
in  the  United  States,  the  proportion  of  sick  to  1000  of  population  of 
different  ages  was  as  follows :  — 


Age. 

Males. 

Females. 

15  to  25 

69 

6-8 

25  to  35 

8-6 

9-7 

35  to  45 

12-2 

11-5 

45  to  55 

16-8 

14-4 

55  to  65 

25-5 

20-4 

65  and  over 

44-5 

35-3 

In  the  state  of  Massachusetts  on  1st  June  1890  out  of  a  total  popu- 
lation of  2,238,9-43  there  were  reported  41,512  sick  and  defective,  of 
whom  25,490  were  males  and  16,022  females,  giving  a  ratio  of  23*44 
for  males  and  23-46  for  females  per  1000  of  population. 

The  ratio  per  1000  at  different  age  groups  was  as  follows  :  — 


Ages. 

Males. 

Females. 

15  to  25 

9-74 

6-90 

25  to  35 

12-38 

8-84 

35  to  45 

21-80 

13  11 

45  to  55 

57-14 

21-76 

55  to  65 

71-17 

3419 

65  and  over 

9641 

60-84 

MEDICAL   STATISTICS 


In  each  1000  of  the  total  sick  and  defective  there  were  as  follows :  — 


Male. 

Female. 

Total  of  all  diseases 

623-9 

719-6 

Rheumatism 

176-8 

176-2 

Consumption 

34-5 

51-3 

Cancer  and  tumours  . 

9-0 

36-9 

Nervous  system . 

37-8 

80-7 

Circulatory  system     . 

56-8 

70-7 

Urinary  organs  . 

48-4 

22-4 

Bones  and  joints 

42-1 

64-8 

Total  deformed,  ex.  spine 

23-4 

18-6 

Total  lost  arms  . 

30-6 

3-8 

Total  lost  legs    . 

313 

6-4 

Total  lame 

105-6 

84-0 

Accidents  and  injuries 

77-9 

29-3 

Paralysed  . 

82-2 

101-2 

There  are  no  figures  available  as  to  the  amount  of  sickness  among 
children,  but  it  is  probably  much  greater  among  them  than  in  adult  life, 
corresponding  generally  to  the  greater  mortality  of  the  earlier  years  of 
life. 

It  is  not  probable  that  anything  like  complete  returns  of  sickness  will 
be  obtained  in  the  near  future  for  any  large  body  of  the  general  popula- 
tion. The  registration  of  diseases  will  be  confined  to  infectious  and 
spreading  diseases  —  that  is  to  say,  to  diseases  which  are  known  or 
supposed  to  be  preventable  —  and  the  more  unusual  the  disease  the  more 
likely  is  the  registration  to  be  complete.  In  England  and  the  United 
States,  nearly  all  cases  of  Asiatic  cholera,  small-pox  and  yellow  fever  will 
be  registered,  while  the  registration  will  ahvays  be  defective  for  such 
diseases  as  measles,  scarlet  fever,  diphtheria  and  typhoid  fever.  The 
only  means  then  at  our  command  for  calculating  the  number  of  cases  of  a 
given  disease,  occurring  in  a  given  community  during  a  given  time,  is  by 
taking  the  number  of  deaths  reported  as  due  to  that  disease,  and  multiply- 
ing this  by  the  ratio  of  deaths  to  cases,  a  ratio  obtained  from  hospital 
and  other  medical  records,  being  what  is  called  the  "  case  mortality." 
This  method  contains  many  sources  of  error.  Many  forms  of  disease 
which  render  life  more  or  less  of  a  burden  seldom  or  never  appear  in 
the  registration  records  as  a  cause  of  death ;  while  even  of  those  diseases 
which  are  reported  as  the  cause  of  a  considerable  proportion  of  deaths, 
it  is  usually  impossible  to  establish  any  definite  and  certain  relation 
between  the  number  of  cases  of  the  disease  and  the  number  of  deaths 
reported  even  for  the  acute  specific  diseases,  such  as  scarlet  fever, 
measles,  yellow  fever,  etc.  The  mortality  varies  greatly  in  different 
epidemics,  such  variations  appearing  to  depend  partly  upon  particular 
conditions  of  the  specific  micro-organisms  to  which  such  diseases  are 
generally  attributed,  and  partly  upon  particular  conditions  of  the  people, 


SYSTEM  OF  MEDICINE 


and  the  environment  as  to  race,  density  of  population,  temperature, 
moisture,  etc.  For  example,  in  1867  yellow  fever  entered  the  United 
States  by  two  distinct  routes  —  one  from  Vera  Cruz,  and  the  other  direct 
from  Havana.  At  that  time  the  United  States  had  troops  along  the 
southern  border  of  the  country,  and  hence  we  have  a  series  of  returns 
showing  both  the  number  of  deaths  and  the  cases  of  sickness  from  this 
disease  in  a  given  population.  Now  in  those  places  where  the  disease 
was  of  Mexican  origin,  the  cases  were  more  fatal  than  in  those  where  it 
was  of  Cuban  origin ;  the  ratio  of  deaths  being  400  per  1000  cases  for 
the  first  of  those  groups,  and  284  for  the  second.^ 

The  statistics  of  diseases  with  reference  to  their  etiology,  using  this 
term  in  its  widest  sense,  have  attracted  much  attention  within  the  last 
fifty  years,  but  the  data  have  been  derived  mainly  from  mortality 
statistics.  The  immediate,  or  so-called  efficient  causes  of  disease  are 
physical  or  chemical  agents,  micro-organisms,  or  sensory  impressions 
leading  to  disordered  brain  action ;  but  these  agencies  produce  different 
effects  in  different  persons.  The  same  exposure  to  cold  may  give  rise  in 
one  man  to  eoryza,  in  another  to  pneumonia,  in  a  third  to  rheumatism, 
in  a  fourth  to  diarrhoea,  and  in  fifty  others  to  no  apparent  disturbance 
whatever.  The  hsematozoon  of  malaria,  the  bacillus  of  tubercle,  or  the 
bacillus  lanceolatus,  produce  their  specific  effects  in  some  people  but  not  ■ 
in  others. 

If  the  axiom  that  "  like  causes,  under  like  circumstances,  produce 
like  effects,"  be  as  true  for  the  living  human  body  and  all  its  parts 
as  it  is  for  a  laboratory  experiment  in  chemistry  or  physics,  it  follows 
that  the  different  results  as  to  production  of  disease  brought  about  by  the 
same  immediate  cause  must  be  due  to  differences  in  the  circumstances 
—  that  is,  to  differences  in  structure  and  function  of  the  human  beings 
upon  which  they  act. 

These  differences  may  be  inherited  and  innate,  or  connate  without 
being  inherited,  or  acquired  after  birth  ;  and  are  indicated  by  such  words 
as  temperament,  diathesis,  idiosyncrasy,  immunity,  acclimatisation,  etc. 
That  such  differences  exist  is  well  known  to  every  phj-sician,  and  he 
takes  them  into  account  in  diagnosis,  prognosis,  and  in  hygienic  and 
therapeutic  advice.  He  knows,  for  example,  that  delirium  in  specific 
fevers  has  a  very  different  significance  in  certain  families  from  that 
which  it  has  in  others  ;  that  malaria  and  chorea  affect  the  white  more 
than  the  black  or  yellow  races  ;  but  as  yet  we  have  little  definite  scien- 
tific information  as  to  the  relative  effect  and  importance  of  such  circum- 
stances upon  liability  to,  or  effects  of  different  forms  of  disease.  Such 
information  can  only  be  obtained  by  comparing  a  large  number  of  cases 
by  statistical  methods  to  see  if  any  general  laws  can  be  deduced  there- 
from, and  then  studying  individual  cases  or  groups  of  cases  which  form 
an  exception  to  these  laws. 

The  influence  of  age  upon  mortality  is  well  known,  and,  through  the 

1  War  Department,  Surgeon-General's  Office,  Circular  iVo.  1,  p.  xviii. 


MEDICAL   STATISTICS  13 

labours  of  W.  Farr  and  other  vital  statisticians,  it  can  now  be  exjjressed 
in  mathematical  terms,  not  for  any  single  individual  but  for  the  aver- 
age of  a  large  number  of  jDCople,  by  means  of  life  tables.  It  may  be 
summed  up  in  the  law  of  Gompertz,  as  modified  by  Makeham,  namely, 
that  after  the  age  of  puberty  the  vital  power  of  the  organism,  or  the 
sum  of  its  powers  to  resist  death,  diminishes  by  a  series  consisting  of 
the  sum  of  two  terms,  one  of  which  is  a  constant  quantity,  while  the 
other  increases  in  geometrical  progression. 

It  is  evident  that  the  same  law  must  apply  to  a  considerable  extent 
to  sickness,  and  we  have  shown  above  that  sickness  rates  vary  with  age 
very  much  as  mortality  rates  do.  The  dominating  influence  of  age 
upon  sickness  and  mortality  is  usually  not  sufficiently  appreciated  by 
medical  men  who  prepare  and  publish  statistical  records  of  hospitals  or 
dispensaries.  It  is  hardly  possible  to  draw  useful  conclusions  as  to  the 
mortality  of  most  of  the  diseases  of  adult  life,  unless  the  cases  and  their 
results  are  given  by  age  groupings. 

The  following  table,  compiled  from  the  records  of  eighteen  hospitals 
for  the  last  fifteen  years,  indicated  the  differences  in  the  fatality  of 
certain  diseases  in  patients  of  different  ages :  — 


[Table 


H 


SYSTEM  OF  MEDICINE 


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This  table  includes  32,185  cases  of  pneumonia  witli  an  average  or 
gross  death-rate  of  22-25  per  cent.  It  shows,  however,  that  the  propor- 
tion of  deaths  steadily  increased  from  8-2  per  cent  in  the  cases  between 
ten  and  twenty  years  of  age,  to  57  per  cent  in  the  cases  sixty  years  of 
age  and  upward ;  hence  the  giving  of  gross  death-rates  only  for  a  few 
dozen,  or  even  a  few  hundred  cases  of  pneumonia,  to  show  the  influence 
of  a  particular  mode  of  treatment,  is  almost  useless.  The  same  increase 
in  the  death-rate  with  increase  of  age  is  shown  in  typhoid  fever,  the 
gross  death-rate  for  the  10,638  cases  reported  being  19  per  cent  of  the 
cases,  varying  from  12-9  to  65-6  per  cent  in  different  age  groups.     In 


MEDICAL  STATISTICS 


n 


consumption  also  the  hospital  death-rate  increases  with  advancing  age, 
but  iiot  to  such  a  marked  extent ;  while  in  diphtheria  it  rapidly  falls  after 
ten  years  of  age.  But  the  hospital  death-rate  in  consumption  given 
above  is  misleading,  since  the  figures  are  taken  from  annual  reports,  and 
the  same  cases  are  reported  two  or  three  times.  The  hospital  death-rate 
for  116,673  cases  of  consumption  was  443-4  per  1000,  which  signifies, 
not  that  the  death-rate  in  this  disease  is  a  little  over  44  per  cent  of  the 
cases,  but  that  the  average  duration  of  the  disease  is  a  little  over  two 
years,  the  true  death-rate  being  about  90  per  cent. 

The  fatality  of  different  diseases  will,  of  course,  be  indicated  in  the 
special  articles  treating  of  them,  but  the  following  are  the  death-rates  of 
a  few  as  indicated  by  hospital  records  —  age  not  being  stated :  — 


Disease. 

Cases. 

Deaths. 

Kate  per 
luuu. 

Pneumonia    . 
Typhoid  fever 
Diphtheria     . 
Scarlet  fever 
Acute  pleurisy 
Acute  bronchitis 
Acute  nephritis 

36,273 

37,986 

7,090 

5,757 

20,871 

30,408 

2,207 

9438 

5657 

2526 

7:57 

2229 

913 

562 

260-1 
148-9 
356-2 
128-0 
106-7 
30-0 
254-6 

The  following  table  shows  the  case  mortality  of  certain  diseases  as 
shown  by  the  Norwegian  reports  for  the  four  years  1888-1891  inclu- 
sive :  — 


Diseases. 

Cases 
treated. 

Deaths. 

Deaths  in  1000 
Cases  treated. 

Meningitis  simplex  (leptomeningitis 

cerebralis  acuta)   .... 

1,311 

1,015 

774-2 

Cancer      

7,082 

4,641 

655-3 

Croup       

1,646 

961 

583-8 

Phthisis  pulmonalis .... 

26,374 

11,844 

449-1 

Cerebro-spinal  meningitis 

170 

58 

341-2 

Puerperal  fever        .... 

2,034 

621 

305-3 

Bright's  disease        .... 

7,070 

1,840 

200-3 

Diphtheria 

30,473 

7,010 

2.30-0 

Pneumonia 

46,085 

6,873 

149-1 

Typhoid  fever 

7,467 

755 

101-1 

Scarlet  fever 

24,657 

1,547 

62-7 

Dysentery 

1,013 

59 

58-2 

"Whooping  cough      .... 

27,914 

1,327 

47-5 

Pleurisy 

11,659 

388 

33-3 

Measles 

36,149 

1,169 

32-3 

Acute  diarrhoea  and  Cholera  nostras 

101,491 

3,212 

31-6 

Rheumatic  fever      .... 

13,654 

250 

18-3 

Acute  catarrh  and  bronchitis  . 

227,466 

3,493 

15-3 

Influenza 

93,149 

794 

8-5 

Mumps 

6,087 

2 

0-3 

Let  us  now  compare  the  number  of  deaths  from  certain  diseases  with 
the  number  of  population  in  which  they  occurred,  that  is,  the  death-rates 
of  the  vital  statistician. 


i6 


SYSTEM   OF  MEDICINE 


The  following  table  shows  the  average  annual  death-rates  from  each 
of  certain  causes  per  10,000  living  population,  during  a  period  of  about 
ten  years  in  different  countries  :  — 


ci 
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1=1 

Khode  Island 
Connecticut . 

Massachusetts 
New  Jersey  • 

Wales 
Ireland 
Scotland 
Belgium 
Sweden 
Prussia 
Austria 
Saxony 
Norway 
Bavaria 
Holland 

MEDICAL   STATISTICS 


17 


In  dealing  with  medical  statistics  we  usually  have  no  data  as  to 
population,  and  the  best  rates  we  can  obtain  to  show  the  relative  prev- 
alence of  a  given  disease  in  different  localities,  or  in  the  same  locality 
at  different  times,  are  rates  per  1000  deaths  from  known  causes. 

The  following  table  shows  these  rates  for  the  countries  and  periods 
given  in  the  preceding  table  :  — 


VOL.    I 


CO  '^  qq  QO  -^ 
c:  cc  .— I  ^  CO 


•^  cs  CO  t— 


rt  1-1  (M  CM 


lO         t-h  O  :0  -*  CO 


Wf^ 


•-  S  g  o 


t~-  l^         ^  *-?  "'7  '^ 

10   CM  CO   -*   r-l   .— ( 

CO  00  CO   ^  O  CO 


^CO^IM-^-*!—-* 


CD  Ci  t~  CO 


CO.-^COt-~00t^CiTti 


O  C35  O  CI 
t^  !V2  o  l-~ 


CO  Oi  >— '  CO  t^  l>-  O 
TtH  I— I  t~  CM  to  CO  "-0 
i-H  CM  CM  ^  O  lO  lis 


.-I  <M  CO  ■* 


CO  Oi         '-^ 
CO  O      \-^ 


1  = 

g  p. 


ooc;-*cococcoco       mcouqio 


t^O'— io«--^-*co 


CO  -rf*  t^  CO 

lO  o  >o  >o 


r--  CM  t^  O  CD  C3i 

o  (i  lO  r-i  o  sR 


'7^  10  '^  p 

o  o  o  CO 


,111111^ 

cocooococor^coco 
cocooocococococo 


0000 

CO  CO  00  CO 
00  CO  00  CO 


rt  rt  3  rt  .3  ^  -S  3  g  g 


ce  d  cfl  g' 

o  o  a; 

OJ    O)  rt  1-5 

TJ   g  CO   . 

2   «  ^   ^ 


SYSTEM   OF  MEDICINE 


It  is  important  to  remember  that  a  table  like  this  does  not  give  true 
mortality  rates,  and  that  the  rates  given  by  it  for  any  given  disease  are 
affected  not  only  by  the  actual  prevalence  of  that  disease,  but  of  other 
causes  of  death,  so  that  very  erroneous  conclusions  may  easily  be  drawn 
from  them  ;  nevertheless,  they  are  often  the  only  rates  available,  and  if 
the  gross  death-rates  of  the  different  localities  are  about  the  same,  or  if 
it  is  possible  to  estimate  their  difference,  some  useful  conclusion  may 
be  drawn  from  a  table  of  this  kind.  For  example,  each  of  these  tables 
indicates  that  typhoid  fever  caused  a  little  more  than  twice  as  great 
a  mortality  in  Massachusetts  as  it  did  in  England ;  and  that  diphtheria 
caused  about  four  times  as  great  a  mortality  in  Massachusetts  as  in 
England.  Where  the  average  annual  death-rate  is  about  twenty  per 
1000,  the  number  of  deaths  due  to  a  special  disease  per  1000  deaths 
from  all  causes  should  be  about  five  times  the  number  of  deaths  from  that 
disease  per  1000  of  population,  if  the  population  has  the  usual  propor- 
tions of  sex  and  age  ;  but  this  ratio  is  not  applicable  in  most  cases,  because 
an  epidemic  of  any  particular  disease  changes  the  proportion  of  deaths  from 
any  other  disease  per  1000  deaths  from  all  causes,  while  the  number  of 
deaths  from  that  other  disease  may  have  remained  the  same  per  1000  of 
population ;  and  the  proportion  of  children  in  a  locality  will  greatly  influ- 
ence the  death-rate  from  diphtheria  and  scarlet  fever,  just  as  the  proportion 
of  old  people  will  influence  the  death-rates  from  pneumonia  and  cancer. 

Next  to  age  in  the  importance  of  its  influence  upon  disease  is 
heredity.  At  present  almost  the  only  data  we  have  on  this  subject 
relate  to  race  differences ;  but  there  are  equal,  and  probably  greater 
differences  in  families  of  the  same  race,  recorded  only  in  a  vague  way 
in  the  memories  of  old  family  practitioners. 

Professor  Allbutt  has  pointed  out  that  studies  of  hereditary  disease 
have  been  limited  mainly  to  observations  of  one  particular  form  of  disease 
in  a  given  family,  Avhile  for  scientific  purposes  what  is  wanted  is  a  record 
of  all  the  diseases,  fatal  and  non-fatal,  which  have  occurred  in  a  given 
family  {Brit.  Med.  Jour.  1888,  11,  287).  A  beginning  of  such  records 
has  been  made  in  the  study  of  insanity  and  its  relations  to  chorea,  neu- 
ralgia, epilepsy,  etc. ;  but  they  are  never  complete  ;  and  it  would  require 
the  records  of  several  generations  in  each  of  many  families  to  furnish  sta- 
tistical data  sufiicient  to  determine  the  relationships  of  diseases  which  are 
supposed  to  be  connected  with  what  are  called  gout  and  rheumatism. 

Certain  portions  of  the  United  States  present  specially  favourable  con- 
ditions for  the  study  of  race  influences  upon  disease  and  mortality,  because 
different  races  may  be  found  there  under  nearly  the  same  conditions  as 
to  climate,  food,  occupation,  etc.,  which  is  not  the  case  if  we  attempt  to 
use  data  derived  from  countries  inha.bited  mainly  each  by  a  different  race. 

The  following  table  shows  for  New  York  City  the  death-rates  per 
1000  of  the  Avhite  population  during  the  year  ending  31st  May  1890, 
with  distinction  of  birthplaces  of  mothers  and  of  eight  groups  of  ages. 
(The  birthplace  of  the  mother  is  the  best  means  at  our  command  for 
indicating  the  probable  race  in  this  case) :  — 


MEDICAL   STATISTICS 


»9 


5S 


t~OCOO»Ot^ThCOi— ILOCOCOO 


■•*iot—  -^co-^coiOt^t^LOr^Tti 


•p-l 


cc 

-n 

-rt 

•rs 

rt 

fTl 

""^ 

C 

t3^ 

1—1 

O   rt 

fl 

ce 

ctf 

m 

rt 

t/; 

n; 

=i 

C3 

P^ 

S    g^   O   el's 


SYSTEM  OF  MEDICINE 


It  will  be  seen  from  this  table  that  the  death-rate  of  those  whose 
mothers  were  born  in  Russia  and  Poland  was  very  low  between  the  ages 
of  fifteen  and  forty-five,  and  that  at  other  groups  of  ages  it  was  also 
lower  than  that  of  any  other  race.  These  people  were  nearly  all  Jews, 
and  were  80,235  in  number.  The  death-rate  of  the  offspring  of  Irish 
mothers  was  high,  much  higher  than  that  of  the  Germans,  and  as  there 
were  about  400,000  of  each  of  these  races,  the  comparison  is  a  fair  one. 

The  Jewish  population  was  poor,  crowded  in  tenement  houses.  The 
interesting  point  to  the  medical  statistician  is.  What  were  the  forms 
of  disease  to  which  the  marked  differences  in  the  death-rates  of  these 
races  were  due  ?  To  answer  this  in  part,  we  will  take  the  statistics 
of  deaths  for  the  six  years  ending  31st  May  1890  for  the  Irish,  the 
Germans,  the  Ilussian  and  Polish  Jews,  the  American  white  offspring  of 
American  mothers,  and  the  coloured  in  New  York  City.  The  average 
annual  death-rate  from  consumption  per  100,000  of  population  was  — 
for  the  Irish,  645-73;  for  the  coloured,  531-35;  for  the  Germans, 
328-80 ;  for  the  American  whites,  205-14 ;  and  for  the  Russian  Polish 
Jews,  76-72.  The  average  annual  death-rate  from  pneumonia  per 
100,000  of  population  was  —  for  the  Irish,  343-99;  for  the  coloured, 
389-50;  for  the  American  whites,  272-87;  for  the  Germans,  214-12; 
and  for  the  Russian  and  Polish  Jews,  170-17. 

It  seems  probable  that  members  of  the  Jewish  race  possess  a  dis- 
tinctly higher  degree  of  immunity  against  the  bacillus  of  tuberculosis  and 
the  micrococcus  of  pneumonia  as  compared  with  the  other  races  above 
mentioned;  and  that  on  the  other  hand  the  Irish  and  the  American 
negro  are  specially  susceptible  to  the  effects  of  these  micro-organisms. 

Professor  Stokvis  has  pointed  out  that  in  all  colonial  armies  in 
warm  climates  the  death-rate  from  diseases  of  the  respiratory  organs  is 
more  than  twice  as  great  among  the  native  troops  as  it  is  among  the 
Europeans  ("On  the  Comparative  Pathology  of  Human  Races,"  etc., 
Practitioner,  Lond.  xlvi.  1891,  p.  233),  while  hepatitis  is  decidedly  more 
fatal  in  the  European  than  in  the  native. 

In  the  Dutch  East  Indian  colonies  the  natives  are  decidedly  more 
liable  to  beriberi  than  the  Europeans ;  but  the  comparative  immunity  of 
the  latter  against  this  disease  appears  to  be  decreasing  in  recent  years. 
Even  when  we  have  the  means  of  comparing  the  death-rates  of  different 
races  in  the  same  locality  it  is  usually  impossible  to  say  how  far  the 
differences  in  these  death-rates  depend  upon  inherited  peculiarities  of 
physical  structure,  and  how  far  they  are  due  to  the  poverty,  uncleanli- 
ness,  and  habits  as  to  different  kinds  of  alcoholic  drinks  which  charac- 
terise the  great  mass  of  the  population  of  certain  races. 

John  S.  Billings. 


ANTHROPOLOGY  AND   MEDICINE 


ANTHROPOLOGY   AND   MEDICINE 

Our  knowledge  on  this  subject  is  scanty  and  far  from  clear ;  and  the 
little  we  believed  ourselves  to  possess  has  been  disturbed  by  recent 
changes  in  pathological  theory.  Divers  diseases  formerly  supposed  to  be 
the  outcome  of  constitutional  and  hereditary  proclivity  are  now  believed 
to  be  the  results  of  infection ;  and  the  remoter  causes  are  apt  to  be 
neglected  in  the  consideration  of  aetiology. 

That  many  pathological  processes  are  known  to  be  common  to  man- 
kind and  to  other  mammalia,  or  even  to  animals  further  removed  from 
us,  while  others  are  reasonably  suspected  to  be  so,  makes  it  d  priori 
improbable  that  any  great  differences  should  subsist  in  the  distribution 
of  diseases  among  different  races  of  men.  On  the  other  hand,  though 
men  and  women  respectively  can  hardly  be  said  to  have  any  peculiar  and 
exclusive  diseases  (except  in  so  far  as  this  results  from  the  differences 
in  their  sexual  organs),  yet  we  see  that  their  respective  liability  to  some 
at  least  of  these  diseases  varies.  A  curious  instance  of  this  is  afforded 
by  cretinism  and  goitre  :  goitre  being  much  more  common  in  women  than 
in  men,  while  cretinism  is  pretty  evenly  distributed  —  if  anything  there 
is  a  preponderance  of  male  cretins. 

The  most  conspicuous  difference  in  the  external  aspect  of  men  and  of 
races  of  men  is  in  colour ;  and  here  comparative  pathology  would  lead 
one  to  look  for  some  corresponding  differences  in  susceptibility  to  disease, 
for  the  experience  of  horse-breeders  and  veterinarians  is  pretty  clearly 
expressed  on  this  point.  Thus  Youatt  says  that  the  dark  chestnut,  as  a 
rule,  yields  to  no  other  colour  in  any  quality ;  but  that  the  light  chest- 
nut, which  appears  to  be  the  analogue  of  the  sanguine-blond  man,  is 
spirited,  but  irritable  and  delicate  in  constitution.  Black  horses,  again, 
number  among  them  some  of  the  very  finest  of  their  species  ;  but  many 
of  them  are  heavy  and  dull  in  temperament,  and  there  is  an  idea  afloat 
that  they  are  particularly  liable  to  malignant  disease.  Here  we  may  be 
led  to  think  of  the  choleric  and  the  melancholic  temperaments.  Among 
breeds  of  sheep,  the  blackfaced  have  the  reputation  of  being  hardier  than 
the  whitefaced.  Certain  black  pigs,  according  to  Darwin,  can  eat  with 
impunity  what  would  be  poisonous  to  white  ones  on  the  same  pasture ; 
and  like  differences  are  seen  in  black  and  Avhite  rats.  On  the  whole, 
hoAvever,  the  deposition  of  pigment  in  the  skin  and  hair  of  mammals 
would  seem  to  be  the  result  of  processes  which  connote  or  accompany 
health  and  vigour  rather  than  the  opposite. 

The  statistics  of  morbidity  and  mortality,  which  alone  could  yield 
a  sound  foundation  for  generalisations  on  this  subject,  are  unfortunately 
imperfect,  or  altogether  wanting,  in  the  regions  where  the  material  would 
be  most  valuable  —  those  regions,  namely,  where  nations  of  different 


SYSTEM  OF  MEDICINE 


colours  and  constitutions  of  body  live  side  by  side  under  comparable 
conditions.  In  fact,  we  bave  hardly  any  trustworthy  statistics,  except 
from  the  most  civilised  of  the  countries,  whose  populations  are  com- 
pounded from  more  or  less  distinct  divisions  of  the  human  race  \_mde 
Dr.  Billings'  art.  on  "  Med.  Statistics  "]. 

Much  information,  more  or  less  trustworthy,  as  to  the  distribution  of 
disease  among  different  races,  may  be  gleaned  from  Hirsch,  Lombard, 
Boudin,  Oesterlen,  Bordier,  etc. ;  but  even  where  the  facts  can  be  relied 
on,  they  are  generally  capable  of  interpretations  that  make  them  of  little 
value  for  our  purpose.  Thus,  when  we  learn  that  aneurysm  is  four  times 
more  common  in  San  Francisco  among  foreigners  than  among  native 
Americans,  we  must  remember  that  a  far  larger  proportion  of  the 
foreigners  are  males  in  the  prime  of  life,  and  that  most  of  the  hard 
bodily  labour  is  performed  by  foreigners. 

Negroes  are  said  to  be  exempt,  or  nearly  so,  from  piles  and  from  vari- 
cose veins,  and  the  cause  assigned  is  the  greater  strength,  in  them,  of  the 
walls  of  the  blood-vessels.  Apoplexy,  on  the  other  hand  (using  the  word 
in  the  ordinary  sense),  appears  to  have  no  racial  preferences.  Thus,  in 
ISTew  Orleans  negroes  and  whites  are  said  to  die  of  apoplexy  in  the  pro- 
portions respectively  of  103  and  91.  Within  Europe  —  England,  Scot- 
land, Prussia  and  Italy  yield  almost  exactly  the  same  figures  for  death  by 
apoplexy :  in  all  of  them  these  vary  between  10  and  11  per  10,000 
living;  Switzerland  and  Holland  yield  8-5  and  7-9,  but  Ireland  only 
5-9.  The  deaths  from  brain  disease  of  all  kinds,  as  returned,  are  singu- 
larly few  in  the  insular  parts  of  Scotland  and  in  the  Highlands,  where 
the  inhabitants  are  in  blood  very  near  akin  to  the  Irish,  so  that  here  one 
might  have  supposed  one  had  lighted  on  a  real  case  of  hereditary  exemp- 
tion, or  at  least  favourable  hereditary  constitution ;  but  the  fact  that 
Shetland,  where  the  race  is  Norse,  returns  fewer  deaths  from  brain 
disease  than  even  the  Highlands  and  the  other  islands,  is  sufficient  to 
negative  the  idea  that  the  Gaelic  race  has  any  such  special  immunity. 
The  rate  of  mortality  from  this  class  of  diseases  is  certainly  lower  in 
quiet  rural  districts  than  amid  the  hurry  and  worry  or  excesses  of  towns, 
and  this  may  account  for  some  degree  of  the  apparent  immunity;  the 
remainder  must  be  attributed  to  the  tendency  to  set  down  all  cases  of 
death  in  advanced  life  to  simple  "old  age."  In  Shetland  and  the 
Hebrides  about  25  per  cent  of  the  deaths  are  thus  certified. 

In  cancer,  again,  the  enormous  differences  in  mortality  reports  are 
doubtless  largely  due  to  the  non-recognition  of  internal  growths.  But 
the  differences  reported  to  exist  in  divers  registration  districts  in  England 
seem  too  great  to  be  wholly  due  to  this  cause,  and  the  extreme  varia- 
tions in  both  directions  are  by  no  means  such  as  would  have  been 
expected  on  such  a  hypothesis.  For  example,  rural  districts  in  general 
seem  to  suffer  quite  as  much  as  cities,  and  ancient  cities  more  than  great 
centres  of  industry,  even  allowing  for  the  difference  of  constitution  of 
the  population  in  respect  of  age  \yide  Mr.  Haviland's  art.  on  "  Med. 
Geography  of  Great  Britain  "]. 


ANTHROPOLOGY  AND  MEDICINE 


23 


There  is  some  little  ground  for  considering  cancer  to  be  a  disease  of 
civilisation,  or  of  civilised  communities  and  races,  though  here  of  course 
the  question  of  failure  in  diagnosis  comes  in  with  double  force.  The 
most  formidable  death-rates  that  we  have,  such  as  990  per  millicHi 
living  in  Urontheim  and  930  in  Lombardy,  come  from  highly-civilised 
communities.  Cancer  is  said  to  be  rife  in  China,  but  rai-e  in  Egypt, 
the  scene  of  a  yet  older  civilisation.  It  is  thought  to  be  uncommon  in 
the  negro  race  generally,  whereas  we  have  seen  that  it  is  prevalent  in 
Norway,  among  one  of  the  blondest  populations  in  the  world.  The 
asserted  rarity  in  Iceland  may  perhaps  be  remanded  for  further  evi- 
dence ;  could  it  be  proved,  it  would  be  of  great  importance,  the  Nor- 
wegians and  Icelanders  being  of  the  same  race.  That  the  disease  is 
strongly  hereditary  scarcely  any  one  doubts;  and  I  shall  presently 
submit  some  evidence  to  show  that  in  Britain  it  is  especially  common 
among  people  of  dark  complexion. 

Gout  is  another  strongly  hereditary  disease,  common  in  certain 
races  and  communities,  but  very  rare,  perhaps  non-existent,  in  others. 
Roughly  speaking,  it  is  a  disease  of  the  ruling  races  and  the  higher 
classes ;  of  the  civilised  man,  not  of  the  savage  ;  of  the  Avhite  man, 
not  of  the  negro ;  of  cold  and  temperate  rather  than  of  hot  climates. 
Probably  there  exist  large  communities  of  men  among  whom  it  never 
occurs  ;  but,  given  some  of  the  requisite  exciting  causes,  habitual  but 
not  extreme  excess  in  eating  and  drinking,  disproportionate  use  of  the 
brain  as  compared  with  the  muscles,  consumption  of  certain  kinds  of 
drinking-water,  etc.,  it  could  doubtless  be  produced  in  any  race  and 
in  almost  any  climate.  Negroes,  as  I  have  said,  are  generally  free ; 
but  Lobengula,  the  famous  king  of  the  Matabele,  drank  much  beer, 
and  suffered  severely.  The  reported  distribution  of  the  disease  is  very 
instructive.  Thus,  in  India,  it  is  said,  the  Hindus  scarcely  ever  suf- 
fer; the  Mussulmans,  freer  in  diet,  sometimes.  Gout  occurs  in  China, 
where  the  mandarin  class  unite  most  of  the  requisite  factors.  In  Mad- 
agascar, the  comparatively  clever  and  light-complexioned  ruling  race, 
the  Hovas,  suffer  from  it;  the  subject  negroes  are  not  known  to  be 
attacked.  In  the  United  States  of  America  it  occurs  in  the  cities,  but  is 
little  known  elsewhere ;  the  American  farmer  is  active  and  temperate. 

The  registered  death-rafe  from  gout  in  England  is  about  25  per 
million  living,  in  Scotland  it  is  4-3  per  million,  in  Queensland,  Avhere 
much  more  fresh  meat  is  eaten  than  in  England,  about  5.  The  chief 
missing  factor  is  probably  beer ;  but  at  least  we  are  justified  in  saying 
that  in  these  cases  differences  of  regimen  and  climate  reduce  the  mor- 
tality in  the  same  race  to  about  one-fifth. 

Still,  it  must  be  acknowledged  that  the  distribution  of  gout  has  a 
racial  aspect.  In  France,  according  to  Hirscli,  Lorraine,  Normandy  and 
Lyons  are  said  to  be  its  chief  pasture-grounds  :  others  add  Burgundy 
and  blame  the  wine.  The  natives  of  all  these  districts  have  more  or 
less  of  the  Germanic  element  in  them.  In  Spain,  the  least  Iberian  of 
Spaniards,  the  Asturians,  are  the  most  gouty.    The  Belgians,  the  Dutch, 


24  SYSl'EM  OF  MEDICINE 

the  Danes,  the  Northern  Germans,  the  Upper  Austrians,  and,  in  Eussia, 
the  upper  classes  of  St.  Petersburg  and  the  Baltic  provinces  (Germans 
again)  are  all  said  to  suffer  from  it.  If  there  be  one  thing  which 
all  these  people  have  in  common,  it  is  that  fondness  for  heavy  feeding 
which  has  been  a  characteristic  of  our  own  most  gouty  nation  from 
time  immemorial,  and  belongs  particularly  to  the  true  Saxon-English 
type. 

Phthisis  has  always  been  a  sort  of  battle-ground  for  the  believers  in 
infection,  and  the  believers  in  hereditary  transmission  and  the  suscepti- 
bility of  particular  types.  Until  quite  recently,  though  the  former 
opinion  ruled  in  Southern  Europe,  the  latter  was  almost  universally  held 
in  England.  And  though  even  now  clinical  and  practical  experience 
point  in  the  same  direction  as  formerh*,  the  general  and  geographi- 
cal history  of  the  disease  seem  to  support  the  infective  theory.  The 
effects  of  local  conditions  of  soil  and  climate,  though  undoubtedly  very 
powerful,  are  not  always  distinct,  and  may  be  used  in  support  of  either 
theory. 

The  local  statistics  of  phthisis  are  of  verj-  great  interest,  and  could 
not,  of  course,  be  dealt  with  satisfactorily  within  the  compass  of  this 
essay.  Some  of  them  seem  to  point  to  the  applicability  to  phthisis  of 
the  "virgin  soil "'  doctrine,  Avhich  at  first  sight  seems  incompatible  with 
that  of  the  importance  of  heredity. 

Among  the  more  important  points  which  may  be  taken  as  estab- 
lished are — 

1.  The  extreme  rarity  of  phthisis  at  very  high  elevations. 

2.  Its  rarity  in  high  latitudes :  for  example,  in  Iceland. 

3.  That  some  of  Mr.  Haviland's  conclusions  as  to  local  mortality  are 
correct  —  for  example,  that  damp  clayey  soil  coincides  with  a  high 
phthisical  death-rate  ;  ^  and  that  the  warm,  fertile,  ferruginous-red-sand- 
stone tracts  of  country  are  most  remarkable  for  low  death-rates ;  "  a 
sheltered  position  and  a  warm,  fertile  soil,  well  drained,  being  coincident, 
as  a  rule,  throughout  England  and  Wales,  with  a  low  mortality  from 
phthisis." 

4.  That,  among  bodily  characters,  tall  stature  is  the  most  distinctly 
unfavourable. 

The  following  opinions  may  be  put  forward  more  doubtfully  :  — 

1.  That  though  local  situation,  varieties  of  social  habit,  occupation, 
and  the  like,  overbear  and  obscure  in  Britain  anything  like  racial  ten- 
dency, it  would  appear  that  the  Gaelic  and  Kymric  or  Ibero-Keltic  stocks 
are,  caeteris  paribus,  rather  more  subject  to  phthisis  than  the  Saxon  and 
Scandinavian.  (The  principal  objection  to  this  statement  is  furnished 
by  the  very  unfavourable  position  of  Suffolk,  one  of  the  most  purely 
Anglian  counties.) 

2.  That  the  tropical  negro  is  particularly  subject  to  phthisis,  at  least 
when  removed  from  his  own  country.  The  Melanesians,  or  Oriental  or 
Pacific  negroes  may  be  here  included ;  these  are  the  people,  incorrectly 

1  Bowditcb  and  Buchanan. 


ANTHROPOLOGY  AND  MEDICINE  25 

called  Polynesians,  who  work  in  the  Australian  sugar-fields,  and  though 
well  fed  and  fairly  lodged,  die  of  consumption  in  very  large  proportions  — 

Phthisical  Death-rate  in  Queensland,  1890  and  1891. 

"  Polynesians "  per  1000  living  .  .  .       16-76 

Chinese  ......        1-17 

Europeans  and  Colonials        .  .  ,  .  -98 1 

It  is  needless  to  cite  statistics  of  the  decimation  of  the  true  African 
negro  in  other  climates  than  his.  own.  In  some  cases  the  figures  are 
even  more  ajjpalling  than  those  I  have  quoted  from  Queensland ;  and  in 
some  of  the  countries  into  which  negroes  have  been  introduced  they 
seem  to  melt  away  chiefly  from  this  cause.  The  most  remarkable 
exception  to  the  rule  is  that  furnished  by  the  southern  jjortion  of  the 
United  States  of  America.  Here,  though  within  the  temperate  zone,  a 
negro  peasantry  has  been  firmly  established,  thrives  and  multiplies.  It 
is  even  said  that  the  death-rate  from  phthisis  in  the  Southern  States 
generally  is  lower  among  the  blacks  than  the  whites.^  If  it  be  so  it  is 
because  the  former  are  the  jjeasantry,  and  a  fairly  well  fed  and  lodged 
peasantry,  with  a  wholesome  amount  of  bodily  labour;  Avhereas  the 
whites  are  generally  inhabitants  of  towns  and  villages,  with  inferior 
conditions  of  life,  quoad  liability  to  phthisis. 

The  mortality  from  this  disease  waxes  and  wanes  in  different  countries 
in  a  manner  that  invites  speculation  on  the  causes  of  change.  England 
and  Holland  used  to  be  thought  its  special  seats.  But  now  for  a  con- 
siderable time  xjhthisis  has  appeared  to  be  on  the  wane  in  England,'  and 
the  death-roll  therefrom  in  the  cities  of  Erance  and  Germany  and  North- 
ern Italy  has  been  growing  or  becoming  more  visibly  formidable.  It  has 
also  grown  in  Scotland  coincidently  with  the  growth  of  urban  popula- 
tion, and  with  what  has  been  regarded  as  improvement  in  the  dwellings 
of  the  rural  population.  In  Xorth  Germany  the  western  provinces  yield 
heavier  rates  than  the  eastern :  and  here  too,  though  some  might  rely 
upon  the  racial  difference  between  the  true  German  and  the  Slav,  I 
believe  the  real  difference  to  consist  in  a  rather  more  elaborate  civilisa- 
tion, which  brings  with  it  air  tight  houses  and  other  fair-seeming  but 
really  evil  conditions. 

Yellow  fever  is  one  of  the  mcst  selective  and  fastidious  of  diseases ; 
almost  as  much  so  as  the  sweating  sickness  of  the  Middle  Ages,  which  on 
its  first  appearance  is  said  to  have  sought  out  the  well-to-do  and  lusty 
Englishman,  abroad  as  well  as  at  home,  and  let  the  starveling  and  the 
foreigner  go  scatheless.  In  Xew  Orleans,  for  example,  there  is  said  to 
be  a  regular  scale  of  exemption,  eom^jlete  in  the  case  of  the  full-blooded 

1  Blakeney,  VHal  Statistics;  of  Queensland. 

2  But  see  article  "  Statistics." 

3  Partly,  no  doubt,  from  a  change  of  name,  but  not,  I  think,  wholly  so.  The  great  in- 
crease of  deaths  registered  under  bronchitis  and  pnsumonia  has  been  at  other  ages  than 
tliose  at  which  phtliisis  has  decreased. 


26  SYSTEM  OF  MEDICINE 

negro,  less  in  the  mulatto  or  other  man  of  colour,  less  still  in  the  dark- 
complexioned  Creole  of  Spanish  or  French  descent;  while  even  the 
Southern  European  suffers  less  than  the  Englishman,  and  the  Scandi- 
navian fares  worst  of  all.  This  sounds  a  little  too  artificial ;  but  all 
agree  that  the  dark  skin  connotes  a  kind  of  acclimatisation  to  the 
scourge  similar  to  that  which  long  residence  confers.  We  have  here, 
perhaps,  the  most  conspicuous  instance  of  race  peculiarity  in  disease, 
the  hereditary  anomalies  of  pigmentation  in  the  negro  being  clearly 
connected  with  his  exemption  from  a  disease  in  which  that  function  is 
much  implicated.  The  yellow  colour  of  the  fat  in  the  negro,  and  the 
comparative  whiteness  of  the  stools,  'should  be  remembered  in  this 
connection. 

Scarlatina  is  much  milder  and  less  formidable  in  Southern  than  in 
Northern  Europe.  More  than  one  reason  suggests  itself  for  this; 
but  the  greater  frequency  of  enlarged  tonsils  in  the  lymphatic  tem- 
perament, which  is  so  common  in  ISTorth- western  Europe,  supplies  one  of 
these. 

Small-pox  is  exceedingly  fatal  to  peoples  among  Avhom  it  is  intro- 
duced for  the  first  time.  No  doubt  this  is  partly  owing  to  terror  at  the 
appearance  of  a  new  and  dreadful  enemy,  and  to  ignorance  of  proper 
methods  of  treatment,  etc. ;  but  we  can  hardly  doubt  that  it  is  also  con- 
nected with  the  fact  that  any  such  organisin  flourishes  best  in  a  virgin 
soil.  The  frightful  amount  of  destruction  of  life  by  small-pox  among 
the  North  American  Indians,  especially  on  its  first  introduction,  can 
hardly  be  accounted  for  in  any  other  Avay.  Thus  the  Mandan  nation 
was  almost  destroyed ;  it  has  even  been  stated  that  in  their  principal 
village  only  forty  out  of  2000  survived  the  invasion ;  but  it  has  never 
been  asserted,  so  far  as  I  am  aware,  that  Avith  vaccination  and  proper  care 
the  Indians  suffer  more  from  small-pox  than  other  races.  To  show  that 
other  races  suffer  almost  equally  under  similar  conditions,  we  may  quote 
the  earliest  epidemic  of  small-pox  in  Iceland,  when  18,000  out  of  52,000 
were  said  to  have  perished.  Some  facts  of  this  sort  might  lead  one  to 
suspect  that  past  diseases  may  exercise  some  kind  of  protective  power 
against  others,  even  when  their  relation  is  much  more  distant  than  that 
of  vaccinia  to  variola.  Thus  we  hear  of  the  discovery  of  a  village 
church  in  Tellemarken  (Norway),  whose  very  existence  had  been  for- 
gotten, the  entire  population  of  its  remote  parish  having,  there  is  reason 
to  believe,  been  swept  off  by  the  black  death.  In  this  case,  probably, 
the  soil  was  virgin  to  many  other  diseases  besides  this  particular  pest : 
or  is  it  that  a  population  which  has  not  been  sifted  through  the  meshes 
of  other  zymotics  is  more  vulnerable  than  another,  though  apparently 
more  healthy  ? 

Whether  the  virgin  soil  hypothesis  be  necessary  to  explain  the 
occasional  destructiveness  of  measles  may  be  doubted.  Though  on  its 
introduction  to  Fiji  it  killed  about  a  fourth  of  the  population,  it  is  said 
not  to  have  been  extraordinarily  severe  among  those  Fijians  who  were 
carefully  nursed  in  European  fashion,  and  protected  from  their  own 


ANTHROPOLOGY  AND   MEDICINE  27 

folly ;  the  mortality  has  been  quite  as  great  in  France  under  bad  sani- 
tary conditions.  There  is  no  sufficient  reason  to  think  that  any  one 
race  is  more  liable  to  be  severely  handled  by  measles  than  another,  under 
equal  conditions.  Negroes  suffer  much  more  than  whites,  it  is  said,  in 
the  United  States ;  but  the  differe:ice  is  only  what  we  find  in  this  country 
between  the  upper  and  the  lower  classes.  Tetanus  and  trismus  neona- 
torum are  supposed  to  be  particularly  fatal  among  negroes ;  but  here 
again  it  is  probably  the  habits  of  the  race  that  are  in  fault,  rather  than 
anything  in  its  physical  constitution.  One  can  hardly  imagine  any  re- 
semblance in  the  latter  respect  between  negroes  and  Icelanders  ;  yet  the 
inhabitants  of  the  Westmann  Islands,  off  the  coast  of  Iceland,  used  to 
lose  the  greater  part  of  their  infants  from  trismus,  until  they  were 
taught  by  Schleisner  to  reform  their  manner  of  treating  them  during 
the  first  few  days  of  life.  Hirsch  assigns  as  a  probable  cause  a  peculiar 
sensitiveness  of  the  negro  skin ;  but  the  suggestion  appears  to  me  un- 
warranted and  gratuitous. 

Chorea  is  said  to  be  unknown  in  China,  and  Ave  may  probably 
assume  with  safety  that  it  is  rare.  Whatever  its  relations  with  rheu- 
matism, it  is  certainly  a  disease  of  the  nervous  temperament  especially. 
For  its  physical  type  see  further  on.  There  are  several  more  or  less 
obscure  diseases  to  which  negroes  seem  to  be  exclusively  or  particularly 
liable.  Of  these  is  the  sleeping-sickness,  described  in  this  work  by  Dr. 
Manson.  The  mysterious  ainhum,  which  resembles  a  limited  leprosy, 
is  not  known  to  attack  other  races ;  but  yaws  certainly  does. 

Of  all  white  races,  the  Jews  are  the  most  likely  to  reward  a  careful 
study  of  special  morbid  tendencies;  but  I  am  not  aware  that  this  has 
ever  been  thoroughly  carried  out.  They  are  known  to  have  a  lower 
death-rate,  wherever  it  has  been  tested,  than  the  Christian  populations 
among  whom  they  live ;  but  this  may  be  due  simply  to  their  sober 
habits  and  carefulness  in  diet,  their  avoidance  of  violent  labour,  and. 
their  great  care  of  their  children.  They  are  believed  to  suffer  much 
from  diabetes,  from  nervous  diseases,  and  from  psoriasis. 

If  we  now  regard  the  subject  from  a  geographical  point  of  view, 
we  shall  be  able  to  make  use  of  the  gigantic  series  of  anthropologico- 
medical  statistics  which  we  owe  to  Dr.  Baxter  and  to  the  American  civil 
war.  Perhaps  the  clearest  and  most  important  fact  that  comes  out  of 
them  is  the  inferiority  of  the  blond-complexioned  man  for  recruiting 
purposes.  Out  of  twenty-two  principal  classes  of  physical  defects, 
twenty  of  which  imply  disease  of  some  kind,  in  only  one,  chronic  rheu- 
matism, did  the  dark-complexioned  recruits  yield  the  larger  percentage 
of  rejections.  As  De  Candolle  says,  the  very  uniformity  of  the  thing 
is  somewhat  suspicious.  He  suggests  that  it  may  be  largely  if  not 
wholly  due  to  the  inclusion  of  great  numbers  of  Germans,  the  German 
emigrants  being  often  of  inferior  physical  type.  Other  possible  sources 
of  fallacy  suggest  themselves  to  me;  but  it  must  be  allowed  that  a 
prima  facie  case  was  made  out  against  the  blonds.  The  excess  of 
blonds  was  most  marked  in  the  rejections  for  phthisis,  and  for  dis- 


28  SYSTEAf   OF  MEDICINE 


eases  of  the  circulatory  and  urinary  systems.  Dr.  Baxter  says  there 
was  an  excess  of  dark  men  among  the  few  rejections  which  took  place 
on  account  of  certain  acute  diseases.  To  this  point  we  will  return 
presently. 

I  have  made  out  a  list  from  Baxter's  data,  showing  in  relative  order 
what  appeared  to  be  the  weakest  points  in  recruits  of  several  national- 
ities and  races :  — 

1.  White  men  born  in  the  United  States  were  frequently  rejected  for  dis- 

eases of  the  digestive  and  urinary  systems,  for  bad  teetli,  and  for 
phtliisis. 

2.  American  Indians  for  nothing ;  they  were  the  soundest  of  all  the  nation- 

alities, as  well  as  the  tallest  and  largest  in  girth. 

3.  Negroes  —  For  urinary  diseases.     Also  very  healthy;  but  were  probably 

picked  men. 

4.  British  Americans  —  For  nothing  specially;  generally  very  healthy. 

5.  Mexicans  —  Diseases  of  the  nervous  and  cutaneous  systems,  syphilis,  dis- 

eases of  the  locomotive  and  generative  systems,  and  local  injuries. 

6.  South  Americans  —  Syphilis  and  respiratory  disease. 

7.  West  Indians  —  Urinary  disease. 

8.  Englishmen  —  For  bad  teeth,  and  for  affections  of  the  digestive  organs. 

9.  Scotland  —  Diseases  of  the  circulatory,  urinary  and  digestive  systems. 

10.  Ireland  —  Diseases  of  the  circulatory  system,  of  the  skin,  and  of  the  diges- 

tive system  ;  syphilis. 

11.  Wales  —  Phthisis,  and  diseases  of  the  urinary  and  locomotive  systems. 

12.  France  —  Diseases  of  the  skin  and  the  nervous  system  ;  bad  teeth. 

13.  Holland  —  Phthisis  ;  diseases  of  the  skin,  eye  and  ear,  and  of  the  respira- 

tory and  locomotive  systems  ;  and  local  injuries. 

14.  Germany  —  Phthisis;  diseases  of  the  circulatory  and  locomotive  systems, 

of  the  ear,  and  of  the  digestive  system. 

15.  Sweden  —  No  morbid  peculiarity  ;  very  healthy. 

16.  Norway  —  Diseases  of  the  ear  and  of  the  locomotive  system. 

17.  Denmark  —  Diseases  of  the  eye. 

18.  Switzerland  —  Diseases  of  the  urinary  system  ;  defects  of  the  teeth,  of  the 

ear,  and  of  the  digestive  system. 

19.  Portugal  —  Hernia ;  diseases  of  the  digestive  and  generative  systeins. 

20.  Italy  —  Diseases  of  the  skin  and  of  the  generative  system  ;  syphilis. 

21.  Russia  —  Diseases  of  the  eye,  of  the  nervous,  circulatory  and  generative 

systems. 

22.  Hungary  —  Diseases  of  tbe  digestive  and  nervous  systems,  of  the  ear,  of 

the  generative  and  respiratory  systems  ;  hernia  and  phthisis. 

23.  Poland  —  Diseases  of  the  eye,  and  of  the  circulatory  and  respiratory  sys- 

tems ;  phthisis,  and  local  injuries. 

24.  Spain  — Diseases  of  the  respiratory  organs;  syphilis,  hernia;  diseases  of 

the  generative  and  digestive  systems,  and  of  the  eye.i 

This  list,  like  the  results  of  most  voluminous  collections  of  statistics, 
is  after  all  a  little  disappointing.     It  is  not  easy  to  draw  any  important 

1  The  numbers  examined  were  small  in  the  cases  of  the  Indians,  Mexicans,  South 
Americans,  Spaniards,  Portuguese,  Russians,  Hungarians,  and  Poles. 


ANTHROPOLOGY  AND  MEDICINE  29 

general  conclusions  from  it  except  perhaps  this,  that  the  native  and 
naturalised  races  of  North  America  stand  better  than  the  recently 
imported.  Thus  the  red-skins,  the  aborigines,  stand  best ;  and  nearly 
as  well  stand  the  West  Indians,  the  coloured  men  of  the  States,  and  the 
British  Americans  —  mostly,  I  suppose,  French  Canadians,  —  a  hardy, 
unsophisticated  peasantry,  largely  crossed  with  Indian  blood. 

Respiratory  disease  is  found  rife  among  Spaniards  and  South  Ameri- 
cans, but  not,  as  might  have  been  expected,  among  Mexicans,  West 
Indians  or  Portuguese.  The  numbers  were  perhaps  insufficient,  except 
in  the  case  of  the  West  Indians. 

Dr.  Baxter  makes  a  remark  on  a  certain  relation,  signs  of  which 
appear  in  some  of  his  tables,  thoiigh  not  in  my  abstract  of  them.  It  is  a 
sort  of  general  resemblance  in  the  nosology  of  the  British  races,  among 
whom,  I  think,  he  means  to  include  the  American  whites,  as  compared 
with  the  other  races  observed.  He  found  the  proportion  of  rejections 
to  increase  with  age  and  with  height.  To  some  small  extent  the  latter 
fact  was  due  to  the  former  one,  but  the  increase  of  phthisis  with  a 
stature  beyond  65  inches  was  far  too  great  to  be  accounted  for  in  that 
way.  The  same  may  be  affirmed  of  cardiac  disease  and  varix,  both  of 
which  appear  to  increase  rapidly  with  increase  of  stature.  Hernia, 
however,  contrary  to  the  opinion  of  Boudin,  does  so  very  little,  or  not  at 
all.  General  debility,  as  a  cause  of  exemption  from  service,  decidedly 
lessens  with  increase  of  stature. 

In  all  these  there  is  a  distinct,  though  not  very  great  excess  of  men 
of  light  complexion.  There  are,  however,  a  number  of  morbid  conditions 
entailing  rejections,  the  majority  of  the  sufferers  wherefrom  are  set  down 
as  dark,  though  none  of  these  are  of  great  importance  numerically. 
Most  notable  are  dropsy,  cancerous  and  other  tumours,  cataract,  certain 
defects  or  affections  of  the  nervous  system  —  as  imbecility,  neuralgia, 
chorea  —  chronic  alcoholism,  chronic  pleurisy,  and  certain  affections  of 
the  portal  system,  as  liver  disease,  haemorrhoids  and  prolapsus.  It  may 
be  noted  that  most  of  these  are  precisely  the  vices  of  the  "  melancholic 
temperament." 

Next  in  value,  for  our  purposes,  to  the  great  American  statistics  are 
those  of  the  French  recruiting  service ;  not  so  much  for  their  intrinsic 
importance  as  for  the  light  thrown  upon  them  by  Boudin  and  Broca,  and 
by  the  investigations  of  Topinard  into  the  distribution  of  complexions, 
and  by  those  of  CoUignon  into  that  of  head-form  in  that  country.  More- 
over, great  as  is  the  assimilative  power  of  the  French  nation,  its  principal 
anthropological  types  —  the  Ky mric,  the  Keltic,  the  Mediterranean,  the 
Norman,  etc.  —  still  remain  tolerably  distinct. 

French  anthropologists  generally  take  the  view  that  the  Norman 
and  the  Kymric  types  are  but  varieties  of  one,  —  the  tall,  blond,  long- 
headed North  European  type ;  and  that  this,  so  far  at  least  as  it  appears 
in  France,  is  characterised  not  only  by  these  three  qualities,  but  also  by 
tendency  to  chest  disease,  to  dental  caries,  to  varices,  and  to  some  other 
affections,  from  all  of  which  the  short,  thick-set,  dark,  round-headed  Kelt 


30  SYSTEM   OF  MEDICINE 

of  the  central  provinces  is  comparatively  free.  The  southern  and  south- 
western portions  of  the  country  are  occupied  partly  by  the  last-mentioned 
race,  but  partly  by  short,  dark,  long-headed  people,  often  classed  together 
for  convenience  as  the  Mediterranean  or  Iberian  race ;  but  probably 
capable  of  analysis  into  more  than  one  type  or  stock,  not  to  speak  of 
various  admixtures  added  during  the  historic  period.  We  should  there- 
fore have  in  the  French  recruiting  statistics  an  opportunity  almost 
unequalled  of  testing  the  comparative  morbidity  of  different  types  of 
man,  and  the  nature  of  hereditary  morbid  tendencies,  could  we  rely  on 
the  carefulness  of  the  medical  examination  of  recruits.  Unfortunately, 
however,  there  is  intrinsic  evidence  that,  during  the  period  for  which 
we  have  published  statistics,  this  used  to  be  by  no  means  sufficiently 
careful  and  systematic. 

For  example,  it  was  the  practice  usually  to  measure  the  conscripts, 
and  reject  those  under  size,  before  investigating  the  other  possible  dis- 
qualifications. Of  course  this  plan,  otherwise  unobjectionable,  had,  from 
the  medico-statistical  point  of  view,  the  disadvantage  that  the  infirmities 
of  the  undersized  men  were  not  disclosed  or  tabulated,  and  that  those 
departments  which  yielded  a  large  proportion  of  small  men  did  not 
exhibit  in  the  reports  their  actual  proportion  of  myopia,  chest  disease, 
and  so  forth,  but  only  the  proportions  occurring  in  the  taller  men.  But 
sometimes  this  order  seems  to  have  been  reversed,  with  the  effect  of 
assigning  to  the  department  or  commune  under  examination  too  high  a 
stature,  but  its  full  proportion  of  infirmities.  These  things  must  be 
borne  in  mind  in  the  examination  of  the  table  which  I  have  constructed 
in  order  to  exhibit  the  relative  morbidities  of  several  groups  of  depart- 
ments, selected  on  anthropological  grounds.  The  column  headed,  "  Do., 
probable,  corrected,"  is  the  residt  of  an  attempt  to  neutralise  the  errors 
resulting  from  these  defects  of  method.  Though  conjectural,  I  have  no 
doubt  it  comes  much  nearer  to  the  truth  than  the  ofiicial  statement. 
Boudin's  book  was  published  when  France  had  eighty-six  departments ; 
she  subsequently  gained  three,  and  then  again  lost  other  three,  so  that 
the  number  is  once  more  eighty-six.  In  forming  my  table  I  have  always 
taken  the  several  departments  in  what  may  be  called  the  order  of  excel- 
lence ;  thus,  under  the  column  of  *'  Dolichokephaly  "  No.  1  would  be  the 
department  with  most  long-headed  men ;  under  that  of  "  Mortality  "  No. 
1  would  be  the  department  with  the  lowest  death-rate,  No.  86  that  with 
the  highest ;  under  that  of  "  Myopia  "  No.  1  would  be  the  department 
with  the  fewest  short-sighted  youths,  and  so  forth.  In  making  my 
groups  I  have  thrown  together  the  ordinal  figures  belonging  to  several 
departments,  and  set  down  the  average  in  the  table.  Thus,  in  the  case 
of  the  ten  departments  yielding  the  tallest  men  (or  rather  the  fewest 
undersized  men),  I  set  down  5.  But  the  order  in  which  they  produce 
tall  men  is  slightly  different  from  that  in  which  they  are  free  from 
dwarfs,  so  that  the  average  position  of  these  same  ten,  in  that  column, 
comes  out  as  low  as  12. 

Bertillon's  order  of  mortality  also  requires  explanation.    Instead  of 


ANTHROPOLOGY  AND  MEDICINE  31 

assessing  the  mortality  simply  on  tlie  aggregate  population  of  all  ages, 
Bertillon  calculated  the  death-rate  for  each  of  twelve  age-periods  on  the 
population  living  at  such  ages  respectively,  and  averaged  the  several 
orders  thus  obtained  in  order  to  get  the  proper  rank  of  the  department. 
The  result  is  sometimes  a  startling  change  in  its  position.  Thus  the 
Seine-et-Marne  stands  fifty -fifth  on  the  ordinary  plan,  with  a  death-rate  of 
23-5.  This  low  position  is  really  owing  to  the  great  number  of  children 
sent  out  from  Paris  to  be  nursed  in  this  neighbouring  department,  who 
sustain  a  frightful  mortality.  The  ultimate  rank  of  the  Seine-et-Marne, 
on  Bertillon's  plan,  would  be  the  twenty -third ;  the  average  of  its  several 
ranks,  which  I  have  chosen  for  use  in  my  table,  being  29.  The  Seine-et- 
Oise  similarly  leaps  from  the  sixty-fifth  to  the  fortieth  place,  with  an 
average  rank  of  41.  Indre,  where  the  infant  mortality  is  low,  falls  from 
tenth  to  fiftieth,  with  average  49,  and  Creuse  from  sixth  to  fifty-first, 
with  50. 

The  table  (p.  32)  is  full  of  instruction,  and  yields,  on  examination,  some 
valuable  and  unexpected  results,  of  a  nature  not  directly  germane  to  our 
inquiries.  Thus,  the  very  pregnant  fact  comes  out  that  high  mortality 
and  military  inefficiency  —  or  unsound  health  from  the  recruiting-officer's 
point  of  view — stand  in  no  direct  relation  to  each  other:  in  truth  the 
relation  is  very  frequently  inverse.  Thus,  of  all  my  fifteen  categories 
the  Breton  departments  stand  worst  in  regard  to  mortality,  but  best 
by  far  in  point  of  soundness ;  while  the  ten  thinly-peopled  low^-country 
departments  have  the  worst  rate  of  exemption  for  unsoundness,  but, 
with  one  exception,  the  lowest  rate  of  mortality. 

The  most  promising  lines  of  investigation  for  us,  however,  are  those 
afforded  by  pulmonary  disease  (including  especially  phthisis),  by  mental 
derangement,  by  myopia,  and  by  defects  of  the  teeth. 

Of  these  the  first,  as  we  have  learned  already,  has  some  relation  to 
tall  stature,  and  this  law  is  borne  out  by  our  table,  wherein  the  depart- 
ments of  highest  stature  take  the  forty-eighth  rank,  but  those  of  lowest 
stature  the  thirty-fourth.  There  appears  no  evidence  that  colour,  per  se, 
has  anything  to  do  with  the  matter ;  the  comparatively  blond  Lor- 
rainers,  for  example,  standing  very  Avell  in  this  as  in  most  other  respects, 
and  the  dark  Provencals  very  badly.  The  great  towns  stand  ill,  of 
course ;  but  when  we  find  that  the  ten  departments  where  the  northern 
dolichokephalic  race  is  most  in  evidence,  and  the  five  of  Normandy,  and 
the  five  which  I  have  selected  as  best  exhibiting  the  combination  of  tall 
stature,  long  head,  and  blond  complexion,^  agree  in  yielding  a  high 
average  of  phthisical  recruits,  little  doubt  remains  on  my  mind  that  we 
have  to  do  with  an  affair  of  race  or  heredity.  This  is  in  some  degree 
confirmed  by  the  Belgian  statistics,  which  exhibit  the  Flemings  and  Bra- 
bancons  as  yielding  more  tall  recruits  and  more  cases  of  phthisis  than 
the  Walloons.^    Here,  as  in  other  parts  of  our  subject,  cause  and  effect 

1  Viz.,  Pas  de  Calais,  Somme,  Aisne,  Oise,  and  Calvados,  the  last  only  a  Norman  de- 
partment.   I  excluded  Nord  and  Seine  Inferieure  as  having  a  strongly  urban  character. 

2  See  Vanderkindere's  and  Houze"s  papers  on  Belgian  Anthropology. 


32 


SYSTEM  OF  MEDICINE 


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ANTHROPOLOGY  AND  MEDICINE  33 


are  almost  inextricably  confounded;  and,  in  order  to  understand  the 
problems,  the  local  history  and  conditions  must  be  studied.  Thus  in 
France  — • 

Of  10  brachykephalic  departments,  only  1  has  more  than  the  average 

density  of  population. 
Of  10  Nortliern  dolichokephalic  departments  10  have  more. 
Of     5  Norman  ,,  5  ,, 


Of    4  Breton 

Of  10  Most  blond 

Of  10  Darkest 

Of  10  Southern  dolichokephalic 


We  in  England,  with  our  almost  unchequered  experience  of  higher 
phthisical  death-rates  in  cities  than  in  rural  districts,  would  be  inclined 
to  say  at  once,  "Here,  in  the  greater  density  of  population,  is  the  one 
and  sufficient  reason  for  the  greater  ai]tiount  of  phthisis  in  the  recruits 
from  Flanders  and  Picardy  and  Normandy  !  "  This  would  be  too  hasty 
a  conclusion.  In  France,  as  ray  table  shows,  the  hard-wrought,  ill-fed 
peasantry  of  the  plains  suffer  much  from  phthisis  and  scrofula.  The 
peasantry  of  Limburg,  the  most  Germanic  province  of  Belgium,  and 
perhaps  the  most  rural  except  Luxemburg,  stand  about  the  worst  in 
this  respect.  On  the  other  hand  Bretagne,  the  least  phthisical  part  of 
France,  has,  as  we  have  seen,  a  dense  population. 

The  fact  is  the  tall,  long-headed  blond  population  is  where  it  is 
by  reason  of  its  physical  and  moral  qualities ;  its  striving,  ambitious, 
masterful  character,  which  enabled  it  to  occupy  the  best  and  most  fertile 
parts  of  France,  leaving  the  hills  and  heaths  to  the  dark,  short-headed 
Kelts. 

Mental  alienation  has  not  the  same  distribution  as  phthisis  and 
pulmonary  disease,  which  seem  to  affect  the  dark  southern  or  Mediter- 
ranean race  as  much  as  the  fair  northern  one ;  sparing  only  the  sturdy, 
dark,  broad-headed  people  of  the  centre,  and  the  anomalous  Bretons. 
The  number  of  the  insane  seems  to  be  large  throughout  the  blond  area,^ 
where  it  is  probably  a  race-character  ;  and  also,  of  course,  in  the  districts 
of  the  great  cities. 

It  has  been  affirmed  that  myopia  is  structurally  connected  with 
dolichokephaly,  the  deep  orbit  and  the  long-axed  eyeball  going  naturally 
with  the  long  head.  A  certain  amount  of  evidence  has  been  adduced  in 
support  of  this  idea ;  and  the  tall  blond  race  has  been  saddled,  in  the 
minds  of  some  anthropologists,  with  yet  another  hereditary  defect.  The 
evidence  of  my  table  is  not  conclusive  either  for  or  against  this  view 
but  it  certainly  does  something  to  render  it  unlikely.  Of  the  five  de- 
f  lartments  selected  as  representative  of  the  type,  one  only,  the  Aisne,  had 
an  excess  of  myopes ;  and  of  the  ten  most  blond  departments  only  two, 

'  I  flraw  this  inference  from  Boudin's  fignres,  vol.  ii.  235-7;   but  they  are  perhaps 
hardly  sufficiently  detailed,  though  very  striking. 

VOL.    I  D 


34  SYSTEM  OF  MEDICINE 

viz.,  Eure  and  Seine  Inferieure.  In  fact,  myopia  distinctly  belongs  to 
the  dark-eyed  inhabitants  of  the  south  of  France,  and  to  those  of  the 
cities,  with  the  strange  exceptions  of  Lyons  and  the  urban  district  of 
the  ISTord :  Brachykephals  have  their  full  share  of  it. 

The  subject  of  defective  teeth  would,  of  course,  furnish  material  for  a 
goodly  volume.  So  far  as  my  materials  testify,  good  teeth  in  France  go 
with  short  average  stature,  dark  complexions,  and,  less  distinctly,  with 
broad  heads.  Bad  teeth  concur  with  tall  stature,  and  almost  as  clearly 
with  long  heads  and  blond  complexion.  Or,  to  put  it  in  another  way, 
teeth  are  good  in  the  mountains  as  a  rule,  bad  in  the  plains,  and 
especially  bad,  as  Boudin  himself  remarked,  around  the  mouths  of  all 
the  great  rivers.  They  are  good  among  the  Auvergnats  (or  central 
Kelts),  and  especially  so  among  the  Bretons ;  also  in  the  Catalans  of 
Rousillon,  etc. ;  bad  among  the  northern  blond  long-heads  (including 
the  Normans),  and  among  the  Gascons ;  moderately  good  among  the 
Ligurians.  In  all  these  cases  the  boundaries  are  pretty  clearly  drawn, 
so  as  almost  irresistibly  to  suggest  that  either  the  hereditary  constitution 
of  the  several  races  or  kindred,  or  something  in  the  local  (may  I  say 
tribal)  habits  and  customs  Biust  have  to  do  with  the  phenomena.  For 
example,  the  Loire  Inferieure  was  formerly  politically  a  part  of  Bretagne, 
but  its  people  were  not  Bretons  in  blood  and  customs.  Accordingly  the 
Bretons  have  a  very  high  mortality  and  very  good  teeth ;  the  Nantese,  or 
Lower  Loire  folk,  have  a  low  mortality  and  very  bad  teeth.  On  the 
other  hand  the  neighbouring  department  of  Mayenne  was  not  Breton 
politically,  but  its  people  are  said  to  resemble  the  Bretons  in  character. 
Accordingly  they  have  a  rather  high  mortality  and  excellent  teeth ! 

This  connection  between  good  teeth  and  a  high  death-rate  is  strange, 
but  unquestionable.  Of  the  ten  departments  which  furnish  the  fewest 
exemptions  for  defective  teeth,  every  one  has  an  excessive  mortality, 
and  in  most  cases,  and  on  the  average,  a  very  excessive  one.  They 
are  all  in  two  masses,  viz.,  1.  Auvergne  and  Lyonnais  ;  2.  Bretagne 
with  Mayenne.  If  we  seek  for  dietetic  causes  of  caries,  we  shall  find 
that  the  great  wine-producing  districts,  Gironde,  Dordogne,  Marne,  Cote 
d'Or,  as  well  as  the  cider-drinking  Normandy,  are  among  the  worst  on 
the  list.  But,  after  all,  there  is  plenty  of  sour  wine  in  Auvergne  and 
of  cider  in  Bretagne. 

On  the  whole,  then,  I  am  disposed  to  subscribe  to  the  belief  of  the 
French  anthropologists,  that  we  have  here  another  example  of  a  heredi- 
tary and  constitutional  defect.  But  it  is  one  which  cannot  be  dated 
back  indefinitely ;  it  must  have  been  developed  on  French  soil.  Even 
now  the  Scandinavians,  the  purer-blooded  cousins  of  the  northern  French, 
are  generally  "  euodont ;  "  and  it  is  certain  that  when  the  Saxons  invaded 
England,  and  the  Franks  and  Normans  Gaul,  they  were  still  so.  If  Harold 
of  Denmark,  the  conqueror  of  the  Cotentin,  had  not  been  a  singular 
exception,  he  would  hardly  have  been  nicknamed  Blue-tooth. 

In  the  British  Isles  we  have  no  such  groundwork  of  statistics  to 
work  upon  as  those  on  which  I  have  been  building  from  America  and 


ANTHROPOLOGY  AND  MEDICINE  35 

Prance,  and  I  have  little  more  than  personal  observation  whereto  to 
trust.  This,  however,  is  sufficient  to  enable  me  to  assert  that  phthisis 
is  not  here,  as  some  have  supposed,  especially  prevalent  among 
blonds.^  The  proportions  of  the  several  colours  of  hair  and  eyes  in  the 
sufferers  are  not  very  different  from  those  which  obtain  in  the  general 
population.  If  anything,  there  is  even  an  excess  of  black  and  very  dark 
hair.  Some  statistics  given  me  by  Dr.  Edward  Liddon  of  Taunton, 
from  the  Brompton  Consumption  Hospital,  are  confirmatory  of  my 
own.  I  i/im/t,  however  (on  this  point  statistics  are  unavailable),  that 
hereditary  phthisis  in  the  upper  ranks  often  presents  itself  in  a  frail 
blond  type  with  very  light  hair ;  and  I  am  sure  that  a  fine  transparent 
skin  is  a  sign  of  vulnerability.  In  fact,  the  typical  victim  of  phthisis 
is,  in  my  opinion,  a  tall  person  with  blue  eyes,  a  transparent  complex- 
ion, and  dark  hair.  Such  persons  are  also  more  liable  to  haemorrhages ; 
it  would  seem  that  in  them  other  structures  partake  of  the  delicate 
organisation  of  the  skin. 

I  have  already  said,  api-opofi  of  the  supposed  absence  of  chorea  from 
the  Chinese,  that,  whatever  its  connection  with  rheumatism,  it  is  a 
disease  specially  belonging  to  the  nervous  temperament.  Fatal  and 
severe  cases  almost  always  present  the  signs  of  that  temperament. 
There  is  usually  something  remarkable  about  the  development  of  pig- 
ment ;  the  hair  is  often  coal  black,  but  sometimes  extremely  light, 
flaxen,  or  pale  red.  Epileptics,  cataleptics,  ecstatics,  thought-readers, 
clairvoyants  are  very  frequently  of  one  or  other  of  these  strongly- 
contrasted  colour-types.  Mania  seems  to  occur  rather  more  often  in 
the  xanthous  type,  with  chestnut,  red  or  fair  hair ;  but  with  regard  to 
melancholia  the  observation  of  the  ancients  was  undoubtedly  correct  : 
it  belongs  especially  to  the  type  which  they  called  melancholic,  whose 
outward  signs  are  tall  stature,  olive  complexion,  and  straight  dark  hair. 

More  than  one  theory  has  been  advanced  as  to  the  physical  con- 
stitution which  furnishes  the  best  seed-bed  for  cancer.  For  example,  it 
has  been  said  to  be  very  common  in  persons  with  orange-hazel  eyes,  or 
with  eyes  in  which  the  colour  is  much  mixed  or  broken,  in  which  the 
general  effect  on  a  distant  view  is  green.  My  OAvn  observations  have 
not  confirmed  this  notion.  Cancer,  in  my  opinion,  is  most  common  in 
people  who  have  a  fairly  healthy  constitution  in  other  respects.  The 
prevailing  complexion,  among  the  subjects  of  cancer  in  this  country,  is 
dark.  Out  of  sixty-seven  such,  English  and  Scotch,  I  found  eight  with 
black  or  brown-black  hair,  and  thirty-two  with  dark  brown ;  thirty-four 
had  light,  ten  neutral,  and  twenty-three  dark  eyes.  These  figures  vary 
from  those  of  the  surrounding  non-cancerous  population  very  decidedly 
in  the  direction  of  darkness.  Dr.  Roger  Williams,  who  has  also  investi- 
gated this  subject  and  on  a  somewhat  larger  scale,  has  kindly  shown 
me  his  figures,  which  bear  out  my  own  conclusion.  It  will  be  remem- 
bered that  Dr.  Baxter's  American  statistics  also  agree  with  our  own 
on  this  point.  Of  course  it  does  not  necessarily  follow  that  cancer  is 
1  See  analysis  of  upwards  of  1000  cases  in  Races  of  Britain,  pp.  222,  223. 


36  SYSTEM   OF  MEDICINE 

at  all  more  prevalent  among  generally  swarthy  than  among  generally 
blond  nations;  nor  am  I  aware  of  any  evidence  in  favour  of  such  a 
belief.  On  the  contrary,  there  is  some  reason  for  supposing  it  to  be 
a  disease  Avhose  development  is  favoured  by  civilisation,  comfort  and 
intellectual  progress  ;  and  these  are  on  the  whole  most  prevalent  in 
the  races  whom  Huxley  calls  Xanthochroi,  although  it  is  the  swarthy 
individuals  among  them  who  suffer  most. 

John  Beddoe. 

REFERENCES 

1.  Oesterlen.  Handbuch  der  medicinischen  Statistik.  Tubingen,  1875.  —  2.  Lom- 
bard. Climatologie  m^dicale.  Paris,  1877.  —  3.  Bertillon.  D^mographie  Figuree 
ds  la  France,  etc.  Paris,  1874.  —  4.  Boudin.  Geographic  medicale.  Paris,  1857. — 
5.  Lagneau.  Anthropologic  de  la  France.  Paris,  1879. — fi.  Bordier.  Geographic 
medicate.  Paris,  1884.  —  7.  Baxter.  Medical  Statistics  of  the  Provost-MarshaV s 
Bureau.  Washington,  1875.  —  8.  Hirsch.  Handbook  of  Historical  and  Geographical 
Pathology.  Translated  by  C.  Creighton,  M.D.  London,  188o.  —  9.  Haviland.  Geo- 
graphical Distribution  of  Disease,  etc.    London,  1875. 

J.  B. 


ON  TEMPEEAMENT 

Temperament  is  usually  understood  to  denote  a  certain  combination  of 
physical  and  mental  characteristics.  Its  practical  importance  is  of  two 
kinds ;  as  a  guide  to  the  disposition  to  certain  kinds  of  disease,  and 
as  a  guide  to  the  disposition  to  certain  lines  of  conduct:  the  subject 
of  temperament  has  been  treated  accordingly  by  two  classes  of  writers, 
medical  and  philosophical.  The  two  have  treated  the  subject  in  differ- 
ent ways :  the  physician  has  considered  chiefly,  and  often  exclusively, 
the  physical  aspect  of  temperament ;  the  psychologist,  on  the  other  hand, 
has  regarded  temperament  as  a  type  of  mental  character  with  tendencies 
to  certain  forms  of  emotion,  and  has  neglected  the  physical  side.  The 
doctrine  of  temperament  was  originally  founded  on  a  physiological 
basis,  and  physical  conceptions  of  temperament  prevailed  till  the  end 
of  the  last  century.  Kant  then  took  up  the  subject,  and  although  he 
made  use  of  terms  derived  from  the  character  of  the  blood,  his  treat- 
ment was  exclusively  psychological.  Since  the  time  of  Kant  the  sub- 
ject of  temperament  has  been  treated  more  fully  by  psychologists  than 
by  physicians,  and  the  popular  use  of  the  term  shows  that  the  word  has 
now  come  to  mean  a  certain  type  of  mind  rather  than  a  certain  type 
of  physical  organisation.  The  comparative  neglect  of  temperament  by 
recent  writers  on  medicine  is  not  surprising.  Medical  practice  has 
gradually  been  more  and  more  influenced  by  the  exact  methods  of 
modern  physiology ;  thus  it  is  natural  that  the  doctrine  of  temperament, 
resting  on  simple  observation  of  more  or  less  vague  characters,  should 
have  fallen  into  disuse.  At  the  present  time,  although  the  subject  of 
temperament  is  specifically  mentioned  by  few,  its  importance  is  being 


ON   TEMPERAMENT  37 


more  recognised.  The  predisposition  of  certain  individuals  to  certain 
forms  of  disease,  and  the  different  effects  which  the  same  dose  of  the 
same  drug  may  have  on  different  individuals,  are  well-recognised  facts 
which  show  the  importance  of  what  is  popularly  called  "  constitution." 
But  though  the  importance  of  constitution  or  temperament  is  acknowl- 
edged, little  has  yet  been  done  to  study  the  subject  on  modern  methods. 
Whenever  it  has  been  studied,  as  by  Stewart  in  his  book,  Our  TerriTpera- 
ments,  the  old  classification  has  been  adhered  to  with  far  from  satisfactory 
results.  The  importance  of  temperament  is  also  being  more  recognised 
in  relation  to  many  problems  of  practical  life  —  to  such  questions  as  the 
methods  of  education  and  the  choice  of  occupation  in  life.  Yet  here 
again  little  has  been  done  in  the  scientific  study  of  the  subject.  The 
doctrine  of  temperament  falls  under  the  head  of  individual  as  opposed 
to  general  psychology,  under  the  head  of  that  branch  of  psychology 
which  deals  with  the  differences  which  distinguish  different  minds 
rather  than  of  that  which  deals  with  the  laws  of  mind  in  general. 
Individual  psychology  has  been  comparatively  neglected  not  only  by 
the  older  school  of  psychologists,  but  also  by  the  recent  experimental 
school ;  and  it  is  but  quite  recently  that  a  beginning  has  been  made  in 
the  systematic  investigation  of  the  mental  characters  on  which  a  scien- 
tific doctrine  of  temperaments  should  be  based. 

In  order  to  establish  such  a  doctrine,  it  will  first  be  necessary  to 
study  more  closely,  and  by  more  exact  methods  than  hitherto,  the  phys- 
ical differences  which  distinguish  different  individuals.  Much  has  been 
done  in  this  way  by  anthropologists ;  but  their  investigations  have  been 
carried  out  chiefly  from  an  ethnological  stand-point,  and  it  is  probable 
that  their  methods  will  have  to  be  modified  to  suit  the  different  end  in 
view.  A  second  necessity  is  the  investigation  of  mental  differences  by 
exact  methods.  This  has  hitherto  been  the  greatest  difficulty  in  the 
way  of  a  scientific  doctrine ;  but  experimental  psychology  is  now  suffi- 
ciently advanced  not  only  to  show  how  this  may  be  done,  but  to  have 
taken  some  steps  in  this  direction.  Up  to  the  present  time  the  most 
important  work  on  these  lines  of  investigation  has  been  done  by  Mr. 
Galton.  On  the  physical  side  his  anthropometrical  researches  furnish 
the  kind  of  material  which  is  needed  to  establish  the  existence  of  dif- 
ferent groups  of  physical  organisation.  He  has  also  made  some  advance 
on  the  mental  side.  His  division  of  individuals  according  to  the  nature 
of  their  mental  imagery,  which  has  been  further  developed  by  Charcot 
and  Binet,  is  a  valuable  contribution  to  individual  psychology,  and  an 
example  of  the  kind  of  distinction  to  be  made  out.  At  present  the  most 
important  work  on  the  mental  side  is  being  done  by  Professor  Kraepelin 
of  Heidelberg.  He  and  his  school  work  at  the  subject  from  the  psychi- 
atrical point  of  view;  and  one  important  division  of  their  work  has 
been  the  investigation  of  certain  fundamental  properties  of  the  mind 
which  are  of  great  importance  in  the  study  of  temperament.  These 
include  the  capacity  for  mental  work,  the  susceptibility  to  fatigue  from 
mental  work,  the  power  of  recovery  from  such  fatigue,  the  extent  of 


38  SYSTEM  OF  MEDICINE 

the  influence  of  practice,  and  the  power  of  concentration  of  attention. 
They  have  also  investigated  the  relations  of  bodily  and  mental  fatigue, 
the  depth  of  sleep,  and  other  questions  of  psychical  or  psycho-physical 
capacity.  In  all  these  investigations  they  have  found  that  individual 
differences  occur ;  and  it  is  in  such  differences  as  these,  so  important  in 
relation  to  practical  life  as  well  as  to  insanity,  that  we  may  hope  to  find 
the  materials  for  a  new  classification.  It  would  be  fruitless  here  to 
attempt  to  formulate  a  new  sj^stem  of  temperaments.  Such  an  attempt 
should  only  be  made  on  the  basis  of  experience  gained  in  the  investiga- 
tion of  physical  and  mental  characters  by  methods  such  as  those  of 
Galton  and  Kraepelin. 

A  few  suggestions  in  this  direction  may,  however,  be  made.  There 
has  been  singular  unanimity  among  both  medical  and  philosophical 
writers  in  favour  of  a  fourfold  division  of  temperaments.  Both  Kant 
and  Lotze  accepted  the  old  division,  while  modifying  and  describing  the 
mental  characteristics  more  full}^  than  had  been  done  before.  Wmidt 
has  retained  the  old  types,  but  defines  them  on  the  basis  of  the  strength 
of  the  emotions,  and  of  the  rate  at  which  they  change.  Thus,  in  the 
choleric  temperament  the  emotions  are  strong  and  change  quickly ;  in 
the  melancholic,  strong  but  change  slowly;  in  the  sanguine,  weak  and 
quick ;  in  the  phlegmatic,  weak  and  slow.  One  recent  writer  goes  so 
far  as  to  say  that  the  fourfold  division  must  be  approved  ''by  all  who 
advocate  intelligently  any  theory  upon  the  subject."  In  spite  of  this 
consensus  of  opinion,  it  would  probably  be  best  to  put  the  older  classi- 
fication on  one  side,  and  to  start  afresh  from  the  beginning. 

In  one  direction,  however,  it  may  be  well  to  take  advantage  of 
previous  methods ;  the  old  doctrine  had  a  pathological  basis,  and  it  is 
probable  that  pathological  investigation  may  give  us  the  clue  to  a  more 
satisfactory  method.  It  is  customary  to  speak  of  certain  dispositions 
to  disease  as  diatheses,  of  Avhicli  the  nervous  diathesis  and  the  uric  acid 
diathesis  may  be  given  as  examples.  The  exact  investigation  of  the 
physical  and  mental  characters  of  these  diatheses  has  yet  to  be  carried 
out,  and  probably  no  more  useful  contribution  to  the  doctrine  of  tem- 
perament could  be  made  than  such  an  investigation. 

Another  line  of  inquiry  which  might  be  useful  is  the  study  of  the 
different  characters  of  the  two  sexes,  and  of  various  ages.  The  temper- 
aments of  age  have  been  most  fully  considered  by  Lotze.  He  regarded 
the  sanguine  as  the  temperament  of  childhood ;  the  melancholic,  or  as 
he  called  it,  the  sentimental,  as  the  temperament  of  youth  ;  the  choleric 
of  manhood,  and  the  phlegmatic  of  old  age.  The  reaction  to  disease  is 
known  to  vary  with  the  different  epochs  of  life,  and  it  is  probable  that 
exact  investigation  of  the  characteristics  of  different  ages  may  enable  us 
to  define  groups  of  temperament  useful  both  from  the  pathological  and 
sociological  points  of  view.  It  would  be  especially  interesting  to  dis- 
cover whether  the  individual  who  retains  in  adult  life  the  mental  traits 
which  are  found  to  be  characteristic  of  childhood,  retains  also  youthful 
characteristics  in  his  physical  organisation. 


ON  THE  LA  WS   OF  INHERITANCE  IN  DISEASE  39 

Another  possible  basis  for  a  classification  of  temperaments  is  purely 
psychological.  As  a  working  hypothesis  at  the  present  time,  the  cus- 
tomary tripartite  division  of  mind  might  be  accepted,  and  an  endeavour 
be  made  to  find  the  physical  and  mental  traits  which  characterise  the 
three  types  of  Auguste  Comte  —  the  man  of  thought,  the  man  of  feel- 
ing, and  the  man  of  action. 

It  must  be  remembered  that  a  satisfactory  doctrine  of  temperaments 
has  not  only  to  be  useful  in  defining  the  nature  of  the  more  special 
disposition  to  react  in  certain  ways  to  disease,  but  also,  and  perhaps 
more  essentially,  in  defining  the  nature  of  the  disposition  to  react  in 
certain  ways  to  other  and  more  general  features  of  the  environment. 

W.  H.  E.  Rivers. 

REFERENCES 

(a)  Temperament 

1.  Kant.  ^n^/iropoZo.gie,  Werke  vii.  S.  610.  — 2.  Prichard.  Cydopssdia  of  Practi- 
cal Medicine. — 3.  Lotze.  Microcosmus  (Eng.  trans.),  vol.  ii.  p.  24. — 4.  Laycock. 
Med.  Times  and  Gazette,  1862.  —5.  Henle.  Anthropologische  Vortrage,  Heft  i.  S.  103. 
—  6.  Wundt.  Grundziige  der  phys.  Psychologic,  4th  Aufl.  Bd.  ii.  S.  519.  —  7.  Ladd. 
Elements  of  Physiological  Psychology,  p.  574.  —  8.  Stewart.  Our  Temperaments. 
London,  1887.  —  9.  Siebeck.  Geschichte  der  Psychologic,  ii.  S.  278.  — 10.  Hutchinson. 
Pedigree  of  Disease.    London,  1884. 

(&)  Other  References 

1.  Galton,  F.  Inquiries  into  Human  Faculty,  London,  1883  ;  Natural  Inheri- 
tance, p.  71. — 2.  Kraepelin.  Ueber  geistige  Arbeit,  Jena,  1894.  Psychologische 
Arbeiten,  Bd.  i.  S.  1,  1895.  Der  psychologische  Versuch  in  der  Psychiatric. — 3.  Oehrn. 
Psychologische  Arbeiten,  Bd.  i.  S.  92.  Experimentelle  Studien  zur  Individual-psycho- 
logic. —  4.  Venn,  John.  "  On  the  Correlation  of  Mental  and  Physical  Powers,''  Monist, 
vol.  iv.  No.  1,  1893. —5.  Charcot.      CEuvres,  t.  iii.  p.  188. —6.  Binet.     Pev.  philos. 


t.  XXXV.  p.  104.    1893. 


W.  H.  R.  R. 


ON  THE  LAWS   OF   INHERITANCE   IN   DISEASE 

We  all  of  us  have  had  two  parents,  and  with  the  rarest  exceptions  four 
grandparents.  Most  of  us  have  had  eight  great  grandparents,  and 
probably  to  a  large  majority  no  fewer  than  sixteen  persons  have  stood 
in  the  relation  of  great-great-grandparents.  Now. since  tendencies  to 
individual  peculiarities,  involving,  it  may  be,  liability  to  special  forms  of 
disease,  may  be  transmitted  not  only  from  parents  and  grandparents,  but 
from  much  more  remote  ancestors  also,  it  is  obvious  that  their  investiga- 
tion presents  us  with  a  very  complicated  problem.  In  many  instances 
it  is  almost  hopeless  to  investigate  transmission  from  individual  to  in- 
dividual, and  we  may  arrive  at  safer  conclusions  by  estimating  average 
prevalence  in  races,  families,  or  classes  of  society.     It  is  in  this  latter 


40  SYSTEM  OF  MEDICINE 

. ^. 

way  only  that  many  questions  which  present  themselves,  not  only  to  the 
physician,  but  to  the  biologist  and  to  the  student  of  sociology,  can  be 
satisfactorily  looked  at.     \_Vide  art.  on  "Anthropology  and  Medicine."] 

We  must,  however,  in  the  beginning  endeavour  to  define  approxi- 
mately what  we  believe  to  be  possible  as  to  hereditary  transmission. 
Without  venturing  to  do  more  than  mention  the  Weissmann  logomachy, 
which  has  recently  disturbed  the  creeds  of  some  biologists,  I  will  take 
permission  to  avow  my  belief  that  with  the  sperm  and  germ  supplied  by 
parents  there  may  pass  to  the  offspring  tendencies  to  the  reproduction  of 
all  that  these  parents  had  acquired  up  to  the  date  of  the  sexual  congress. 
By  the  term  ''  acquired  "  is  aneant  all  that  has  been  received  by  modifi- 
cation of  vital  processes,  not  what  has  been  imposed  or  taken  away  by 
external  violence.  Not  only,  however,  may  offspring  derive  from  parent 
cells  peculiarities  of  cell  and  tissue  structure  with  the  proclivities  attach- 
ing to  them,  but  it  is  also  in  a  high  degree  probable,  that  in  some  in- 
stances parasitic  elements  or  specific  poisons  may  pass  directly  into  the 
tissues  of  the  embryo.  Such  parasitism  may  be  absolutely  latent  in  the 
parent,  and  may  remain  so  for  indefinite  periods  in  the  offspring. 

We  have  then  an  inheritance  of  structural  peculiarities  aiid  tenden- 
cies which  is  more  or  less  certain,  and  in  addition  to  it  an  inheritance  of 
parasitic  germs  or  of  poisons,  which  is  uncertain  and  in  a  sense  accidental. 
Respecting  this  inheritance  of  specific  poisons  it  is  necessary  here  to 
premise  that  Avhat  takes  place  may  be  contamination  in  utero  rather 
than  inheritance  in  the  more  strict  sense  of  the  word.  The  two  parents 
do  not  stand  in  an  exactly  similar  relation  to  their  offspring  in  this 
matter.  The  father  cannot  possibly  convey  any  poison  unless  it  be  pres- 
ent in  his  semen  ;  the  mother,  on  the  other  hand,  is  in  vital  relations  with 
the  foetus  for  nine  months  after  conception,  and  may,  at  any  date  during 
that  period,  convey  to  it  any  poison  which  has  meauAvhile  found  its  way 
into  her  blood.  Thus  variola  cannot  possibly  be  conveyed  by  the  father 
to  the  foetus  so  as  to  develop  only  after  the  birth  of  the  latter ;  but  the 
mother  may  communicate  it  during  any  period  of  her  pregnancy  up  to 
the  last  month.  The  same  is  the  case  with  syphilis,  and  possibly  with 
so2ne  other  specific  diseases. 

It  may  be  convenient  to  speak  first  of  the  laws  of  inheritance  of 
these  diseases  which  are  caused  by  specific  poisons.  Of  these  the 
principal,  and  the  one  respecting  which  most  is  known,  is  s^yphilis ;  and 
it  may  be  allowed  to  stand  as  an  illustration  of  the  rest.  The  facts  in 
our  possession  make  it  very  probable  that  when  syphilis  is  derived  by  a 
child  from  a  parent,  it  is  conveyed  by  the  actual  transference  of  some 
specific  material,  probably  of  a  particulate  and  organic  nature.  The  child 
does  not  inherit  any  modification  of  tissues  which  the  parent  may  have 
undergone,  but  takes  over  specific  germs  which  are  destined  to  multiply 
in  its  blood  and  produce  phenomena  of  similar  character  and  in  similar 
order  to  those  which  its  parent  has  previously  manifested.  This  char- 
acter and  this  order  may  be  greatly  modified,  but  they  will  be  essentially 
the  same.     Thus,  however  much  the  health  of  a  parent  may  have  been 


ON   THE  LAWS   OF  INHERITANCE  IN  DISEASE  41 

damaged  by  syphilis,  lie  will  transmit  to  his  offspring  nothing  unless 
the  specific  virus  of  the  disease  be  present  in  his'  semen,  and  in  those 
particular  spermatozoa  which  go  to  the  fertilisation  of  that  particular 
ovum.  A  man  might  on  this  hypothesis  beget  a  syphilitic  child  one 
week,  and  a  non-infected  one  the  next ;  nay,  it  is  even  possible  that  of 
twins  one  may  receive  the  poison  and  the  other  escape  it.  It  is  needful 
to  state  this  definitely,  for  although  we  have  as  yet  no  direct  proof  of 
this  proposition,  the  hypothesis  is  necessary  to  any  clear  comprehension 
of  the  facts. 

The  following  are  the  facts  which  appear  to  have  been  established 
respecting  the  inheritance  of  syphilis :  — 

That  the  father  may  infect  his  offspring  (the  mother  having  never 
suffered  in  any  degree),  and  that  this  is  by  far  the  most  frequent  mode 
by  which  the  taint  is  transmitted. 

That  the  mother  may  infect  her  offspring,  and  that  she  may  do  this 
not  only  at  the  time  of  conception,  but  at  any  period  during  pregnancy, 
up  to  within  the  last  few  weeks. 

That  there  is  much  uncertainty  whether  a  child  will  or  Avill  not 
receive  the  poison  of  syphilis  when  born  of  parents  one  or  both  of  whom 
are  tainted.  Thus  a  child  may  wholly  escape  under  circumstances 
apparently  the  most  dangerous. 

That  the  nearer  the  conception  to  the  date  of  primary  disease,  in 
one  or  both  parents,  the  greater  the  risk  to  the  child. 

That  in  the  tertiary  stage  a  parent  may  suffer  severely  and  yet 
have  healthy  offspring. 

That  the  severity  of  the  disease  in  the  child  is  in  no  relation  to  that 
shown  by  the  parent  —  many  of  the  worst  instances  occurring  in  children 
of  parents  who  were  apparently  in  good  health.  Severity  in  the  child 
is  therefore  probably,  as  in  the  adult,  a  matter  of  idiosyncrasy  in  the 
recipient,  and  not  of  peculiarity  as  to  source. 

Of  twins  one  may  suffer  and  the  other  escape. 

Although  it  is  the  rule  for  the  first-born  after  the  parental  acquisition 
to  suffer  and  for  younger  ones  to  escape,  yet  now  and  then  remarkable 
exceptions  to  the  rule  may  occur. 

That  with  rare  exceptions,  the  period  during  which  a  parent  retains 
the  poison  of  syphilis  in  a  transmissible  state  is  limited.  In  the  father 
it  rarely  exceeds  two  years,  but  as  regards  the  mother  nothing  trust- 
worthy can  be  stated. 

Although  in  the  case  of  syphilis  no  one  has  yet  succeeded  in  recog- 
nising the  specific  germ  which  is  its  cause,  whilst  in  tiiberculosis  this 
is  supposed  to  have  been  accomplished,  yet  the  fact  respecting  contagion 
and  inheritance  remains  far  more  vague  and  uncertain  in  the  latter  than 
in  the  former  malady.  When  a  disease  may  be  obtained  by  contagion 
unwittingly  and  very  easily  —  its  germs  possibly  being  almost  omni- 
y) resent  —  it  becomes  very  difficult  to  prove  anything  as  to  inheritance. 
Thus  there  are  not  wanting  those  who,  relying  too  exclusively  upon 
modern  doctrines  of  bacillary  causation,  and  supporting  their  creed  by 


42  SYSTEM  OF  MED  I  CI  ATE 

so-called  statistics,  are  disposed  to  deny  altogether  the  effect  of  inheri- 
tance in  tuberculosis.  In  the  investigation  of  this  important  question, 
we  must  not  restrict  ourselves  to  the  narrow  platform  of  tubercular 
disease  of  the  lungs.  We  must  comprise  all  the  various  maladies  with 
which  we  now  associate  the  tubercle  bacillus,  and  take  in  all  forms  of 
bone,  joint,  and  gland  scrofula,  with  also  the  various  affections  of  the 
eye  and  the  skin  (lupus  and  its  allies)  which  are  in  such  association.  If 
in  this  way  we  take  cognisance  of  the  whole  domain  of  scrofula  and  tuber- 
culosis, it  is,  I  think,  impossible  for  any  one  acquainted  with  the  facts  to 
disbelieve  in  the  power  of  hereditary  transmission,  and  rest  only  on  the 
theory  of  contagion  from  without.  The  subject  is  one  much  too  compli- 
cated to  be  well  suited  for  illustration  by  statistical  calculations  ;  these 
are  as  likely  to  mislead  as  to  help  us. 

Two  factors  are  admittedly  of  great  importance  in  reference  to  the 
development  of  tubercular  affections :  we  must  take  cognisance  not  only 
of  the  bacillus  itself,  but  also  of  the  state  of  the  tissues  upon  which  it  is 
implanted.  The  possibilities  of  inheritance  are  therefore  twofold.  It 
may  be  that  the  bacillus  itself  may  pass  bodily  or  potentially  with  the 
sperm  or  germ  from  parent  to  child,  or  it  may  be  that  a  condition  of 
tissues  liable  to  its  attacks,  but  for  the  time  free  from  its  presence,  may 
be  the  result  of  transmission.  If  we  are  permitted  to  name  the  tissue- 
condition,  which  is  prone  to  favour  the  development  of  the  tubercle 
bacillus,  the  name  "scrofula"  will  perhaps  be  convenient  for  the  present. 
A  child  may  then  inherit  "  scrofula  "  without  the  bacillus,  or  the  bacillus 
without  "scrofula";  or,  what  probably  is  most  common,  both  may  be 
present  together.  Pathological  facts  leave  us  in  no  doubt  that  the 
tubercle  bacillus  may  find  its  way  into  the  body  of  the  foetus  in  utero 
and  may  there  develop.  Whether  it  does  so  in  association  with  the 
semen,  or  in  union  with  the  maternal  germ ;  or  whether  it  is  always 
derived  by  the  ovum  from  the  mother's  blood,  we  are  as  yet  uninformed. 
We  may  plausibly  conjecture  that  any  one  of  these  three  modes  is  an 
easy  possibility.  The  life  history  of  the  tubercle  bacillus  is  probably  by 
no  means  wholly  known  to  us.  We  do  not  know,  for  instance,  what  are 
the  conditions  or  how  long  the  periods  under  and  during  which  it  may 
remain  latent  in  the  tissues.  Many  clinical  facts  suggest  that  it  may 
in  some  resting  form  be  present  in  most  persons  —  waiting  until  some 
local  damage  or  some  degradation  of  general  health  gives  it  opportunity 
for  development.  The  prevailing  creed  which  suspects  external  conta- 
gion as  the  cause  of  all  scrofulous  and  tuberculous  attacks  is  probably  a 
much  too  narrow  one.  It  is  clear,  however,  that  as  regards  the  heredity 
of  phthisis  and  scrofula,  we  can  at  present  do  little  more  than  state 
preliminary  facts  and  suggest  possibilities.  We  are  by  no  means  yet  in 
a  position  to  put  forward  conclusions. 

If  we  turn  from  tuberculosis  to  leprosy,  a  malady  which  is  possibly 
a  congener,  we  shall  encounter  similar  sources  of  uncertainty.  Yet,  if 
we  can  get  a  clear  view  of  the  facts,  the  two  will  perhaps  throw  some 
light  on  each  other.    Firstly,  a  bacillus  very  like  that  of  tubercle  attends 


ON   THE  LA  WS   OF  INHERITANCE  IN  DISEASE  43 


the  development  of  all  the  most  severe  forms  of  leprosy.  When  leprosy 
ends  fatally  it  is  often  by  the  supervention  of  pulmonary  disease  not 
distinguishable  from  phthisis.  The  facts  as  regards  contagion  are  much 
the  same  in  the  two,  and  are  matters  chiefly  of  conjecture.  In  both 
maladies  it  is  certain  that  almost  unlimited  opportunities  for  contagion 
may  occur  without  any  evidence  of  its  accomplishment.  Now,  until 
quite  recent  times,  the  belief  in  the  hereditary  transmission  of  leprosy 
has  been  almost  universal.  The  more  careful  investigations  of  modern 
observers  have,  however,  thrown  much  doubt  upon  this  creed.  It  is 
quite  certain  that  the  children  of  lepers,  born  out  of  leper  districts  — 
in  England  or  the  United  States  for  example  —  never  inherit  it.  The 
occurrence  of  the  disease  in  the  children  of  lepers  in  a  leprosy  district  is 
no  evidence  at  all ;  for  obviously  they  have  been  exposed  to  the  endemic 
cause  whatever  that  may  be.  If  it  be,  after  all,  a  food  disease,  they  may 
have  partaken  of  the  tainted  substance.  The  recent  inquiries  of  the 
Leprosy  Commission  in  India,  which  collected  facts  at  the  Schools  for  the 
Children  of  Lepers,  pointed  to  the  conclusion  that  there  is  no  jDroof  of 
heredity,  since  these  children  did  not  manifest  the  disease  in  greater 
proportion  than  others.  The  very  prolonged  periods  during  which 
leprosy  may  remain  absolutely  latent  (ten  years  or  more)  introduces, 
however,  an  element  of  uncertainty  into  all  these  investigations.  We 
may  safely  believe  that  in  the  case  of  leprosy  the  influence  of  heredity 
is  a  very  small  factor,  but  it  would  be  unwise  to  deny  its  possibility. 

If  we  turn  now  to  the  consideration  of  maladies  which  are  induced, 
not  by  any  specific  virus,  but  by  the  inheritance  of  anatomical  or 
physiological  peculiarities,  a  few  general  propositions  may  be  ventured. 

There  is  probably  no  peculiarity,  whether  of  structure,  of  function, 
or  both,  which  can  be  acquired  or  augmented  during  the  life  of  the 
individual  which  may  not  be  reproduced  in  his  or  her  offspring ;  yet 
the  transmission  of  such  peculiarities  is  by  no  means  a  matter  of  cer- 
tainty :  one  child  may  suffer  and  another  escape.  Of  this  uncertainty 
double  parentage  is  probably  the  chief  explanation. 

It  is  quite  possible  for  an  individual  in  whom  any  given  tendency 
derived  from  a  parent  may  never  have  disclosed  itself  to  transmit  such 
tendency.  Thus  a  disorder  or  peculiarity  present  in  a  grandfather  may 
be  revealed  in  his  grandchild  just  as  special  features  in  the  countenance 
or  other  resemblances  may  be  transmitted.  It  is  possible,  indeed,  that  a 
peculiarity  of  structure  leading  to  derangement  of  function  may  be  trans- 
mitted through  many  generations,  and  yet  show  itself  in  very  few  indi- 
viduals in  each.  Under  some  laAv,  as  yet  not  well  understood,  it  is  possible 
for  a  peculiarity  of  structure  to  show  itself  suddenly  in  several  children 
of  the  same  parents,  there  being  no  proof  of  its  previous  occurrence  in 
the  progenitors.  To  this  group  of  maladies  the  term  family  diseases 
has  been  given ;  but  it  must  be  clearly  understood  that  it  refers  to  the 
members  of  one  single  family  and  not  to  descendants  in  several  generations. 

Illustrations  of  the  wide  topic  upon  which  we  now  enter  occur  on 
every  side.     The  inability  to  digest  the  albumen  of  eggs  and  of  milk 


44  SYSTEM   OF  MEDICINE 

whicli  is  often  met  with  as  an  idiosyncrasy  in  related  individuals  in 
several  generations  must  depend  upon  the  constitution  of  the  gastric 
juice,  which  in  its  turn  is  due  to  some  peculiarity  in  the  glandular 
apparatus  of  the  stomach.  It  may  serve  as  an  example  of  a  thousand 
other  peculiarities,  some  more  and  soine  less  well  marked.  To  the 
whole  group  we  give  the  name  idiosyncrasies ;  and  although  we  leave 
them  for  the  most  part  unexplained  they  are  none  the  less  real,  and 
dependent  no  doubt  upon  actual  structural  aberrations.  Very  often  a 
sufferer  knows  that  some  predecessor  —  grandparent  or  great-grand- 
parent—  had  the  same  peculiarity.  Were  habits  of  family  observation 
and  record  more  cultivated,  no  doubt  such  evidence  would  be  still  more 
frequently  forthcoming. 

Psoriasis  does  not  very  often  affect  several  brothers  and  sisters,  but 
it  frequently  seems  to  be  transmitted  from  parent  or  grandparent.  Thus 
it  may  persist  through  many  generations,  but  still  affect  but  very  few 
individuals.  Its  subjects  are  almost  always  in  good  health,  and  the 
balance  of  evidence  as  to  its  nature  would  incline  us  to  suspect  that  it 
depends  upon  an  inherited  peculiarity  of  the  structure  of  the  skin. 

The  laws  of  inheritance  come  to  our  aid  in  explanation  of  many 
of  the  peculiarities  presented  by  exceptional  diseases  of  the  skin ;  and 
these  in  turn  illustrate  the  laws  of  inheritance  in  a  very  instructive 
manner.  Inherited  peculiarities  in  structure  must  be  invoked  to  explain 
such  phenomena  as  excessive  tendency  to  freckle;  the  liability  to  blister 
in  the  sun,  proneness  to  chilblains,  liability  to  urticaria  and  pruritus. 
It  is  for  the  most  part  those  who  have  inherited  a  skin  in  which  the 
sebaceous  glands  are  large  who  become  the  subjects  of  comedonous  acne. 

Amongst  the  "  family  diseases  "  which  chiefly  show  themselves  on 
the  skin  we  have  the  common  forms  of  xeroderma  or  ichthyosis ;  and 
the  rare  malady  known  as  Kaposi's  disease,  or  xeroderma  pigmentosum. 
In  ichthyosis  almost  invariably  one-half  of  the  family  of  children  suffer 
whilst  the  others  wholly  escape.  Evidence  of  it  is  often  but  not  always 
present  at  birth.  There  appears  to  be  no  regard  to  sex.  The  same 
statements  are  true  of  Kaposi's  malady,  which  consists  of  a  most 
excessive  tendency  to  the  formation  of  freckles,  which  are  apt  to  run 
into  ulceration.  Its  occurrence  reveals  a  congenital  imperfection  in 
the  structure  of  the  skin,  which  renders  it  unable  to  withstand  the 
irritation  of  ordinary  sunlight.  In  this  feature  it  has  much  in  common 
with  retinitis  pigmentosa,  a  disease  occurring  often  in  several  members 
of  one  family,  and  due  to  degenerative  changes  in  the  retina  apparently 
induced  by  exposure  to  light. 

The  tendency  to  bleed  on  slight  cause,  which  constitutes  the 
"  hsemorrhagic  diathesis,"  affords  us  another  good  example  of  a  family 
disease.  It  is,  however,  not  one  of  those  which  is  restricted  to  a  single 
generation,  being  almost  always  an  heirloom,  and  with  the  peculiarity 
that  it  manifests  itself  almost  exclusively  in  the  male  sex.  It  is  quite 
possible  that  our  inferences  on  this  latter  point  may  be  somewhat  exag- 
gerated, for  the  menstrual  relief  in  women  not  improbably  prevents  other 


ON   THE  LAWS   OF  INHERITANCE  IN  DISEASE  45 

forms  of  haemorrhage,  and  in  families  in  which  the  males  are  bleeders 
menstruation  in  the  women  is  often  x^rofuse.  The  proved  relationship 
of  haemophilia  to  inherited  gout  leads  to  the  consideration  of  the  latter 
malady  itself  in  reference  to  inheritance.  This  is  a  topic  which  requires 
much  patient  attention  to  detail  for  its  clear  apprehension.  It  is  not  a 
simple  matter :  we  must  not  restrict  our  conception  of  gout  to  attacks 
of  acute  podagra,  but  must  include  in  the  term  all  the  conditions  which 
lead  up  to  such  attacks,  or  can  be  proved  to  be  in  association  with  them. 
By  general  consent  the  liability  to  gout  is  hereditary ;  indeed  it  may 
even  be  doubted  whether  in  its  more  typical  forms  it  is  ever  acquired  in 
a  single  generation.  That  the  gouty  state  may  be  induced  by  luxurious 
living  and  defective  exercise  is  a  proposition  which  no  one  will  deny ; 
that  it  can  be  so  induced  with  equal  facility  in  all  persons  is,  however, 
well  known  not  to  be  the  case.  In  some  very  slight  errors  in  self-man- 
agement will  cause  it ;  whilst  in  others  no  excess,  however  long  contin- 
ued, seems  to  be  sufficient.  The  difference  as  we  observe  it  under  the 
existing  conditions  of  society  is  probably  in  the  main  a  difference  in  the 
strength  of  inheritance,  though  at  the  same  time  it  may  be  true  that 
certain  differences  in  race,  family,  and  temperament  may  in  the  first 
instance  have  made  themselves  felt.  Of  the  middle  classes  of  society 
in  England,  and  amongst  other  communities  where  gout  has  been  long 
prevalent,  it  may  be  held  that  all  inherit  the  tendency  more  or  less 
remotely.  If  we  attempt  to  explain  in  what  that  tendency  consists,  we 
must  begin  by  saying  that  in  the  first  place  it  consists  in  peculiarities 
of  appetite  and  digestion,  and  next  in  defects  in  the  excretory  organs. 
The  man  who  inherits  gout  inherits  peculiarities  of  stomach  and  kidneys, 
and  of  all  organs  which  are  concerned  in  the  assimilation  of  food  and 
the  depuration  of  the  blood.  We  may  take  this  as  perhaps  the  simplest 
expression  of  the  inheritance  of  gout;  but  there  must  follow  on  it  the 
assertion  that  he  inherits  also  peculiarities  of  various  other  kinds.  His 
cartilages  and  ligaments,  his  nerves,  his  muscles,  his  blood-vessels,  in 
fact  every  tissue  in  his  body,  has  acquired  some  modification,  and  with 
it  some  special  proclivity  to  disease.  Congestions,  inflammations,  nerve 
pains,  whatever  may  have  been  their  exciting  causes,  will  in  him  assume 
a  special  character  and  lead  to  specialised  results.  Thus  the  offspring 
of  generations  of  gouty  ancestry  may,  in  virtue  of  such  descent,  suffer 
from  various  maladies  which  stand  in  no  direct  relation  with  errors  in 
diet,  defective  assimilation,  or  the  accumulation  of  urates  in  the  blood. 
One  of  these  is  the  weakening  of  blood-vessels,  which  is  the  proximate 
cause  of  haemophilia,  and  may  also  find  its  expression  in  epistaxis, 
haemorrhagic  purpura,  bleeding  into  the  vitreous,  and  other  phenomena. 
In  the  same  way  inherited  gout  may  be  the  parent  of  iritis  in  early  life, 
and  of  various  forms  of  joint  disease  at  all  periods  of  life,  which  are 
wholly  unassociated  with  the  deposit  of  urate  of  soda  in  the  structures. 
It  is  an  inheritance  of  tissue  proclivity  independently  of,  though  usually 
in  addition  to,  peculiarities  of  assimilation  and  excretion.  Nor  must  it 
be  forgotten  that  these  inherited  liabilities  may  have  been  inextricably 


46  SYSTEM   OF  MEDICINE 

mixed  with  others.  Feebleness  of  circulation,  instability  of  nerve  func- 
tion, scrofula,  and  other  causes  of  disease,  may  have  joined  with  inheri- 
tance of  gout,  and  the  resulting  state  may  thus  be  a  very  complicated  one. 

It  is  not  necessary  to  say  more  than  a  few  words  respecting  the 
heredity  of  congenital  defects  in  the  growth  of  external  parts.  It  is 
univei-sally  admitted  that  such  defects  as  coloboma  iridis,  harelip, 
superfluous  digits,  webbed  digits,  and  the  like  may  be  and  commonly 
are  hereditary.  We  also  observe  respecting  them  that  occasionally  they 
occur  in  many  members  of  the  same  family ;  whilst  there  is  little  or  no 
evidence  as  to  their  occurrence  in  former  generations.  This  has  been 
especially  noted  in  certain  instances  of  harelip  and  defects  in  the  iris, 
and  it  is  especially  of  iiiterest  in  reference  to  the  explanation  of  other 
forms  of  ''  family  disease." 

Another  important  law  Avhich  receives  occasional  illustration  in  these 
very  obvious  hereditary  defects  is  that  of  ''  transmutation  in  transmis- 
sion." By  this  expression  is  meant  that  the  defect  reproduced  is  not 
always  exactly  the  same  as  that  in  the  predecessor.  Thus  one  child 
may  have  a  superfluous  digit,  and  another  of  the  same  family  merely  a 
deformed  and  overgrown  one.  What  is  hereditary  is  clearly  a  liability 
to  disturbance  in  the  development  of  a  certain  portion  of  protoplasm, 
but  falls  short  of  the  necessary  production  of  identity  of  result.  This 
law  is  probably  of  wide  applicatioi  under  conditions  in  which  it  is  not 
so  easy  to  prove  its  influence.  In  the  case  of  various  forms  of  skin 
disease  it  may  be  conjectured  that  a  liability  to  defective  formation  of 
the  skin  in  general  is  the  antecedent  rather  than  a  definite  proclivity  to 
one  single  type  of  malady.  Thus  an  inheritance  from  a  parent  who  has 
suffered  from  psoriasis  may  possibly  be  transmitted  as  ichthyosis,  or 
some  form  of  chronic  eczema  or  lichen.  Many  of  the  known  facts  as 
regards  "family  diseases"  support  the  belief  that  some  law  of  unity 
in  variety  influences  their  production. 

Jonathan  Hutchinson. 


MEDICAL   GEOGEAPHY   OF   GEE  AT   BEITAIN 

That  branch  of  medicine  Avhich  has  for  its  subject  the  Geographical 
Distribution  of  Disease,  may  be  said  to  have  had  a  very  remote  origin 
in  the  ancient  Coan  School  of  Medicine,  of  which  the  family  of  Hip- 
pocrates were  the  founders.  In  this  school  the  study  first  sprang 
into  existence  as  far  as  we  can  judge,  and  then  flourished  for  a  time 
under  the  care  of  the  author  of  Airs,  Places,  and  Watei's,  the  head 
of  the  above  distinguished  family,  whose  genius,  common-sense,  and 
vast  experience,  extending  over  an  unusually  long  life  of  active  prac- 
tice among  the   isles  of  the  Greek  Archipelago,   and   the  mainland 


MEDfCAL   GEOGRAPHY  OF  GREAT  BRITAIN  47 

of  Greece,  Thrace,  and  the  Coast  of  Asia  Minor,  enabled  him  to 
accumulate  a  vast  number  of  clinical  facts  bearing  upon  the  relation 
between  certain  classes  of  disease  and  certain  conditions  of  soil,  water, 
and  atmosphere.  Within  the  circumference  of  his  wide  experience  he 
had  almost  every  variety  of  land-surface  from  the  Mount  Olympus  to 
the  paludal  lakes  of  the  plain,  and  the  swamps  alongside  the  river 
mouth ;  over  those  lands  he  noted  the  sweep  of  the  atmospheric  currents, 
the  different  lie  and  aspects  of  their  slopes  towards  wind  and  sun.  Of 
the  winds  he  studied  their  moisture,  dryness,  and  temperature,  and  at- 
tributed the  excess  or  defect  of  these  qualities  to  their  courses  over  the 
neighbouring  lands  and  seas.  The  different  effects  of  the  various  waters 
on  mankind  —  the  hard,  the  soft,  the  brackish,  and  paludal  —  were  also 
noted  by  Hippocrates,  and  locally  the  effects  of  Aveather  and  seasons 
were  also  studied  by  him,  whether  in  his  reports  of  clinical  cases,  or  of 
epidemics  (1). 

In  the  etiology  of  disease  Hippocrates  evidently  foresaw  the  great 
importance  of  the  physical  configuration  of  the  land,  its  aspects  and 
soils,  and  the  influence  of  the  two  great  factors  of  local  climates,  the 
sun  and  the  atmosphere,  —  the  latter  ever  varying  in  its  currents, 
temperature,  moisture,  and  adventitious  constituents,  Avhether  of 
mechanical,  vegetable,  or  animal  origin.  The  later  results  of  the 
study  of  medical  geography  justify  these  early  anticipations  of  that 
great  physician. 

Since  the  death  of  Hippocrates  (b.c.  480-357)  the  subject  stood  still 
until  the  publication  by  Dr.  Alexander  Keith  Johnston  of  his  well-known 
Physical  Atlas  of  Natural  Phenomena  (2),  in  which  maps  appeared  of  the 
geographical  distribution  of  certain  diseases.  The  data  were  gathered 
principally  from  the  works  of  our  naval,  military,  and  mercantile  marine 
medical  officers  and  others,  within  whose  stores  of  facts  there  are  many 
that  might  still  be  profitably  studied. 

In  1856  the  eminent  French  physician  and  medical  geographer, 
Boudin,  published  his  GeograpJue  Medicale,  based  principally  on  the 
statistics  of  the  French  army  —  the  first  statistics  used  in  the  study  of 
medical  geography.  In  this  work  France  was  divided  into  departments, 
each  so  shaded  as  to  indicate  death-rates,  or  the  number  of  conscripts 
rejected  on  account  of  certain  diseases  in  proportion  to  the  populations. 

In  England  the  data  for  constructing  maps  of  disease  distribution 
were  not  published  in  serviceable  form  until  the  late  Dr.  William  Farr 
issued  his  Decennial  Supplement  for  1851-1860  to  the  Registrar- 
General's  (Major  Graham)  25th  Annual  Report  in  the  year  1864.  Dr. 
Farr  published  two  supplements,  including  the  decennial  periods  1851- 
1860  and  1861-1870,  giving  the  number  of  deaths  from  twenty-five 
different  causes  at  certain  age-periods,  among  males  and  females  sepa- 
rately, for  each  of  the  630  registration  districts  during  each  of  these  ten 
years ;  since  then  the  present  Registrar-General  has  confused  the  sexes 
and  rendered  his  supplement  for  1871-1880  useless  for  this  branch  of 
study. 


48  SYSTEM   OF  MEDICINE 

The  history  of  disease  distribution  is  fully  dealt  with  in  my  recently 
published  work  (3)  ;  I  will  now  give  the  salient  facts  resulting  from  my 
own  investigations  from  the  year  1868  up  to  the  present  time. 

The  first  firm  step  in  the  study  of  the  medical  geography  of  Great 
Britain  was  made  Avithin  a  short  time  of  the  publication  by  Dr. 
William  Farr,  C.B.,  of  the  supplement  already  referred  to.  In  this 
important  and  model  report  the  deaths  from  twenty-four  different  causes 
during  the  ten  years  1851-1860,  in  each  of  the  630  registration  districts 
of  England  and  Wales,  were  arranged  in  two  tables,  one  for  males  and 
one  for  females  respectively.  The  mean  populations  of  each  sex  in  each 
district  were  divided  into  so  many  (17)  age-periods,  giving  (1)  the  mean 
number  of  males  and  females  living  during  the  decennium  at  each  age- 
period;  and  (2)  the  number  of  deaths  from  each  of  the  twenty-four 
causes  during  the  same  time  at  each  of  the  said  age-periods :  thus  the 
death-rate  from  each  cause  at  each  age-period  could  be  calculated  —  the 
mean  populations  at  the  different  ages  being  given  in  the  same  column 
as  the  actual  number  of  deaths  from  the  different  causes.  With  the 
life  and  death  statistics  so  arranged  the  medical  geography  of  England 
and  Wales,  and  the  construction  of  maps  showing  the  geographical 
distribution  of  each  cause  of  death  in  the  630  districts,  became  possible 
for  the  first  time  in  the  annals  of  medicine;  and  future  investigations 
into  the  causes  of  the  varieties  of  the  several  distributions,  as  well  as  of 
the  marked  inequality  of  the  distribution  of  each  individual  cause  of 
death,  found  a  solid  basis.  Such  a  map  once  constructed  and  coloured 
in  varying  shades,  enables  the  student  at  once  to  compare  it  with  other 
maps  of  the  geology,  physical  geography,  hydrography,  meteorology, 
etc.,  of  the  country  under  observation ;  and  lastly,  with  other  maps  of 
the  distribution  of  other  diseases  over  the  same  area,  and  of  the 
distribution  of  the  yield  of  such  crops  as  wheat,  a  plant  whose  habits 
and  peculiar  construction  I  have  shown  to  be  remarkable  exponents  of 
local  climates. 

In  1875,  Avhilst  my  first  folio  edition  was  going  through  the  press, 
the  Registrar-General  of  Scotland  issued  his  Supplement  to  the  Annual 
Reports  for  the  ten  years  1861-1870,  which  contained  a  summary  of  the 
deaths  in  each  of  the  thirty-three  counties  during  that  period  from 
heart  disease,  phthisis,  and  cancer:  he  did  not,  however,  take  the 
precaution  of  separating  the  sexes,  or  of  giving  the  number  of  deaths 
and  the  mean  populations  at  each  age-period.  It  enabled  me,  how- 
ever, to  extend  my  inquiries  and  to  construct  sketch  maps,  although 
very  imperfect  ones,  of  the  distribution  of  the  above  causes  of  death  in 
that  part  of  Great  Britain. 

I  will  now  give  an  outline  of  what  has  been  achieved  in  the  medical 
geography  of  England  and  Wales. 

Heart  Disease.  —  The  first  map  constructed  was  that  of  the  geo- 
graphical distribution  of  heart  disease  and  dropsy  during  1851-1860, 
amongst  a  mean  population  of  18,996,916,  or  9,278,742  males  and 
9,718,174  females,  distributed  over  630  registration  districts,  amongst 


MEDICAL    GEOGRAPHY  OF  GREAT  BRITAIN  49 


whom  had  occurred  236,973  deaths  from  this  cause,  of  whom  109,527 
were  males  and  127,446  females. 

As  the  annual  death-rates  from  this  cause  were  found  to  differ  only 
as  11-8  (males)  to  13-1  (females),  a  careful  study  of  the  death-rates  of 
the  two  sexes  in  each  district  was  made  :  the  diiference  in  the  mortality 
attributable  to  sex  was  found  too  small  to  necessitate  two  maps, 
especially  as  the  organ  affected  was  common  to  both.  The  map,  there- 
fore, represented  the  deaths  of  both  sexes,  namely,  236,973,  or  nearly 
a  quarter  of  a  million,  and  at  all  ages.  The  districts  having  a  mortality 
from  heart  disease  ahove  the  average  of  the  whole  country  (12-0  to  every 
10,000  living)  were  coloured  in  shades  of  hlue,  the  darkest  blue  repre- 
senting the  highest  mortality ;  and  those  having  death-rates  below  the 
average  were  coloured  red  in  different  shades,  the  darkest  red  represent- 
ing the  lowest  mortality. 

A  map  was  constructed  and  coloured  in  accordance  with  the  above 
scale,  which  ranged  from  4-6  —  the  lowest  rate  —  to  19-21,  the  highest 
annual  death-rates  to  every  10,000  males  and  females  living  in  each 
registration  district  during  the  ten  years  1851-1860. 

Tlie  Map  of  Heart  Disease.  —  When  a  map  of  the  630  districts  in 
England  and  Wales  is  coloured  on  such  a  scale,  and  each  separate 
district  coloured  with  a  shade  of  blue  or  red  according  to  its  death-rate, 
it  will  be  found  that  instead  of  the  map  presenting  the  appearance  of 
a  "  crazy-patch  work,"  it  will  be  characterised,  according  to  the  disease 
chartographed,  by  groups  of  red  and  blue  districts,  which  suggest  at 
once  to  the  observer  that  some  unknown  general  condition  gives  a 
certain  measure  of  uniformity  to  the  forms  and  positions  of  the  groups 
he  sees  before  him. 

The  observer  must  now  compare  the  disease-map,  and  its  remarkable 
groups  of  high  and  loiv  mortality,  with  a  good  map  of  the  physical 
geography  of  the  same  country  —  such  as  that  constructed  by  the  late 
Sir  A.  C.  Eamsay  (Stanford)  —  and  carefully  note  each  physical 
feature  represented  on  it  with  each  group  of  high  and  Ioav  mortality. 
This  will  prove  an  easier  task  than  at  first  it  appears  to  be,  for  every 
country,  even  the  smallest  islands,  have  their  water-partings  and 
river-catchment  basins,  their  ridges  of  high  ground,  and  their  valleys 
in  the  lower,  through  which  the  rivers  and  their  tributaries  take  their 
courses  to  the  ocean  or  some  inland  sea.  Throughout  Great  Britain 
these  river-catchment  basins  have  been  well  defined  on  excellent  maps 
which  help  the  student  at  every  step  of  his  investigation.  In  the  case 
of  heart  disease  the  first  glance  at  the  two  maps  will  disclose  the 
following  remarkable  coincidences :  —  (1)  The  east  coast  of  England  and 
the  west  coast  of  Wales — in  fact,  those  parts  of  the  country  most  exposed 
to  the  force  of  the  sea-winds — are  characterised  by  almost  continuous 
groups  of  low  mortality,  red.  (2)  Wherever  on  the  physical  map  the 
outlets  and  courses  of  the  large  rivers  are  seen  to  have  their  axes 
corresponding  in  direction  with  the  prevailing  winds  —  such  as  the 
south-west  and  north-east  —  groups  of  low  mortality  are  observed  oa 

VOL.   I  E 


5° 


SYSTEM    OF  MEDICINE 


the  disease-map  invariably  to  extend  far  into  the  country,  as  in  the 
cases  of  the  Tyne,  the  Tees,  the  Humber,  the  ISTorfolk  and  Suffolk  rivers, 
the  Thames,  the  Severn  and  Avon,  the  Welsh  rivers,  the  Mersey,  the 
Westmorland  and  Cumberland  rivers.  On  the  other  hand,  (3)  wherever 
the  trends  or  axes  of  the  rivers  are  more  or  less  at  such  angles  to  the 
courses  of  the  prevailing  winds  as  to  preclude  their  free  access,  and  force 
them  to  blow  over  their  valleys  instead  of  sweeping  up  through  them, 
there  on  the  disease-map  we  see  groups  of  high  mortality  (blue).  In 
the  latter  instance  the  river  valley  systems  are  imperfectly  air-flushed, 
as  in  Hampshire,  Dorsetshire,  Devonshire,  Herefordshire,  and  other 
districts  where  the  axes  of  the  rivers  are  opposed  to  perfect  ventilation 
by  the  prevailing  and  other  winds. 

The  exceptions  to  the  littoral  groups  of  low  mortality  are  found  to 
be  in  those  districts  characterised  on  the  physical  map  by  high  pre- 
cipitous and  rock-bound  coasts,  which  protect  the  land  to  the  leeward, 
and  thus  offer  barriers  to  air-flushing.  Coincident  with  these  conditions 
are  groups  of  districts  of  high  mortality  (blue),  as  in  Northumberland, 
the  North  Hiding,  Somersetshire,  and  Devonshire.  With  these  facts 
before  us  we  begin  to  understand  the  importance  of  the  characters  of  the 
foreshores  of  a  country ;  for  in  studying  the  two  maps  in  detail,  district 
by  district,  we  are  constantly  meeting  with  the  coincidences  of  flat 
foreshores  and  low  mortality,  and  precipitous  foreshores  and  high 
mortality,  which  are  in  harmony  with  the  low  mortality  of  the  well- 
flushed  valleys  and  the  high  mortality  of  those  imperfectly  ventilated. 

Since  tlie  above  results  Avere  obtained  I  have  visited  all  the  high- 
est mortality  districts,  and  found  that  great  prevalence  of  endemic 
rheumatism  in  one  form  or  other  coincided  with  the  heavy  death-rates 
from  heart  disease.  I  have  also  mapped  out  the  data  for  1861-1870, 
and  found  that  the  distribution  of  liUjli  and  low  mortality  groups  during 
the  second  corresponds  with  those  of  the  first  decennium.  During  the 
ten  years  1861-1870  the  mean  population  amounted  to  10,417,596 
males  and  10,971,619  femdes,  of  whom  died  from  heart  disease  136,531 
males,  and  151,916  females,  equal  to  a  total  mortality  of  288,447,  which 
added  to  the  mortality  from  this  cause  during  the  first  period,  brings  the 
total  mortality  to  more  than  half  a  million  deaths  spread  over  twenty 
years  (525,420),  and  enables  us  to  formulate  the  proposition :  (a)  That 
throughout  England  and  Wales  low  mortality  from  heart  disease  is  found 
in  all  those  districts  where  the  valley-systems  are  open  to  the  free  air- 
flushing  by  the  prevailing  and  other  sea-winds ;  and  on  the  other  hand 
Mgh  mortality  is  found  in  all  those  districts  with  protected  valley-systems, 
the  river  courses  of  which  are  at  such  angles  as  to  preclude  free  air-flush- 
ing, and  to  force  the  winds  to  blow  over  instead  of  uip  through  them. 
Such  unventilated  valleys  are  equivalent  to  the  "  stuffy  hollows  "  which 
the  experience  of  Hippocrates  taught  him  to  denounce,  and  which,  as  I 
found  by  another  investigation  even  in  such  a  fertile  county  as  Devon, 
were  incapable  of  producing  a  wheat-yield  above  twenty-one  bushels  per 
acre,  the  average  for  England  and  Wales  being  twenty-nine  bushels. 


MEDICAL    GEOGRAPHY   OF  GREAT  BRITAIN  51 

We  now  proceed  to  the  medical  geography  of  a  totally  different  cause 
of  death  —  cancer;  and  as  this  disease  is  twice  as  prevalent  among 
females  as  among  males,  we  shall  confine  ourselves  to  its  distribution 
amongst  that  sex. 

Cancer.  —  During  the  ten  years  1851-1860,  amongst  the  female  popu- 
lation above  stated  (9,718,714),  there  occurred  throughout  England 
and  Wales  42,137  deaths  at  all  ages  from  this  cause,  —  a  death-rate 
equal  to  4-33  to  every  10,000  females  living ;  whereas  amongst  the  male 
population  (9,278,742)  there  occurred  only  18,059  deaths  at  all  ages, 
equal  to  an  annual  death-rate  of  1-94  to  every  10,000  living,  or  less 
than  half  that  for  the  other  sex.  The  scale  represents  the  usual  six 
degrees  of  mortality,  those  above  the  average  in  shades  of  blue,  and 
those  helow  in  shades  of  red,  representing  different  annual  death-rates  — 
the  lowest  between  1-2  to  every  10,000  living  (darkest  red),  and  the 
highest  6-7  (darkest  blue).  The  scale  for  deaths  among  females  at  and 
above  thirty-five  years  of  age  ranged  for  the  same  period  from  below 
10  to  18  and  upwards. 

A  map  of  the  630  registration  districts  of  England  and  Wales  so 
coloured  according  to  the  mortality  at  all  ages,  or  at  and  above  thirty- 
five  years  of  age,  presents  certain  well-defined  groups  of  high  (blue)  and 
low  (red)  mortality  as  in  the  case  of  heart  disease,  but  differs  from  this 
in  certain  important  features. 

If  we  place  such  a  map  by  the  side  of  the  one  of  physical  geography, 
we  shall  find  that  the  highest  mortality  groups  cluster  around  the  lower 
courses  of  fully-formed  rivers  that  seasonally  flood  their  riparial  districts, 
from  the  Tweed  to  the  Thames  on  the  east  coast,  and  from  the  Stour  to 
the  Tamar  on  the  south,  whilst  along  the  west  coast  of  England  and 
Wales,  with  the  exception  of  the  districts  watered  by  the  North  Devon 
Taw,  the  Severn,  the  Dee,  and  the  Eden,  low  mortality  predominates. 
On  the  east  coast  we  see  the  lower  courses  of  the  Tweed,  the  Tyne, 
the  Swale,  the  Derwent,  the  Humber,  the  Witham,  the  Ouse,  the 
Yare,  the  Stour,  and  the  Thames,  all  characterised  by  groups  of  high 
mortality.  We  see  similar  groups  surrounding  the  lesser  rivers  of 
the  south  coast ;  and  among  the  rivers  emptying  themselves  into  the 
Bristol  Channel  we  have  the  notable  examples  of  the  Severn  and  Avon 
marked  by  groups  of  high  death-rates,  and  farther  north  the  rivers 
Dee  and  Eden.  So  far  the  map  of  physical  geography  will  aid  us  up 
to  a  certain  point  as  regard  the  high  mortality  groups ;  but  when  we 
proceed  to  discuss  those  of  low  mortality  we  find  that  we  must  have 
recourse  to  a  geological  map  of  England  and  Wales,  such  as  Green- 
hough's,  although  in  the  final  stages  of  our  work  we  must  study  each 
district  and  each  parish  separately  side  by  side  with  the  maps  of  the 
Geological  Survey.  For  this  purpose  the  Sanitary  County  Diagrams,  on 
a  4-miles  to  the  inch  scale,  are  very  useful,  especially  as  an  index  map 
of  the  geology  of  Great  Britain  is  being  published  by  the  Geological 
Survey  on  the  same  scale.  On  comparing  the  low  mortalitj^  groups  of 
districts  with  the  same  areas  in  the  geological  and  physical  maps,  we 


52  SYSTEM  OF  MEDICINE 

shall  find  that  they  correspond  with  the  most  elevated  tracts  of  country 
—  tracts  where  floods  are  rare  or  temporary ;  in  fact,  the  lowest  mortality 
groups  follow  the  courses  of  the  water-partings,  whilst  the  highest,  as 
we  have  seen,  are  to  be  found  in  the  lowest  and  most  frequently  flooded 
valleys.  The  geological  map  further  informs  us  that  the  areas  covered 
by  the  lowest  mortality  groups  correspond  with  areas  of  the  older 
rocks,  such  as  the  Cambrian,  Silurian,  and  Mountain  Limestone ; 
whereas  the  highest  mortality  areas  are  coincident  with  the  more  recent 
formations,  especially  when  they  consist  of  days,  such  as  the  Oxford, 
Lias,  Gault,  Wealden,  London,  and  the  still  more  recent  alluvial. 

We  are  therefore  able  to  summarise  the  above  facts  in  this  propo- 
sition :  that  the  cancer  fields  in  Eiigland  and  AY  ales  are  found  in  the 
sheltered  and  low  lying  vales,  traversed  by  fully  formed  and  seasonally 
flooded  rivers,  and  composed  of  the  more  recent  argillaceous  formations; 
and  that  the  districts  having  the  lowest  death-rates  from  this  cause 
occupy  the  more  elevated  areas  composed  of  the  oldest  rocks,  amongst 
which  the  limestone  areas  are  coincident  with  the  very  lowest  mortality. 

Phthisis  among  Females. — In  studying  the  distribution  of  phthisis 
we  shall  again  have  recourse  to  the  map  of  physical  geography.  We 
have  now  to  deal  with  populations  having  in  their  midst  an  indefinite 
number  of  individuals  bearing  in  their  lungs  the  bacillus  tuberculosis  of 
Koch.  In  every  district  there  are  males  and  females  acting  as  hosts  to 
this  parasite ;  and  clinical  observation  tells  us  that  such  individuals  are 
at  all  times  liable  to  fatal  disease  when  exposed  to  certain  persistent 
causes  of  irritation  and  subsequent  inflammation  of  the  lung  tissue  in 
the  neighbourhood  of  the  parasitic  colonies.  Amongst  these  are  sudden 
chills  from  exposure  to  cold  when  heated,  or  to  more  protracted  chills 
from  dampness  of  clothing.  But  there  is  another  source  of  irritation 
of  the  delicate  mucous  membrane  of  the  lungs  ending  too  frequently  in 
inflammation  and  suppuration  of  the  lung  tissue,  namely,  exposure  to 
the  force  of  strong  winds  from  the  sea.  We  all  know  the  almost 
instantaneous  effects  of  exposure  to  such  winds  even  among  the  health- 
iest and  strongest,  as  evidenced  by  watering  of  the  eyes  and  running  at 
the  nose,  signs  of  temporary  catarrh,  which  too  frequently  extends 
to  the  lungs,  and  there,  in  the  consumptive,  arouses  the  fatal  activity 
of  the  hitherto  dormant  tubercle  bacillus. 

Now  of  the  9,718,174  females  who  lived  during  the  ten  years  1851- 
1860  more  than  a  quarter  of  a  million  died  from  phthisis  pulmonalis 
(269,618),  —  the  scale  of  six  degrees  ranging  from  17-20,  the  loivest 
(darkest  red),  to  37-40,  the  highest  (darkest  blue). 

Eemembering  what  the  heart  disease  map  taught  as  to  the  effect 
of  the  prevailing  sea-winds  blowing  up  through  and  air-flushing  the 
valleys  lying  in  this  direction,  we  shall  have  no  difficulty  in  recognising 
the  areas  most  exposed  to  the  force  of  the  sea-winds;  and  on  the 
contrary,  those  other  areas  that  are  so  shut  in  by  barriers  to  their 
free  access  as  to  form  unventilated  hollows,  in  which  those  with 
damaged  lungs  find  protection  from  their  force  and  other  qualities  of 


MEDICAL    GEOGRAPHY  OF  GREAT  BRITAIN  53 

the  sea  gales  which  render  them  injurious  to  lungs  which  are  either 
morbidly  sensitive  or  already  invaded  by  the  bacillus  of  Koch.  Thus 
along  the  coast  of  the  eastern  counties,  and  far  inland  from  the  low 
foreshores,  we  observe  a  large  and  important  group  of  high  mortality 
districts.  This  area  in  the  heart  disease  map  is  characterised  by  an 
equally  large  group  of  low  death-rates.  Again,  a,long  the  coast  of 
Wales,  up  to  its  central  ridge  or  back-bone,  is  another  large  group  of 
very  high  mortality  which  corresponds  to  the  large  group  of  low 
mortality  from  heart  disease.  Again,  along  with  the  low-lying  north- 
western foreshore  and  far  inland  —  an  area  well  exposed  to  the  sea- 
winds,  especially  to  those  from  the  north-west  —  and  that  which  on  the 
heart  disease  map  showed  a  low  mortality,  is,  however,  in  this  phthisis 
map  coloured  in  the  darker  shades  of  blue,  indicating  a  very  high 
mortality  from  the  latter  cause.  On  the  other  hand,  the  low  mortality 
groups  of  phthisis  are  to  be  found  on  the  leeward  side  of  the  Welsh  back- 
bone where  the  air  is  purest,  but  robbed  of  its /orce,  which  had  been  broken 
on  the  windward  side  of  the  mountains  where  the  highest  mortality  pre- 
vailed. Again,  if  we  study  the  low  mortality  groups  along  the  north-east 
coast  of  Yorkshire  and  Northumberland,  we  shall  find  that  these  areas 
are  protected  by  the  precipitous  cliffs  of  the  coast  lines  from  the  full  force 
of  the  sea-winds.  If  we  now  take  the  protected  Thames  valley,  where 
so  much  rheumatism,  heart  disease,  and  cancer  prevail,  we  shall  find 
another  large  group  of  low  mortality  from  phthisis,  notwithstanding  the 
dampness  of  the  climate  arising  from  clays  and  floods. 

If  we  now  compare  the  phthisis  and  cancer  maps,  we  shall  become 
aware  of  the  strong  contrast  that  one  bears  to  the  other.  As  a  rule 
where  high  mortality  groups  (blue)  are  found  in  the  one,  low  mortality 
groups  {red)  are  seen  in  the  other,  and  vice  versa;  this  arises  from  the 
fact  that  cancer  prevails  in  the  deep,  low-lying,  well-protected  river- 
valleys,  where  the  force  of  the  sea-winds  is  mitigated.  If  we  now 
examine  the  low  mortality  groups  of  cancer  we  shall  find  them  on  the 
high,  dry  Palgeozoic  and  much  exposed  formations,  where  phthisis  pre- 
vails. 

The  propositions  as  regards  the  distribution  of  heart  disease,  cancer, 
and  phthisis,  laid  down  for  England  and  Wales  are  equally  applicable 
to  those  causes  of  death  in  North  Britain. 

The  benefits  to  be  derived  from  this  study,  which  is  far  too  vast  to 
be  adequately  handled  within  the  space  of  this  article,  are  of  a  two- 
fold character.  To  the  medical  practitioner  the  maps  are  guides  in  his 
consulting  room,  which  enable  him  to  avoid  recommending  places  unfit 
for  the  relief  .of  the  several  diseases  under  disciission.  With  such  maps 
before  him  he  would  hardly  recommend  a  member  of  a  cancerous  family 
to  reside  in  a  low-lying,  oft-flooded  argillaceous  district ;  or  of  a 
phthisical  family  to  take  up  his  abode  where  he  would  be  exposed  to 
the  full  force  of  strong  sea-winds ;  or  a  rheumatic  person  with  threatened 
heart  affection  to  continue  living  in  the  stuffy,  unventilated  hollows 
first  described  by  Hippocrates. 


S4  SYSTEM  OF  MEDICINE 

Secondly,  the  maps  will  direct  the  bacteriologist  to  the  localities 
where  the  several  diseases  prevail,  and  to  the  soils  that  seem  to  favour 
or  to  repress  the  vitality  and  distribution  of  pathogenic  parasites. 
We  have  yet  to  discover  the  microbe  that  determines  the  rheumatism 
which  ends  in  heart  disease,  and  seems  to  be  scattered  by  air-flushing 
winds,  and  accumulated  in  the  supra-soil  atmosphere  of  pent-up  valleys. 

Alfred  Haviland. 

REFERENCES 

1.  CEuvres  completes  d'Hlppocrate,  ed.  Littre,  vol.  ii. 

2.  Dr.  Alexander  Keith  Johnston.  —  Map  35,  "  Geographical  Distribution  of  Health 

and  Disease."    W.  &  A.  K.  Johnston,  Edinburgh. 

3.  Alfred  Havxland. —  The  Geographical  Distribution  of  Disease  in  Great  Britain, 

2nd  edition.     Sonnenschein  and  Co.    London,  8vo. 

4.  Alfred  Haviland.  —  Climate,  Weather,  and  Disease.    Churchill,  1855. 

A.  H. 


INFLAMMATION 


Part  I. — A  General  Survey  of  the  Process  of  Inflammation 

Chapter  1.  Introduction.  —  Chapter  2.  The  Comparative  Pathology  of  Inflarima- 
tion.  —  Chapters.  The  Main  Forms  of  the  Process  of  Acute  Inflammation  ii  the 
Higher  Animals. 

Part  II. — The  Factors  in  the  Inflammatory  Process 

Chapter  1.  On  the  Part  played  by  the  Leucocytes.  —  Chapter  2.  On  the  Inflamma- 
tory Exudation. — Chapters.  On  the  Part  played  by  the  Blood-Vessels.  —  Chap- 
ter 4.  On  the  Passage  of  Corpuscles  out  of  the  Vessels.  —  Chapter  5.  On  the  Part 
played  by  the  Nervous  Sys'tem.  —  Chapter  6.  On  the  Part  played  by  the  Cells  of 
the  Tissue.  —  Chapter  7.  On  Fibrous  Hyperplasia  and  its  Relationship  to  Inflam- 
mation. 

Part  III 

Chapter  1.  On  Classification.  —  Chapter  2.  On  Systemic  Changes  accompanying 
Local  Injury  and  Inflammation.  —  Chapter  3.  Conclusion.  —  Bibliography. 

PART  I. — «A  General  Survey  of  the  Pro'cess  of  Inflammation 

Chapter  1. — Introduction 

Definition   of   Inflammation.  —  It  is  usual  to  begin  the  description  of 
a  morbid  process  by  defining  that  process.     In  the  case  of  inflamma- 

1  The  following  article  is  an  attempt  to  bring  into  order  the  very  numerous  recent 
researches  upon  the  inflammatory  process,  and  to  show  whither  they  appear  to  tend ;  it 
pretends  in  no  wise  to  be  a  complete  treatise  upon  the  development  of  our  knowledge  of 
the  subject.  Space  alone  has  forbidden  that  I  should  trace  the  full  history.  I  would 
therefore  strongly  urge  that  as  a  corrective  other  works  be  consulted  in  which  the  earlier 
theories  are  treated  at  length ;  more  especially  would  I  recommend  (as  throwing  light 
upon  the  progress  of  our  knowledge)  Professor  Burdon-Sandersou's  article  upon  Inflam- 
mation in  Holmes's  System  of  Surgery. 


INFLAMMATION  55 


tion,  however,  we  have  to  deal  with  a  process  so  complex,  so  modified  by 
modifications  of  the  man 3^  factors  involved,  and  so  variable  in  its  manifes- 
tations according  to  the  variety  of  its  causes  and  the  region  of  incidence, 
that  the  attempt  to  define  it  has  proved  a  pitfall  to  pathologist  after 
pathologist ;  moreover,  to  advance  a  definition  of  the  process  at  the  begin- 
ning of  this  article  in  terms  differing  to  any  considerable  extent  from 
those  employed  by  previous  writers,  would  demand  a  criticism  of  the  many 
previous  attempts  ;  and  in  order  that  the  definition  put  forward  be  duly 
supported,  would  necessitate  an  essay  covering  the  whole  field  about  to 
be  traversed.  I  shall  then  leave  definition  to  the  end,  until  I  have 
marshalled  my  facts,  and  have  brought  into  line  all  that  appears  to  me 
necessary  for  a  correct  understanding  of  the  process.  The  definition 
must  be  the  summing  up  of  the  subject,  not  the  introduction  thereto. 

Use  of  the  Name.  —  Yet,  in  the  meantime,  inasmuch  as  diverrent 
views  are  held  of  the  limitations  of  the  use  of  the  name  inflammation, 
a  few  words  of  introduction  are  advisable. 

Two  courses  are  before  us :  either  to  employ  the  name  strictly  in 
accordance  with  the  primitive  definition,  and  thus  only  to  include  as 
cases  of  inflammation  those  states  in  which  there  are  present  redness, 
swelling,  heat  and  pain,  rigidly  excluding  all  cases  in  which  these  cardinal 
symptoms  are  not  present ;  or,  on  the  other  hand,  departing  from 
tradition,  to  include  as  inflammations  all  those  morbid  processes  which 
seem  to  have  a  cause  and  progress  inseparable  from  and  merging 
into  the  cause  and  progress  of  the  state  characterised  by  the  classical 
symptoms.  The  first  course  is  impossible ;  it  is  as  though  one  were  to 
declare  that  red  phosphorus  is  not  phosphorus  because  in  externals 
generally  it  does  not  agree  with  the  definition  of  the  yellow  form  made 
years  before  the  allotropic  modification  was  discovered.  We  are  now 
well  agreed  that  of  the  classical  symptoms,  one,  two  or  three  may  b3 
unrecognisable,  and  in  fact  absent;  and  yet  the  condition  of  inflamma- 
tion be  undoubtedly  present.^ 

The  second  is  the  only  possible  course,  that,  namely,  which  associates 
all  those  states  which  under  suitable  conditions  may  result  in  the  pro- 
duction of  the  four  classical  symptoms,  and  moreover  originate  from  a 
common  cause.  Holding  this  view,  it  will  in  the  meantime  be  well  for 
me,  in  order  to  afford  a  starting-point  for  the  description  and  discus- 
sion of  the  subject,  to  select  from  the  many  definitions  one  which  is 
based  not  on  symptomatology,  but  upon  aetiology,  and  indicates  a  common 
origin  for  all  cases  of  inflammation.  I  would  select  that  which  in  this 
country  has  received  the  most  cordial  support,  the  definition  given  by 
Professor  Burdon-Sanderson  in  his  well-known  article  in  Holmes's  System 
of  Surgery :  "  The  process  of  inflammation  is  the  succession  of  changes 

1  A  course  allied  to  this  has  found  favour  of  late  years  among  sundry  surgical  patholo- 
gists, who  would  limit  the  use  of  the  term  to  those  cases  and  ihose  only  in  which  the  classi- 
cal symptoms,  or  the  majority  thereof,  are  present  and  associated  with  suppuration, —  they 
urge  withHiiter  that  inflammation  only  occurs  when  pyogenic  micro-organisms  are  present, 
and  state  that  when  a  wound  heals  aseptically  it  heals  without  inflammation.  This  modi- 
fied course  is  equally  impossible  ;  pyogenesis  must  uot  be  confounded  with  inflammation. 


56  SYSTEM   OF  MEDICINE 

which  occurs  in  a  living  tissue  when  it  is  injured,  provided  that  the  injury 
is  not  of  such  a  degree  as  at  once  to  destroy  its  structure  and  vitality." 
This  definition  includes  too  much.  The  haemorrhage  that  occurs  in 
the  liver  when  it  is  injured,  and  the  changes  that  there  occur  in  the 
extravasated  red  corpuscles,  are  scarcely  to  be  classed  among  inflam- 
matory phenomena ;  the  atrophic  changes  which  occur  in  the  retina,  when 
through  injury  it  becomes  detached,  are  due  mainly  to  malposition 
and  disuse  ra,ther  than  to  the  primary  trauma.  But,  as  Dr.  Burdon 
Sanderson  has  pointed  out,  the  definition  has  this  great  advantage, 
that  stating  the  cause,  it  clearly  recognises  infiammation  as  a  process 
and  not  as  a  state.  The  external  manifestations  of  this  process  under 
favourable  conditions — where  the  region  injured  is  a  loose  and  vascular 
tissue,  and  where  the  injury  is  sufficiently  severe  or  extensive  —  are  red- 
ness, swelling,  and  heat  with  pain :  redness  from  the  congestion  of  the 
vessels ;  swelling  from  the  exudation  of  fluid  and  corpuscles  from  the 
congested  vessels ;  heat  from  the  increased  amount  of  blood  in  the  region, 
and  pain  from  the  pressure  upon  and  irritation  of  the  terminations  of  the 
nerves  in  the  region.  To  these  four  symptoms  may  be  added  a  fifth, 
disturbance  of  function  brought  about  by  this  departure  from  the 
normal  condition  of  the  region.  Under  unfavourable  conditions  —  where 
the  region  injured  is  dense  or  less  vascular,  or  Avhere  the  injury  is  less 
severe  —  one  or  all  of  these  symptoms  may  seem  wanting ;  nevertheless 
a  minute  examination  of  the  tissues  will  show  the  same  succession  of 
changes  as  in  the  former  case. 


Chapter  2.  —  The  Comparative  Pathology  of  Inflammation 

Accepting,  then,  this  working  definition,  in  order  to  arrive  at  a  due 
comprehension  of  the  succession  of  changes  which  we  take  to  constitute 
the  inflammatory  process,  it  will  be  well  with  Metschnikoff '  to  institute 
a  series  of  observations  upon  the  reaction  to  injury  exhibited  throughout 
the  animal  kingdom  from  the  lowest  forms  upwards  to  man.  By  this 
means  we  shall  be  enabled  to  determine  what  factors  in  the  inflammatory 
process  are  from  their  constancy  of  primary  importance ;  what  are  com- 
mon and  esselitial,  and  what  are  superadded  in  the  higher  animals. 

The  Response  to  Injury  among  the  Protozoa.  —  Beginning  our  study 
with  the  lowest  and  simplest  forms  of  life  —  forms  so  lowly  that 
they  have  been  regarded  both  as  animals  and  as  plants  —  we  find  even 
here  phenomena  accompanying  the  reaction  to  injury  which  throw  light 
upon  the  inflammatory  process  as  seen  in  the  higher  animals.  Taking  as 
an  example  the  amoeba,  we  find,  in  the  first  place,  that  the  nucleus  plays  an 

1  The  siicceedinsc  paragraphs  are  of  necessity  very  largely  an  epitome  of  sundry  por- 
tions of  M.  Metschnikoff 's  most  pregnant  work  upon  the  comparative  pathology  of  inflam- 
mation. By  comparing  them  with  the  work  in  question,  it  will,  however,  be  seen  that 
they  depart  from  it  in  several  points :  more  especially  in  dwelling  ujjon  the  extracellular 
activity  of  the  wandering  cells,  and  in  bringing  more  prominently  forward  the  response 
to  injury  on  the  part  of  the  fixed  cells. 


INFLAMMA  TION  5  7 


important  part  in  tliis  reaction.  If,  as  Metschnikoff  has  shown,  one  of 
the  larger  amoebae  be  cut  in  two,  the  region  of  injury  becomes  rapidly 
indistinguishable  —  the  protoplasm  of  each  moiety  closes  up,  leaving  no 
mark  or  scar :  but  of  the  two  parts  that  which  retains  the  nucleus  grows 
and  proliferates  ;  the  other  disintegrates  in  a  longer  or  shorter  time.  Or 
injury  may  induce  changes  in  the  protoplasm  of  the  entire  amoeba:  thus. 
Miss  Greenwood  points  out  that,  without  necessarily  bringing  about 
death,  the  interrupted  current  or  an  aqueous  solution  of  thymol  leads  to 
a  process  of  exudation  or  extrusion  of  clear  hyaline  spheres,  or  of  sj)heres 
holding  crystals  and  granules,  from  the  surface  of  the  organism  —  a  pro- 
cess resembling  that  occasionally  seen  in  the  cells  of  an  inflammatory 
area  in  higher  animals.  ISTor  is  this  all ;  apart  from  changes  in  the 
structure  of  these  unicellular  animals,  differences  may  be  seen  in  the 
behaviour  of  amoebae  towards  foreign  bodies.  It  would  seem,  according 
to  Le  Dantec,  that  amoebae  ingest  non-irritating  foreign  substances  in- 
differently, provided  they  be  sufficiently  small.  Around  each  particle  so 
ingested  a  vacuole  is  formed,  and  the  fluid  in  this  becomes  increasingly 
acid,  and  at  the  same  time  digestive.  Krukenberg,  Reinke  and  Miss 
Greenwood  have  conclusively  proved  these  and  similar  food  vacuoles  in 
the  amoeba  and  other  Protozoa  to  contain  a  pepsine  or  digestive  ferment, 
which,  as  Le  Dantec  has  shown  by  very  delicate  tests,  exerts  its  action 
in  an  acid  medium  (the  general  protoplasm  of  the  cell  body  being  alka- 
line) ;  this  digestive  process  leads  to  the  solution  of  food  stuffs,  pre- 
paring them  to  be  taken  up  by  the  protoplasm  of  the  organism.  If  the 
foreign  substances  be  incapable  of  digestion  they  are  sooner  or  later  ex- 
truded. It  is  by  this  formation  of  digestive  vacuoles  that  the  amoeba  acts 
upon  and  destroys  bacteria,  diatoms,  and  other  microbes  ingested  by  it. 
There  are,  however,  microbic  forms  around  which  it  would  seem  that  no 
proper  vacuolation  is  developed,  or  if  developed,  the  acid  digestive  fluid 
is  neutralised  by  substances  discharged  from  the  parasites ;  where  this 
is  the  case,  instead  of  destruction  there  is  continuance  of  vitality  and 
actual  multiplication  of  the  invading  or  parasitic  form,  leading  to  the 
eventual  death  of  the  amoeba.  Metschnikoff  has  observed  this  chain  of 
events  in  one  of  the  amoebae  which  ingests  and  becomes  the  host  of  a 
minute  rounded  form,  the  Microsphaera.  Phenomena  of  like  nature 
may  be  observed  among  the  ciliate  and  flagellate  infusoria.  While 
these  phenomena  may  primarily  be  regarded  as  the  method  employed 
by  the  Protozoa  for  the  assimilation  of  food  staffs,  they  also  are  clearly 
the  means  whereby  the  Protozoa  defend  themselves  against  living 
organisms  which  have  gained  entrance  into  them,  and  thus  form  the 
reaction  to  possible  injury ;  for  when  in  certain  cases  the  means  of 
defence  are  overcome,  the  parasitic  organisms  gain  the  upper  hand  and 
lead  to  death. 

There  is  yet  another  reaction  to  injurious  influences  exhibited  by 
the  Protozoa  into  which  it  is  necessary  that  I  should  enter  at  some 
length.  This  is  exhibited  by  the  amoeba,  but  can  be  and  has  been  most 
fully  investigated   in  the   myxomycetes  —  multicellular   forms   which 


5S  SYSTEM   OF  AI EDI  CINE 

can  with  equal  propriety  be  classed  as  animals  or  plants,  although 
usually  they  are  included  among  the  latter.  These  organisms  form 
large  plasmodia  (masses  of  protoplasm,  that  is),  in  which,  under  ordi- 
nary conditions,  the  nuclei  are  the  only  indication  of  the  individual 
cells  which  by  their  fusion  have  formed  the  masses.  They  are  to  be 
met  with  in  leaf  mould,  and  on  the  surface  of  moist  decaying  wood  over 
which  they  creep  with  an  amoeboid  movement ;  and  inasmuch  as  they 
may  attain  great  size  —  some  species  attaining  twelve  inches  or  more 
in  length  —  they  form  admirable  material  for  biological  study. 

Ten  years  ago  Stahl,  investigating  one  of  these  myxomycetes  (the 
^thalium  septmim,  an  organism  found  in  tan  pits),  showed  that  if  placed 
upon  a  moistened  surface  close  to  a  drop  of  infusion  of  oak  bark,  the 
Plasmodium  moved  actively  towards  and  into  the  infusion ;  if  placed 
similarly  near  to  a  solution  of  glucose  (0-5  per  cent)  it  moved  with  equal 
rapidity  away,  and  so  also  in  the  case  of  solutions  of  various  salts.  These 
observations  of  Stahl  were  (if  we  except  Engelmann's  observations  in 
1881  upon  the  tendency  of  sundry  bacteria  to  remove  from  regions  poor 
in  oxygen  to  those  Avhere  oxygen  is  present  in  abundance)  the  first  of  a 
series  of  observations  upon  the  attraction  and  repulsion  of  plants  and 
portions  of  plants  by  chemical  substances.  To  this  property  Pfeffer,  who 
has  made  the  fullest  series  of  studies  upon  it,  has  given  the  name  of 
chemiotaxis,  in  place  of  Stahl's  narrower  "  trophotropism " ;  and  one 
speaks  of  a  positive  or  a  negative  chemiotaxis  according  to  the  attrac- 
tion or  repulsion  exerted.  If,  as  Metschnikoff  has  pointed  out,  the 
advancing  edge  of  one  of  these  plasmodia  (of  Physarum)  be  injured  by 
cauterisation,  the  region  of  injury  dies  ;  the  protoplasmic  currents, 
Avhich  had  been  advancing,  reverse  themselves  abruptly,  and  within  an 
hour  the  plasmodium  has  moved  away,  leaving  the  debris  of  the 
destroyed  region  behind.  These  experiments  ai'e  so  simple,  and  the 
results  obtained  seem  so  natural,  that  it  may  be  asked  whether  it  be 
worth  while  to  attach  a  name  to  this  property  of  living  matter.  Yet  the 
name  is  in  itself  an  aid  to  bearing  these  properties  in  mind;  and,  as  will 
be  pointed  out  later,  the  recognition  of  them  is  of  material  help  in  solving 
certain  of  the  difficulties  that  present  themselves  in  the  study  of  inflam- 
mation in  the  higher  animals.  Among  these  myxomycetes  another  fact 
can  be  made  out.  Stahl  observed  that  the  plasmodium  of  Fuligo,  which 
at  first  moves  away  from  a  two  per  cent  solution  of  common  salt,  will 
after  a  time  (more  especially  if  it  has  suffered  from  lack  of  water)  adapt 
itself  to  the  solution,  advancing  its  pseudopodia  or  protoplasmic  processes 
into  it.  With  other  myxomycetes  the  same  adaptation  has  been  observed. 
That  is  to  say,  by  use  or  adaptation  a  negative  may  be  transformed  into 
a  positive  chemiotaxis.     To  this  change  I  shall  have  occasion  to  revert. 

The  Response  to  Injury  among  the  Metazoa.  —  Passing  from  the 
Protozoa  to  the  Metazoa,  we  reach  immediately  (or  almost  immedi- 
ately) a  series  of  beings  in  which  the  division  of  labour  among 
the  cells  has  led  to  the  development  of  three  cell  layers  —  an  outer 
ectoderm,  an  inner  endoderm,  and  an  intermediate  layer  of  mesoderm. 


INFLAMMA  TION     •  59 


Even  in  the  very  lowest  forms  among  tlie  Metazoa  it  is  noticeable 
that  of  these  three  layers  there  is  one,  the  mesoderm,  whose  cells 
have  the  especial  function  of  reacting  when  any  irritant  or  injurious 
stimulation  is  applied  to  the  organism.  Taking  what  are  perhaps  the 
simplest  forms  in  which  to  observe  the  relationship  and  properties  of 
these  layers,  Metschnikoft'  has  studied  these  results  of  injury  in  the  larval 
forms  of  astropecten  and  other  echinoderms.  At  one  well-recognisable 
stage  these  larvse  resemble  little  more  than  the  gastrula  stage  of  the 
embryologist ;  the  endoderm  or  hypoblast  appears  as  a  cul-de-sac  —  an 
invagination  of  the  ectoderm  or  epiblast  —  while  the  mesoderm  is  repre- 
sented by  amoeboid  cells,  budded  off  from  the  endoderm,  lying  or  float- 
ing in  the  semiliquid  substance  filling  the  general  body  cavity.  The 
ectoderm  is  so  delicate  that  any  sharp  substance  can  readily  penetrate 
into  the  body  cavity ;  and,  when  this  happens,  it  is  noticeable  that  the 
wandering  mesodermal  cells  make  their  way  to  the  foreign  body,  attach 
themselves  to  it,  and  fuse  into  plasmodial  masses,  thus  forming  a 
wall,  as  it  were,  around  the  invading  substance,  and  cutting  it  off  from 
the  general  body  system.  Here,  then,  in  an  organism  possessing  neither 
nervous  nor  vascular  system,  the  reaction  to  injury,  where  that  injiiry 
has  not  been  sufl&ciently  intense  to  cause  destruction  of  the  outer  laj^er 
of  cells,  is  simply  and  solely  confined  to  the  wandering  cells  of  the 
body ;  there  is  no  effusion  of  fluid ;  there  is  not  necessarily  phagocytosis 
on  the  part  of  these  cells ;  any  digestive  and  destructive  action  on  their 
part  —  any  attempt  in  this  way  to  remove  the  foreign  body  —  must  then 
be  by  excretion,  hy  extracellular  action.  At  the  same  time,  this  fusion 
of  the  cells  and  formation  of  a  plasmodium  around  foreign  substances  of 
greater  diameter  than  the  individual  mesodermal  cells  may  be  looked 
upon  as  a  mechanism  whereby  the  equivalent  of  intracellular  digestion 
is  gained.  But,  as  among  these  low  forms  cases  occur  in  which,  without 
the  formation  of  plasmodia,  the  cells  perform  their  destructive  action 
upon  bodies  of  larger  size  than  themselves  we  do  not  lack  examples  of 
what  must  be  considered  as  excretory  destructive  powers  on  their  part. 
That  these  cells  in  the  echinoderms  are  also  capable  of  destroying  minute 
foreign  bodies  by  intracellular  action,  that  is,  by  phagocytosis,  has  been 
demonstrated  in  the  larger  transparent  larval  form  known  as  Bipinnaria 
Asterigera;  on  introducing  bacteria  under  its  ectoderm  the  mesodermal 
cells  are  seen  to  approach,  and  by  their  long  pseudopodia  to  adhere  to 
and  ingest  the  still  living  motile  bacteria,  which  are  rapidly  digested. 

Besides  this  reaction  to  injury  on  the  part  of  the  mesodermal  cells, 
a  further  response  is  exhibited  to  a  remarkable  degree  among  the 
lower  Metazoa  —  I  refer  to  the  great  power  of  regeneration  of  lost  parts, 
of  cell  proliferation  leading  to  the  reproduction  of  destroyed  regions. 
This  power  is  best  seen  in  the  classical  example  of  the  Hydra,  which 
may  be  cut  into  many  pieces,  each  one  of  which  is  capable  of 
growing,  so  that  in  a  relatively  short  time  it  becomes  a  fully  formed 
individual.  It  is  interesting  to  note  in  relation  to  the  frequent  ten- 
dency towards  hyperplasia  and  excess  growth  following  upon  injury  in 


6o  SYSTEM  OF  MEDICINE 

the  higher  animals,  that  among  low  forms,  snch  as  Hydra  and  Ceri 
anthus,  the  same  tendency  is  yet  more  strongly  marked.  Thus,  as 
Loeb  points  out,  if  an  incision  be  made  in  the  stem  of  a  Hydra,  a 
whole  new  oral  pole,  provided  with  tentacles,  will  branch  out  from  the 
region  of  cell  destruction.  In  the  actinian  Cerianthus  the  process  is 
not  quite  so  extensive ;  yet  from  the  lower  lip  of  the  lateral  incision  a 
set  of  tentacles  develops  in  all  respects  similar  to  those  around  the 
mouth. 

Ascending  to  the  Worms,  we  find  that  the  protective  agency  devolves 
upon  mesodermal  cells  suspended  in  the  perivisceral  fluid,  and  again 
fonning  the  peritoneal  endothelium.  We  arrive,  that  is  to  say,  at  a 
state  in  which  a  lymphatic  system  may  be  said  to  be  present ;  for  the 
spaces  in  which  the  free  corpuscles  lie  are  strictly  homologous  to  the 
lymph-containing  spaces  of  the  vertebrate  organism,  and  these  corpuscles 
may  be  regarded  as  lymph  corpuscles ;  the  peritoneal  endothelium  cor- 
responds with  the  mesodermal  peritoneal  endothelium  of  vertebrata. 

Among  the  annelids  the  process  of  reaction  to  injury  may  be  well 
followed  in  the  earth  worm  by  studying  the  sequence  of  changes  that 
occur  around  the  gregarines  which  infest  the  male  genital  organs. 
While  these  parasites  are  active  by  their  movements  they  prevent  the 
adhesion  of  the  wandering  cells;  but  so  soon  as  they  pass  into  the 
resting  stage  antecedent  to  spore  formation,  the  cells  form  a  thick  mass 
around  them.  The  parasite  on  its  part  forms  a  thick  cyst  wall ;  never- 
theless, it  may  not  unfrequently  be  observed  that,  despite  this  protection, 
the  parasite  changes  its  appearance  under  the  action  of  the  surround- 
ing Plasmodium,  and  in  fact  is  killed.  While  this  is  happening  no  change 
could  be  detected  by  Metschnikoff  in  the  neighbouring  blood-vessels ; 
these  appear  to  remain  completely  inactive :  no  exudation  is  noticeable 
nor  any  recognisable  change  in  volume. 

While  among  the  Worms  a  well-developed  and  closed  vascular 
system  is  not  unfrequently  present,  in  other  animal  forms,  which  in 
most  respects  present  a  much  more  complex  and  advanced  develop- 
ment, namely,  in  the  Arthropods  and  Tunicates,  this  is  not  the  case. 
In  these  the  blood  pours  from  the  tubular  heart  sooner  or  later  into  the 
lacunae  of  the  general  body  cavity ;  and  whether  veins  be  absent  (as 
is  most  usual),  or  present  (as  in  the  Cephalopods),  the  blood  is  sucked 
back  from  the  body  cavity  into  the  heart.  This  incomplete  circulation, 
interesting  as  it  is  in  connection  with  the  development  of  the  vertebrate 
circulation,  is  interesting  also  from  the  fact  that  its  incompleteness 
in  these  large  and  wide-spread  classes  of  animals  prevents  reaction  to 
injury  from  being  associated  with  vascular  changes.  The  blood  in  these 
animals,  -circulating  through  the  ramifications  of  the  body  cavity,  is 
evidently  a  mesodermal  fluid,  if  it  may  be  so  termed.  Its  corpuscles 
are  clearly  mesodermal ;  and  without  going  into  full  details  as  to  the 
properties  of  these  corpuscles,  it  may  be  said  that  they  represent  an 
interesting  series  of  stages  in  the  subdivision  of  labour.  For  example, 
as  Mr.  Hardy  has  shown  us  in  a  low  form  of  crustacean  like  Daphnia  (the 


INFLAMMATION  6i 


water  flea),  but  one  form  of  cell  is  present,  whereas  in  the  highly- 
developed  Astacus  (the  cray  fish),  there  are  three  distinct  forms  of 
leucocytes  (no  red  corpuscles  being  present),  each  of  which  appears 
to  have  distinct  functions.  The  one  form  in  Daphnia  has  the  property 
of  taking  up  fat  globules  and  food  particles  from  the  alimentary 
tract,  foreign  particles,  such  as  granules  of  carmine  or  Indian  ink,  and 
the  spores  of  parasites  (Monospora,  Metschnikoff)  ;  it  is  granulated,  con- 
taining minute  spherules  which  stain  with  basic  aniline  dyes  (basophile 
granules),  and  under  certain  circumstances  it  may  be  seen  to  explode 
with  lightning-like  rapidity.  In  the  higher  Astacus  there  are  in  the 
circulating  haemal  fluid  two  varieties  of  cells:  one  is  extraordinarily 
explosive ;  when  removed  from  the  body  cavity  it  gives  oft'  fine  blebs 
or  vesicles  of  its  substance  with  such  rapidity  that,  unless  the  greatest 
care  be  taken,  nothing  is  seen  of  the  cell  save  its  nucleus ;  this  form  is 
phagocytic :  the  other  form  is  far  more  stable,  and  is  loaded  with  large 
spherules  which  have  a  great  affinity  for  acid  dyes  —  they  are  eosino- 
philous  —  may  be  actively  extruded,  and  undergo  decomposition ;  these 
cells  never  act  as  phagocytes.  The  third  form,  with  basophile  granules, 
is  rarely  found  in  the  blood,  and  then  only  as  the  result  of  special 
stimuli ;  but  it  is  present  in  considerable  numbers  in  the  peculiar  tissue 
which  forms  a  sheath  around  certain  of  the  arteries  —  Haeckel's  "  Zell- 
gewebe ;  "  this  form  is  phagocytic,  and  can  be  seen  to  contain  globules 
of  ingested  fat. 

As  Metschnikoff  demonstrated,  in  his  most  remarkable  study  upon 
a  disease  of  Daphnia  caused  by  the  entry  of  the  spores  of  a  yeastlike 
organism  (the  Monospora)  into  its  body  cavity,  its  one  form  of  leuco- 
cyte can  be  seen  to  react  swiftly  towards  the  spores;  the  cells  ap- 
proach them,  form  a  plasmodium  around  and  eventually  digest  and 
destroy  them.  If,  on  the  other  hand,  in  consequence  of  their  great 
numbers  or  the  relative  paucity  of  the  leucocytes,  certain  of  the  spores 
be  not  attacked  and  develop  uninterruptedly  into  mature  torulee,  the 
leucocytes  show  no  tendency  to  approach  them  —  in  fact,  their  neigh- 
bourhood leads  to  the  explosion  of  the  leucocytes  —  and  the  torulse, 
multiplying,  lead  to  the  death  of  the  organism.  Often,  again,  brown 
eschars  may  be  recognised  upon  the  transparent  carapace  of  a  Daphnia, 
due  to  injuries  by  other  individuals;  beneath  these  scars  are  to  be  found 
masses  of  leucocytes  which  remain  in  the  region  of  injury  until  the  cells 
of  the  tissue  have  proliferated,  and  there  is  complete  union  and  repair. 

In  addition,  then,  to  the  immediate  reparative  and  protective  re- 
action of  the  leucocytes,  there  is  exhibited  among  the  higher  invertebrata 
a  later  reaction  in  the  shape  of  proliferation  of  the  fixed  cells.  This 
proliferation,  while  not  so  extensive  as  among  the  lower  invertebrates, 
can  nevertheless  be  very  great ;  and  cells  of  all  forms,  whether  of  hypo-, 
meso-  or  cpiblastic  origin,  and  tissues  so  highly  developed  as  the  muscular 
and  nervous,  may  participate  in  it.  In  illustration  of  the  ample  power 
of  tissue  reproduction  after  injury  possessed  by  these  animals,  I  need  but 
mention  the  trite  examples  of  the  reproduction  of  the  hinder  segments 


62  SYSTEM   OF  MEDICINE 

of  divided  worms,  and  in  crustaceans  the  restoration  of  injured  and  cast 
off  claws  and  appendages. 

Many  more  instances  might  be  given  to  show  that  the  reaction  to 
injury  remains  essentially  a  reaction  on  the  part  of  the  wandering  and 
fixed  mesoblastic  cells  of  the  organism,  followed  in  sundry  cases  by 
proliferation  of  the  fixed  epi-,  meso-  and  hypoblastic  cells,  and  by  repair 
where  these  have  been  destroyed.  Although  these  arthropods,  molluscs 
and  tunicates  have  a  vascular  system,  yet,  inasmuch  as  this  is  open,  its 
changes,  if  they  occur,  could  scarcely  modify  the  inflammatory  process. 

The  Response  to  Injury  among  the  Vertebrata.  —  If  now  we  pass  to 
•the  vertebrates,  the  picture  presented  is  fa,r  more  complex :  not  only  do 
these  present  a  highly-developed  nervous  system,  but,  moreover,  the 
blood  is  enclosed  in  a  complete  vascular  system.  We  shall  now  consider 
at  length  the  results  of  an  injury  of  an  organ  in  one  of  these  higher 
animals. 


Chapters.  —  The  Main  Foems  or  the  Pkocess  of  Acute  Inflam- 
mation IN  THE  Higher  Animals 

The  Experimental  Production  of  Inflammation  in  Non-Vascular  Areas. 

—  Let  us  begin  with  the  succession  of  changes  that  occurs  in  the  sim- 
plest case,  namely,  in  a  non-vascular  area,  in  one  of  the  lowest  vertebrate 
forms  —  for  instance,  in  the  embryonic  axolotl  ten  to  fifteen  days  old; 
let  us  curarise  it,  and  apply  a  minute  crystal  of  silver  nitrate  to  the 
side  of  its  flattened  transparent  tail  fin,  washing  away  the  remains  of 
the  crystal  with  salt  solution;  or  again,  we  may  pass  into  the  tail  a 
small  needle  filled  with  finely-powdered  carmine.  By  either  procedure 
a  certain  number  of  cells  is  destroyed.  The  neighbourhood  of  the 
injury  now  becomes  swollen  (it  may  be  by  imbibition  of  water  through 
the  wound),  and  the  surrounding  cells  tumefied,  vacuolated  and  less 
refractile.  This  is  ih.Q  first  stage — that  of  injury  and  modification  of  the 
surrounding  tissue.  In  a  little  time  a  few  wandering  cells  (leucocytes) 
approach  the  injured  region ;  by  the  next  day  these  are  present  in 
fair  numbers,  and  can  be  seen  to  have  taken  up  the  particles  of  carmine 
or  debris  of  the  destroyed  tissue.  This  is  the  second  stage  —  that  of 
immigration  of  leucocytes.  There  are  ho  vessels  in  the  transparent 
fin  of  these  young  axolotls,  no  dilation  of  those  nearest  to  the  fin, 
and  no  diapedesis.  All  the  leucocytes  that  pass  to  the  part  are  pre- 
existing wandering  cells  of  the  connective  tissue, — a  fact  of  some  little 
importance  in  connection  with  the  origin  of  certain  of  the  pus  cells  in  the 
suppurative  process  of  higher  animals.  The  tliird  stage  is  that  of  repair, 
of  proliferation  of  the  injured  epithelium,  return  of  the  fixed  cells  of 
the  tissue  to  their  previous  state,  and  emigration  of  the  wandering  cells. 
A  very  similar  progress  of  events  occurs  if  the  experiment  be  repeated 
upon  the  tail  fin  of  the  young  newt.  The  same  rapid  alteration  in  the 
large  branched  connective  tissue  cells  (which  become  vacuolated  as  their 


INFLAMMA  TION  63 


long  processes  are  drawn  in  and  shortened),  and  the  same  immigration 
of  motile  cells  from  the  surrounding  connective  tissue  are  to  be  seen  ; 
but  here  we  now  find  the  earliest  evidence  of  vascular  participation,  for, 
according  to  Metschnikoff,  complete  arrest  of  the  circulation  may  occur 
in  the  nearest  vascular  loop.  By  the  next  day  the  parts  have  returned 
to  the  normal  condition. 

If  from  these  cases  we  pass  to  mild  inflammatory  disturbances 
affecting  the  non-vascular  regions  of  animals  far  highei-  in  the  scale,  we 
again  discover  a  like  process  of  events.  For  this  purpose  the  cornea 
affords  an  excellent  opx-)ortunity ;  in  health  it  is  absolutely  non-vascular ; 
it  is  perfectly  transparent,  and  is  so  thin  that  it  can  readily  be  examined 
microscopically. 

The  cornea  of  mammalia,  and  indeed  of  vertebrates  in  general,  is 
formed  of  fibres  which  run  in  layers  parallel  to  the  surface.  These 
fibres,  while  roughly  arranged  side  by  side  and  parallel  to  one  another 
in  any  given  layer,  are  placed  at  an  angle  to  the  fibres  of  the  layers 
above  and  below.  Although  free  from  blood-vessels  the  cornea  is 
far  from  being  devoid  of  channels  along  which  lymph  freely  passes. 
Between  the  several  layers  there  exist  spaces  in  which  lie  the  flattened 
connective  tissue  cells  of  the  organ;  and,  by  means  of  numerous  fine 
channels,  these  spaces  around  the  cells  are  connected  with  similar 
spaces  lying  anteriorly,  posteriorly  and  laterally.  Through  this  rich 
anastomosis  of  channels  there  is  a  free  flow  of  lymph.  These  channels 
are  really  continuations  of  the  body  cavity  of  the  animal ;  they  repre- 
sent, and  in  fact  play  the  same  part  as  the  single  body  cavity  of  such  a 
simple  form  as  the  larva  of  Astropecten,  Avhile  the  cells  lying  in  the 
spaces  are  mesoblastic  cells  which  have  become  fixed. 

Few  studies  are  better  calculated  to  impress  the  investigator  Avith  a 
sense  of  the  depth  of  the  well  at  the  bottom  of  which  truth  lies,  than  a 
research  into  the  abundant  literature  dealing  with  observations  upon  the 
stages  of  the  inflammatory  process  as  it  occurs  in  the  cornea,  and  with 
the  deductions  therefrom.  One  after  another  the  adherents  to  succes- 
sive forms  of  inflammatory  belief  have  found  in  experiments  upon  this 
simple  tissue  ample  support  for  their  particular  creeds. 

Selectiiig  from  among  the  many  observations  those  which  have  stood 
the  test  of  time,  I  will  begin  with  the  simplest,  and  pass  on  to  those 
dealing  with  an  increasing  intensity  of  the  inflammatory  process. 

If,  as  Senftleben  first  pointed  out,  the  centre  of  the  cornea  of  a 
rabbit  be  washed  with  a  strong  solution  of  zinc  chloride,  then,  in  favour- 
able cases,  although  the  epithelial  covering  be  gravely  injured,  there  may 
be  no  actual  rupture  of  the  outer  layers  of  the  tissue.  Such  a  cornea 
removed  twenty-four  hours  later  may  show  no  sign  of  migration  of 
leucocytes  —  no  sign,  again,  of  congestion  of  the  vessels  at  the  peri- 
phery. The  only  indications  of  injury  and  reaction  may  be  the  destruc- 
tion of  the  corneal  corpuscles  immediately  beneath  the  caiiterised  area, 
and  the  appearance  of  a  zone  surrounding  this  in  which  the  corneal 
corpuscles  appear  enlarged,  distinct  and  tumefied.     The  process  may 


64  SYSTEM   OF  MEDICINE 

continue  and  advance  insensibly  to. repair  witliout  tlie  intervention  of 
leucocytes  ;  tlie  hypertrophying  cells  of  the  "  granular  "  zone  eventually 
undergoing  karyokinesis,  and  thus  by  multiplication  replacing  the  cor- 
puscles destroyed. 

Here,  then,  necrosis  and  new  growth  of  the  fixed  cells  of  the  tissue 
are  the  only  recognisable  factors  in  the  process  of  repair  of  injury.  It 
must  be  confessed  that  the  conditions  permitting  this  simplest  form  of 
reaction  are  of  rare  occurrence ;  it  is  worthy  of  attention  that  they  can 
exist. 

By  a  slight  modification  of  the  preceding  conditions  another  factor 
may  be  brought  into  play.  If,  after  cauterisation  in  the  manuer  above 
described,  a  break  be  made  into  the  cauterised  surface;  or  if  again, 
without  cauterisation,  a  little  of  the  corneal  tissue  be  removed,  then  in 
a  few  hours  a  small  whitish  opacity  is  to  be  noticed  within  the  corneal 
tissue  in  the  immediate  neighbourhood  of  the  break  in  the  continuity,  and 
upon  examination  this  opacity  is  found  to  be  due  to  a  massing  of  small 
round  cells.  As  there  is  at  this  moment  no  sign  of  proliferation  of  the 
connective  tissue  cells  of  the  cornea,  these  newly-collected  cells  can  only 
be  leucocytes ;  and  further  examination  of  their  properties  proves  them 
to  be  such :  there  is,  however,  no  evidence  of  dilation  of  the  peripheral 
vessels,  no  indication  of  diapedesis  through  their  Avails.  The  leucocytes, 
therefore,  can  only  have  entered  into  the  wound  from  the  cornea  itself 
and  from  the  conjunctiva  and  the  lachrymal  fluid  bathing  it.  In  this 
experiment  the  inflammatory  process  is  represented  by  destruction  of 
tissue  and  immigration  of  leucocytes,  followed  by  repair ;  neither  the 
vascular  nor  the  nervous  system  play  any  part  in  it.  We  are  forced  to 
the  conclusion  that  the  leucocytes  have  massed  themselves  in  the 
injured  area  purely  on  their  own  initiative ;  and  that  there  must  be  an 
attraction,  a  chemiotaxis  or  chemiotropism,  leading  them  actively  to 
approach  the  region  of  cell  destruction. 

The  observations  made  upon  these  two  simple  cases  help  us  materi- 
ally to  understand  the  series  of  events  which  occur  in  more  intense 
inflammation  of  the  cornea,  such  as  that  produced  by  injuring  the  surface 
and  causing  the  entrance  into  the  injured  region  of  a  small  quantity 
of  a  pure  culture  of  the  Pyococcus  aureus.  This  may  be  accomplished 
by  injecting  the  culture  into  the  centre  of  the  healthy  cornea  by  means 
of  the  needle  of  a  Pravaz  syringe  (Jacobs).  The  micrococci  so  intro- 
duced grow  rapidly,  the  growth  so  extending  along  the  lymph  spaces 
that  a  branched  mass  of  the  microbes  is  produced,  having  the  spot  of 
inoculation  as  centre.  Around  the  growth  as  it  extends  may  be  seen 
a  sharply-marked  area  in  which  the  corneal  corpuscles  show  evidences 
of  degeneration ;  the  nuclei  stain  faintly,  anfl  the  corp^lscles,  speaking 
generally,  have  a  shrunken  appearance.  Here,  again,  the  first  effect  of 
a  microbic,  as  of  a  simple  chemical  injury,  is  to  bring  about  degeneration 
of  the  fixed  cells  of  the  tissue.  Within  eighteen  hours  the  zone  of  pro- 
liferating cocci  and  cell  degeneration  is  well  marked;  and  now  the 
second  stage  begins  to  be  clearly  manifest,  namely,  the  determination 


INFLAMMATION  65 


of  leucocytes  to  the  seat  of  injury.  Within  twenty-four  hours  there 
is  a  dense  packing  of  these  corpuscles  around  the  central  degenerated 
area,  and  great  numbers  of  leucocytes  may  be  seen  converging  along  the 
lymph  spaces  from  the  periphery  of  the  cornea.  This  is  the  second  stage 
of  the  process,  the  first  stage  of  reaction  to  the  injury  inflicted  by  the 
invading  micro-organisms.  If,  as  by  Cohnheim '  in  his  original  experi- 
ments upon  the  injury  to  the  cornea,  more  careful  examination  be  made 
into  the  stages  of  the  determination  of  leucocytes,  it  can  be  seen  that  this 
determination  is  closely  related  to  changes  set  up  in  the  vessels  at  the 
,  periphery  of  the  cornea;  they  become  more  prominent,  the  region  has  a 
congested  appearance,  the  smaller  as  well  as  the  larger  vessels  are 
dilated,  and  there  is  abundant  evidence  that  the  leucocytes  are  passing 
out  from  the  contained  blood  into  the  surrounding  lymph  spaces.  In- 
deed the  accumulation  of  leucocytes  shows  itself  first  at  the  periphery  of 
the  cornea  near  the  vessels,  and  gradually  approaches  the  region  of 
injury.  Into  the  mechanism  of  this  diapedesis,  and  into  a  fuller  descrip- 
tion of  the  changes  that  take  place  in  the  blood-current  in  these  distended 
vessels,  I  shall  enter  later  when  discussing  the  changes  in  highly  vascular 
regions.  Suffice  it  to  say  here  that  no  distinction  can  be  made  out  between 
the  behaviour  of  the  leucocytes  in  the  previous  experiment,  when  they 
entered  the  wounded  area  from  the  external  surface,  and  in  this  where 
the  majority  find  their  entrance  from  the  blood;  as  in  the  previous  case 
the  part  played  was  evidently  active,  so  must  it  be  here  also.  We  cannot 
arrive  at  any  other  conclusion  than  that  some  attractive  force  leads  to 
their  determination  towards  the  inflammatory  focus.  As  we  can  easily 
show,  by  repeating  the  experiment,  many  of  these  leucocytes  take  up  and 
contain  numerous  cocci,  while  other  cocci  remain  free  in  the  tissue 
spaces.  Many  of  the  leucocytes  degenerate  and  present  a  broken  down 
appearance ;  and,  as  at  the  same  time  an  increasing  area  of  the  corneal 
tissue  becomes  disintegrated,  an  ulcer  appears.  According  to  the  viru- 
lence of  the  culture  and  the  reaction  on  the  part  of  the  organism,  the 
process  may  now  extend,  a  larger  and  larger  portion  of  the  corneal 
tissue  becoming  affected ;  or,  on  the  other  hand,  there  may  be  an  arrest 
of  the  progress,  the  massing  of  the  leucocytes  preventing,  as  a  barrier, 
the  further  extension  of  the  micrococci  into  the  lymph  spaces ;  ^  while 
at  the  same  time  there  is  an  advance  of  newly-formed  capillary  vessels 
into  the  previously  non-vascular  tissue.  It  is  to  be  noticed  that  the 
blood-vessels  at  the  periphery  of  the  cornea  are  prominent  and  dilated, 
and  from  them  fine  new  vessels  with  very  delicate  walls  pass  towards 
the  injured  region.  At  the  same  time  many  of  the  corneal  corpuscles, 
outside  the  area  of  destruction,  can  by  appropriate  staining  be  seen 
undergoing  mitosis  and  proliferating.  Thus  the  active  repair  of  the 
tissue  is  initiated. 

1  There  can  be  no  question  that  Cohnheim  in  his  experiments  induced  not  a  simple 
keratitis  but  one  which  in  the  absence  of  aseptic  precautions  rapidly  became  septic  and 
suppurative. 

2  Into  the  details  of  this  action  I  shall  enter  more  fully  later. 

VOL.    I  F 


66  SYSTEM  OF  MEDICINE 

The  Experimental  Production  of  Inflammation  in  Vascular  Areas.  — 
From  this  study  of  inflammation,  as  it  occurs  in  a  region  devoid  of 
blood-vessels,  let  us  now  pass  on  to  the  more  complicated  process  of 
inflammation  in  vascular  areas ;  and,  as  in  the»previou^ase  we  considered 
an  ascending  or  advancing  series  of  reactive  changes,  so  here  let  us  begin 
with  the  slightest  injury  associated  with  the  mildest  reaction,  and  pass 
onwards  to  states  in  which  the  inflammatory  manifestations  are  more 
and  more  pronounced. 

If  an  incision  be  made  with  a  perfectly  aseptic  instrument  into  the 
skin,  also  rendered  aseptic,  and  be  so  made  as  to  divide  the  dermis 
and  tissues  immediately  below,  without  at  the  same  time  injuring  any 
large  vessel,  it  is  the  common  experience  of  modern  surgeons  that 
repair  takes  place  with  the  minimal  amount  of  change  recognisable  as 
inflammatory.  Repair  takes  place  indeed  so  rapidly  that,  if  the 
divided  structures  have  come  or  have  been  brought  into  immediate 
contact,  there  may  be  firm  adhesion  at  the  end  of  tAventy-four  hours. 
This  is  primary  union,  or  union  by  first  intention,  Avhich,  rare  in  the 
old  days,  commonly  occurs  in  this  era  of  aseptic  surgery.  The  full 
sequence  of  events  in  these  cases  cannot,  it  is  true,  be  well  determined 
by  continuous  microscopic  examination ;  but  if  the  rabbit  or  dog  be 
employed,  and  tissues,  wounded  in  the  manner  described,  be  removed 
and  examined  at  successive  short  intervals,  we  see  that  the  changes 
Avhich  occur  are  mainly,  nay  almost  entirely,  related  to  the  pre-existing 
cells  of  the  part.  The  section  divides  a  certain  number  of  capillaries ; 
but  in  the  very  act  of  division  the  divided  walls  are  apparently  brought 
together ;  and,  partly  by  this  means,  partly  by  contraction,  the  lumina  of 
these  minute  vessels  become  occluded,  and  the  haemorrhage  into  the 
wound  is  altogether  inconsiderable.  Within  an  hour  after  the  operation 
it  is  evident  to  the  naked  eye  of  a  careful  examiner  that  the  immediate 
neighbourhood  of  the  wound  is  slightly  reddened  and  tumefied,  but 
only  very  slightly ;  and,  associated  with  this,  there  is  a  feeble  exudation 
between  the  apposed  surfaces.  But  the  exudation  is  not  great,  and 
even  within  this  first  hour  after  the  infliction  of  the  wound  there  may  be 
development  of  fibrin  and  coagulation  of  the  exudate,  leading  to  the 
formation  of  a  provisional  cementing  together  of  the  opposed  surfaces. 
In  this  exudation,  and  in  the  tissues  in  the  immediate  neighbourhood, 
the  leucocytes  that  have  undergone  diapedesis  may  be  few  and  far 
between,  and  may  scarcely  attract  attention.  The  reaction,  then,  on  the 
part  of  the  vessels  and  of  the  leucocytes  is  of  the  slightest.  Study  of 
sections  shows  that  the  main  role  is  played  by  the  pre-existing  cells  of 
the  part;  of  these  a  certain  number  (not  so  many  as  might  d  priori  be 
expected)  are  destroyed  immediately,  and  show  all  the  signs  of  disinte- 
gration; a  number  relatively  large  have  been  injured  only,  their  nuclei 
remaining  intact,  though  their  processes  or  some  portions  of  the  cell 
bodies  have  been  cut  through.  It  is  difiicult  to  determine  these 
injuries  in  the  small  cells  of  the  cutaneous  tissues  ;  they  are  better  seen 
in  the  peritoneum  when  slight  inflammatory  changes  have  there  been 


INFLAMMA  TION  67 


induced.  This,  however,  can  be  made  out  that  the  cells  in  the  immedi- 
ate neighbourhood  of  the  wound  became  enlarged,  and,  without  showing 
signs  of  division,  prolong  themselves  (that  is  to  say,  send  out  jjrolonga- 
tions)  into  the  region  of  the  provisional  fibrinous  cicatrix.  In  this  way, 
before  the  end  of  the  second  day,  there  may  be  a  more  or  less  complete 
replacement  of  the  primary  unorganised  cementing  substance  by  organ- 
ised growing  tissue,  —  formed ,  in  the  first  place,  by  the  interlacing  of 
processes  from  the  neighbouring  cells ;  in  the  second,  and  later,  by  a 
multiplication  of  these  cells,  together  with  a  development  of  new 
capillaries,  few  in  number,  which  branch  off  from  the  slightly-congested 
vessels  in  the  neighbourhood.  Thus  in  this  case  the  process  of  repair 
is  characteristically  associated  with  hypertrophy  and  the  new  growth- 
of  the  fixed  cells  of  the  tissue ;  while  vascular  changes,  exudation  and 
leucocytosis,  are  relatively  little  marked.  I  have,  however,  never  come 
across  a  case  in  which  they  have  been  entirely  absent,  save  when  the 
section  has  been  truly  extra- vascular  —  that  is  to  say,  when  it  has  not 
penetrated  into  the  vascular  region  of  the  skin,  and  has  afEected  only 
the  epidermis  and  outermost  layers  of  the  dermis.  In  such  cases  the 
response  to  injury  may  show  itself  purely  as  a  proliferation  of  the 
epithelial  cells. 

As  I  have  said,  observations  of  the  above  nature  labour  under  the 
disadvantage  that  they  must  of  necessity  be  discontinuous.  I  bring 
them  in  at  this  point,  inasmuch  as  they  represent  the  mildest  condition 
of  the  inflammatory  reaction.  I  have  not  personally  observed  this 
series  of  changes  in  tissues  which  permit  of  continued  study  under 
aseptic  conditions  ;  neither  am  I  acquainted  with  any  observations 
wholly  fulfilling  these  conditions  —  made,  that  is  to  say,  upon  trans- 
parent vascular  tissues  subjected  to  the  mildest  aseptic  injury  and 
examined  continuously  under  the  microscope. 

The  response  to  injury  in  the  cases  just  mentioned  was  of  the 
slightest.  Let  me  now  pass  on  to  cases  in  which  it  becomes  more  pro- 
nounced; and  in  order  to  continue  the  comparative  study  of  inflam- 
mation I  would  first  describe  the  series  of  events  in  a  highly  vascular 
and  trayisparent  region  in  a  low  vertebrate  animal,  namely,  in  the 
tadpole's  tail.  If  this  be  injured,  either  by  the  application  of  a  ca^ustic 
or  by  the  introduction  of  a  foreign  inert  body  into  its  substance,  a 
definite  advance  upon  what  was  recognisable  in  the  case  of  the  axolotl, 
for  example,  is  to  be  made  out.  Here  the  tail  is  very  vascular,  the 
wandering  cells  of  the  connective  tissue,  are  very  few  in  number,  while 
the  blood  is  fairly  rich  in  leucocytes  which  are  small  relatively  to  the 
size  of  the  vessels.  The  results  of  injury  are  a  congestion  of  the 
vessels,  noticeable  within  fifteen  minutes,  and  a  well-marked  determi- 
nation of  leucocytes  to  the  injured  region.  These  cells,  in  the  main, 
pass  out  from  the  vessels ;  the  few  leucocytes  pre-existing  in  the  tissue 
appear  to  xjlay  a  very  small  part.  Compared  with  the  axolotl  experiment 
,  this  observation  is  of  considerable  interest.  Instead  of  a  slight  reaction 
slowly  developing  there  is  a  rapid  reaction ;  instead  of  a  slight  accumula- 


SYSTEM  OF  MEDICINE 


tion  of  leucocytes  there  is  a  most  pronounced  accumulation.  If  there  be 
any  meaning  in  the  determination  of  leucocytes  to  the  region  of  injury, 
then  evidently  the  active  participation  of  the  vessels  of  that  region  in 
the  reactive  process  is  fraught  with  benefit  —  it  is  a  further  important 
factor  developed  with  the  development  and  advance  of  the  organism. 

The  fuller  details  of  this  vascular  interference  in  the  inflammatory 
process  have  been  followed  by  many  observers,  among  whom  first  and 
foremost  was  Cohnheim  ;  and  to  this  end  the  frog  has  supplied  the  most 
convenient  means  in  regions  at  once  vascular  and  fairly  transparent, 
such  as  the  web  of  the  hind  feet,  the  tongue,  and  the  mesentery.  Other 
observers  passing  higher  in  the  scale  of  vertebrates  have  employed  the 
mesentery  of  the  cat,  dog,  and  other  mammalia.  SuflS.ce  it  to  say  that, 
with  slight  modifications  due  to  local  conditions  in  the  tissue  examined 
rather  than  to  the  animal  selected,  the  process  has  been  found  to 
present  the  same  features  throughout  the  whole  of  the  adult  vertebrata, 
from  the  reptilia  upwards.  For  general  examination,  perhaps,  the  best 
and  simplest  method  of  observing  the  succession  of  changes  that  follow 
injury  of  a  vascular  area  is  to  be  found  in  what  I  believe  to  be  Coats' 
modification  of  Cohnheim's  original  experiment  upon  the  frog's  web 
(Coats'  Pathology,  1889,  p.  119).  In  order  to  reproduce  as  nearly  as 
possible  the  conditions  of  an  ordinary  wound,  instead  of  employing  a 
caustic  or  chemical  irritant,  a  small  portion  of  the  cutaneous  surface  is 
nipped  off — the  section  being  just  deep  enough  to  pass  through  the 
cutaneous  layers  Avithout  causing  haemorrhage.  For  the  experiment  to 
proceed  satisfactorily,  it  is  necessary  that  the  frog  be  curarised  after 
having  been  pithed.  The  web  of  a  small  frog  is  so  thin  that  the 
changes  occurring  in  and  around  the  vessels  of  the  part  can  readily  be 
followed  even  with  a  high  power  of  the  microscope. 

The  first  change  noticeable  in  the  immediate  neighbourhood  of  the  in- 
jured membrane  is  a  dilation  of  the  vessels,  first  of  the  arteries  and  then  of 
the  veins ;  and  in  this  first  phase  there  is  a  very  evident  acceleration  of 
the  blood  flow.  At  this  early  period  the  capillaries  show  little  evidence 
of  dilation,  but  in  the  course  of  an  hour  expansion  is  readily  distinguish- 
able, and  sundry  capillary  channels,  previously  invisible,  become  occupied 
by  blood  and  show  themselves.  This  first  stage  lasts  for  an  hour,  or  in 
some  cases  perhaps  two,  and  is  followed  by  a  phase  of  slowing  of  the 
blood  current.  While  previously  a  well-marked  axial  stream  of  cor- 
puscles had  been  evident,  with  a  peripheral  zone  of  plasma  devoid  of 
corpuscles,  the  former  now  broadens  out,  the  latter  becomes  less  and 
less,  and  as  it  narrows  an  increasing  number  of  the  clearer  rounded 
haemal  leucocytes  are  to  be  seen  in  it  travelling  at  a  slower  rate  than 
the  more  axial  stream,  and  every  now  and  then  stopping  beside  the 
walls  of  the  vessels,  and  after  a  short  stoppage  passing  on  again.  The 
leucocytes  conduct  themselves  as  if  they  have  become  "  sticky."  ^ 

As  the  current  becomes  yet  slower  all  distinction  between  axial  and 

1  Even  so  low  down  in  the  scale  as  Daphnia  this  same  peculiarity  is  noticeable :  there  la 
health,  as  Hardy  has  pointed  out,  the  leucocytes  move  freely ;  but,  if  the  slightest  injury  be 


INFLAMMA  TION 


peripheral  streams  is  lost ;  the  corpuscles,  closely  packed  together,  fill  the 
whole  lumen ;  the  leucocytes  in  increasing  number  approach  the  vessel 
walls ;  they  adhere  more  firmly,  and  so  long  as  a  current  is  recognisable 
the  action  of  the  stream  leads  them  to  assume  a  pear-shaped  appearance, 
the  rounded  ends  pointing  in  the  direction  of  the  current. 

As  the  stream  slows  gradually  the  corpuscles  may  move  at  last  in  a 
series  of  jerks  synchronous  with  the  heart  beats ;  or  frequently  in  the 
veins  and  capillaries  the  mass  of  blood  may  be  seen  moving  slowly  first 
in  one  direction,  then  in  the  other.  Frequently  one  or  other  of  these 
stages  is  followed  by  complete  stagnation  or  stasis  of  the  blood  in  the 
vessels  of  the  injured  area  —  I  say  frequently,  for  at  other  times  little 
or  no  absolute  arrest  is  seen  in  the  vessels.  Accompanying  this  stage, 
although  observers  employing  other  and  chemical  methods  of  inflicting 
injury  have  in  general  omitted  to  call  attention  to  the  fact,  there  is 
already  a  considerable  oozing  or  exudation  of  clear  fluid  from  the  wound ; 
there  is,  that  is  to  say,  an  outpouring  of  lymph,  and  that  apparently  from 
the  distended  vessels.  Now,  with  the  slowing  of  the  stream  the 
leucocytes,  accumulated  next  to  the  walls  of  the  small  veins  and  within 
the  capillaries,  pass  from  the  interior  to  the  exterior  of  these  vessels ; 
and,  if  the  process  be  studied  carefully  with  a  higher  power,  it  can 
be  seen  that  this  mode  of  passage  is  of  an  active,  or  apparently  active 
nature.^  A  series  of  leucocytes  can  be  distinguished  some  of  which  are 
rounded  or  flattened  in  immediate  contact  with  the  wall  of  the  vein ; 
others  possess  a  prolongation  passing  into  the  wall ;  in  others,  again  (or 
in  the  former  if  they  be  watched  in  the  fresh  specimen),  the  prolongation 
enlarges  on  the  outer  side  of  the  small  vessel  while  the  portion  of  the 
leucocyte  within  the  vessel  becomes  smaller.  The  final  phase  of  this  act 
of  diapedesis  is  that  the  whole  leucocyte  passes  through,  and  is  found  in 
the  lymph  spaces  around  the  vessel  wall.  This  process  of  diapedesis 
may  be  so  general  that  in  the  course  of  five  or  six  hours  all  the  small 
veins  of  the  region  show  a  crowd  of  leucocytes  situated  along  their  outer 
surface.  With  these  a  greater  or  less  number  of  red  corpuscles  may 
also  make  their  escape. 

Although  the  capillaries,  from  the  very  smallness  of  their  diameters, 
do  not  show  the  so-called  "  margination"  of  leucocytes,  nevertheless  this 
same  process  of  diapedesis  may  occur  at  various  points  along  their  course, 
so  that  outside  the  capillaries  also  a  fair  number  of  the  same  small  highly- 
refractile  cells  endowed  with  amoeboid  movements  can  be  observed. 

In  this  modification  of  Cohnheim's  experiment  a  further  stage  is  to  be 
recognised.  While  at  first  the  fluid  exuded  was  clear  and  relatively  free 
from  cells  and  cell  debris,  now,  as  the  inflam.matory  process  continues,  an 
increasing  number  of  leucocytes  is  contained  in  the  exudation.     The 

inflicted  upon  the  carapace,  the  leucocytes,  previously  unadhesive,  soon  show  the  tendency 
to  a'lhere  to  the  walls  of  the  body  cavity  beneath  the  region  of  injury  and  elsewhere. 

1  The  process  can  be  fully  made  out  if  at  this  stage  the  wounded  region  be  removed, 
fixed  immediately  in  weak  osraic  acid,  and  prepared  for  examination  by  the  higher 
powers  of  the  microscope. 


70  SYSTEM  OF  MEDICINE 

leucocytes  do  not  remain  in  tlie  immediate  neighbourhood  of  the  vessels, 
but  many  of  them  pass  on  to  the  injured  surface ;  still  it  would  seem  by 
active  amoeboid  movement.  Thus  at  the  end  of  six  hours  this  surface 
may  be  covered  by  a  serum  or  fluid  in  which  are  great  numbers  of  these 
leucocytes.  Here  then  we  have  the  first  step  towards  the  formation  of 
a  scab  or  provisional  protective  covering  to  the  wound. 

Further  observations  cannot  well  be  carried  out  in  the  pithed  and 
curarised  frog;  but  if  an  unpithed,  non-curarised  animal  be  taken,  and 
the  observations  upon  the  earlier  stage  be  neglected,  it  can  be  made  out 
that  if  irritant  matter  do  not  find  entry  into  the  wound  the  process  may 
be  arrested  at  this  point ;  the  leucocytes  upon  the  surface  may  break 
down,  and  Avith  their  breaking  down  and  the  formation  of  fibrin  a  soft 
scab  be  formed :  the  stasis  of  the  blood  in  the  distended  vessels  may  be 
followed  by  a  re-establishment  of  the  current  and  slow  return  of  the 
vessels  to  their  former  calibre,  while  beneath  the  thin,  soft  scab  the 
epithelial  cells  rapidly  proliferate.  Within  twenty-four  hours  there  may 
be  abundant  evidence  of  this  new  growth  of  the  epithelium  tending 
to  encroach  upon  and  cover  the  wound.  At  the  same  time  the  region 
becomes  less  and  less  populated  with  leucocytes,  so  that  —  not  to  enter 
fully  at  this  point  into  the  reparative  process  —  within  sixty  hours  the 
region  may  show  little  sign  of  the  injury  and  consequent  inflammation. 

On  the  other  hand,  if  irritants  of  a  microbic  nature  enter  the  wound 
the  process  may  extend,  as  in  inflammation  of  the  cornea.  More  especially 
if  the  water  in  which  the  frog  is  kept  become  foul,  there  is  a  tendency 
in  the  inflammatory  processes  to  spread ;  and  in  the  cells  of  the  central 
area,  both  fixed  and  migrated,  to  break  down,  leading  to  the  formation  of 
a  spreading  ulcer.  The  steps  of  this  sequence  of  affairs  it  is  difiicult  to 
follow  by  continuous  microscopic  examination,  partly  on  account  of  the 
increased  opacity  of  the  region,  partly  because  the  process  extends  over 
days  rather  than  hours.  Here,  therefore,  I  merely  mention  this  possible 
extension  of  the  change  with  its  main  naked-eye  appearances. 

It  is  not  possible  by  continuous  observation  to  make  out  the  steps  of 
this  more  extensive  inflammation  characterised  by  excessive  emigration 
of  leucocytes  and  destruction  of  these  together  with  the  fixed  cells  of  the 
tissue  —  the  pyogenetic  inflammation.  Several  observers,  however,  have 
followed  its  successive  stages  by  means  of  examination  of  affected  tissues 
at  successive  intervals  after  the  infliction  of  injury. 

The  Experimental  Production  of  Suppurative  Inflammation.  —  While, 
as  shown  by  Councilman,  Grawitz  and  de  Barry,  Straus,  Leber  and 
others,  a  suppurative  inflammation  may  under  certain  conditions  be 
brought  about  experimentally  by  the  action  of  chemical  irritants,  such 
as  mercury  and  turpentine ;  yet  under  ordinary  pathogenic  conditions 
suppuration  is  induced  by  the  growth  of  micro-organisms  within  the 
tissues.  Hence  it  is  better  to  study  the  conditions  as  induced  by  the 
inoculation  of  pus-producing  microbes  into  one  or  other  tissue.  A  very 
full  series  of  observations  upon  the  development  of  abscesses  through  the 
agency  of  the  Staphylococcus  pyogenes  aureus  has  been  made  by  Hohn- 


INFLAMMA  TION 


71 


feldt.  He  employed  rabbits,  and  inoculated  small  quantities  of  pure 
cultures  of  the  microbe  subcutaneously. 

Four  hours  after  inoculation  the  vessels  of  the  region  were  found 
densely  filled  with  corpuscles,  and  in  them  a  commencing  margination  of 
the  white  corpuscles  was  discernible.  Leucocytes  were  present  within 
the  tissue  in  numbers  greater  than  normal ;  although,  compared  with  later 
stages,  they  were  infrequent.  They  were  of  two  kinds  —  the  mono- 
nuclear in  the  majority,  the  polynuclear  (or  more  truly  the  form  with 
polymerous  nucleus)  in  lesser  numbers ;  both  forms  were  congregated 
mainly  around  the  line  of  entrance  of  the  injecting  needle.  Many  of 
the  connective  tissue  cells  were  so  swollen  as  to  be  rounded  rather  than 
flattened.  The  injected  cocci,  lying  in  the  lymph  spaces,  were  scattered 
through  the  tissue ;  in  part  free,  in  part  already  ingested  by  cells,  not 
only  by  the  leucocytes,  but  also  by  connective  tissue  cells :  the  number 
within  leucocytes  was  not  inconsiderable. 

Preparations  made  at  the  end  of  ten  hours  showed  the  same  conditions, 
but  more  distinctly.  There  was  ample  evidence  of  migration  of  the 
leucocytes,  margination  in  the  congested  vessels,  various  stages  of  passage 
through  the  vascular  walls,  and  large  collections  of  the  cells  in  the  peri- 
vascular lymph  spaces ;  from  these  they  spread  into  the  spaces  between 
the  bundles  of  connective  tissue  fibrils.  The  cocci  lay  in  the  lymph 
spaces  and  were  increased  in  number,  and  the  massing  of  leucocytes  cor- 
responded in  position  to  the  accumulation  of  microbes.  In  these  regions 
the  leucocytes  were  mainly  polymerous  or  multinuclear,  but  in  the  boun- 
dary zone  away  from  the  cocci  the  uninuclear  form  predominated. 

At  the  end  of  twenty  hours  there  was  further  accentuation  of  these 
conditions.  As  yet  an  abscess  proper  had  not  formed,  but  enormous 
numbers  of  leucocytes  were  present,  and  also  of  micrococci;  the  fibrillse 
of  connective  tissue  were  widely  separated  by  the  collections  of  leuco- 
cytes, and  these  cells  clustered  round  and  hid  the  connective  tissue  cells. 

With  the  completion  of  forty-eight  hours  a  well-defined  abscess  had 
formed,  separated  sharply  from  the  surrounding  healthy  tissue.  The 
centre  of  the  abscess  was  seen  to  consist  of  densely-packed  leucocytes 
mingled  with  large  growths  of  cocci.  These  leucocytes  were  almost 
entirely  "  multinuclear ; "  and  in  this  central  area  the  nuclei  of  some 
showed  fragmentation.  Neither  leucocytes  nor  connective  tissue  cells 
showed  the  slightest  indication  of  mitosis.  In  the  central  area  all  traces 
of  the  previous  capillaries  had  disappeared ;  in  the  peripheral  zone  they 
were  easily  recognisable,  being  fully  injected  and  showing  a  marginal 
disposition  of  their  leucocytes,  many  of  which  could  be  seen  (in  osmic 
acid  preparations)  fixed  in  the  process  of  diapedesis. 

The  majority  of  the  cocci  lay  in  these  leucocytes.  Even  where  the 
colonies  of  the  microbes  were  thickest  there  the  majority  were  intra- 
cellular. Passing  towards  the  periphery  the  number  of  cocci  became 
smaller  and  smaller.  At  the  periphery  they  could  be  seen  not  only  to 
be  intracellular,  but  also  free  in  the  lymph  spaces  ;  and  Hohnfeldt,  with 
other  observers,  saw  them  definitely  grouped  within  the  endothelial  cells 


72  SYSTEM  OF  MEDICINE 

of  the  peripheral  vessels.  Thus  it  raay  be  noted  that  at  this  stage  the 
proliferating  microbes  extended  into  the  healthy  tissues  outside  the 
abscess. 

In  the  centre  of  the  abscess  the  original  tissue  had  wholly  disappeared ; 
nearer  the  periphery  light  streaks  and  bundles  of  the  disintegrating 
fibrillae  could  be  recognised  between  the  leucocytes. 

Not  till  about  the  tenth  day  did  new  growth  of  tissue  begin  to  show 
itself.  During  the  preceding  six  days  there  had  been  more  breaking 
down  of  the  polynuclear  leucocytes,  characterised  by  fragmentation  of  the 
nuclei  and  by  fatty  degeneration  of  the  cell  substance.  But  by  the  tenth 
day  the  periphery  had  begun  to  assume  the  appearance  of  granulation 
tissue  ;  it  contained  numerous  capillaries  and  new-formed  connective  tis- 
sue with  characteristic  epithelioid  cells  or  fibroblasts  possessing  large  oval 
pale  staining  nuclei.  In  these  cells,  as  in  the  connective  tissue  cells  of 
the  surrounding  healthy  tissue,  could  the  numerous  steps  of  indirect  cell 
division  be  made  out.  In  this  granulation  tissue  cocci  were  absent  and 
leucocytes  were  infrequent.  In  the  soft,  cheesy  central  area  masses  of 
cocci  were  still  present.  Whether  these  were  living  or  dead  Hohnfeldt 
did  not  determine ;  he  inferred  (what  has  since  been  proved  by  several 
observers  to  be  an  unsafe  inference)  that  inasmuch  as  they  stained  well 
with  aniline  dyes  they  were  alive. 

Thus,  to  sum  up  Hohnfeldt's  observations,  the  processes  occurring  in 
a  suppurative  inflammation  that  ends  in  healing  are  the  following:  — 

1.  Congestion  of  the  region  of  invasion,  with  margination  of  the 
leucocytes. 

2.  Collection,  in  the  region,  of  uninuclear  leucocytes ;  then  diapedesis 
of  leucocytes  with  polymerous  nuclei :  multiplication  of  the  cocci. 

3.  Ingestion  of  large  numbers  of  the  microbes  by  the  polymerous 
leucocytes  and  other  cells,  including  the  endothelial  cells  of  the  vessel 
walls. 

4.  Increasing  immigration  of  leucocytes  until  the  tissue  becomes 
densely  packed.  This  is  accompanied  by  a  yet  greater  proliferation  of 
the  microbes,  which  extend  {i.e.  are  carried  by  lymph  streams  or  by  cells) 
into  the  region  outside  the  developing  abscess. 

5.  Destruction  of  the  tissue  of  the  affected  part. 

6.  Degeneration  of  the  leucocytes  within  the  sharply-defined  abscess. 

7.  Eventual  proliferation  of  the  connective  tissue  at  the  periphery  of 
the  abscess ;  formation  of  fibroblasts  in  the  highly  vascular  surrounding 
zone;  cicatrisation  and  encapsulation  of  the  debris  of  the  leucocytes 
and  micrococci. 

There  are  not  a  few  points  in  connection  with  these  observations  of 
Hohnfeldt  that  deserve  discussion;  very  possibly  he  has  misinterpreted 
certain  of  the  appearances  seen  by  him.  On  the  whole,  however,  he 
draws  a  full  and  accurate  picture  of  the  successive  stages  of  suppiirative 
inflammation,  and  I  may  defer  discussion  to  a  later  review  of  the  action 
of  the  leucocytes  and  of  the  formation  of  fibrous  tissue  respectively. 

However,  before  leaving  this  general  description  of   the  series  of 


INFLAMMA  TION  73 


anatomical  changes  induced  by  injury,  there  is  another  phase  of  the 
inflammatory  process  set  up  by  pathogenic  micro-organisms  which  must 
not  be  passed  over  —  I  refer  to  those  cases  in  wliich,  instead  of  ending 
in  repair,  there  is  extension  and  generalised  disease.  The  stages  pre- 
ceding extension  vary  with  the  nature  of  the  microbe ;  thus,  in  some 
cases,  the  reaction  to  the  invasion  of  the  microbe  is  mainly  leucocytic 
(as  with  inoculations  of  the  micrococci  of  suppuration),  in  others  it  is 
mainly  exudative  or  serous,  the  congestion  of  the  vessels  being  followed 
by  abundant  exudation  of  serum  into  the  tissues.  This  is  the  case  in 
inoculation  of  animals — such  as  rabbits,  guinea-pigs  and  fowls  —  with 
cultures  of  micro-organisms  which  are  peculiarly  virulent  in  their  be- 
haviour towards  these  animals.  Such  a  serous  or  exudative  inflamma- 
tion is,  for  instance,  well  seen  if  the  vibrio  Metschnikovi  be  inoculated 
into  the  pectoral  muscles  of  a  fowl.  Within  twelve  hours,  it  may  be, 
the  seat  of  inoculation  becomes  greatly  swollen,  and  on  section  is  found 
reddened  and  congested;  while  from  it  drains  an  abundance  of  relatively 
clear,  faintly-reddish  serum  containing  but  a  few  leucocytes. 

In  such  a  case  as  this  the  micro-organisms  appear  to  pass  with  ease 
from  the  centre  of  infection  into  the  surrounding  tissues,  and  thence 
into  the  lymphatics  and  general  circulation,  whence  they  may  be 
obtained  within  twenty-four  hours.  Where  there  has  been  a  well- 
marked  abscess  formation  in  the  region  of  invasion  there,  as  already 
indicated,  it  is  true  that  the  microbes  may  be  found  outside  the  abscess 
at  a  fairly  early  period  ;  but,  in  the  main,  proliferation  is  limited  to  the 
abscess,  and  the  blood  remains  free  and  sterile.  Under  certain  condi- 
tions of  great  virulence  of  the  pyogenic  microbes  it  is  found  that  as  the 
abscess  extends  it  becomes  ill-defined  —  there  is  no  sharp  demarcation 
between  the  collected  leucocytes  and  the  surrounding  tissue;  the 
columns  of  leucocytes  spread  indefinitely  from  the  centre,  and  numerous 
micrococci  are  intermingled  with  them.  Where  this  is  the  case  there 
is  a  marked  tendency  for  the  microbes  to  find  their  way  into  the  general 
circulation  from  this  irregular  peripheral  extension  along  the  lymphatic 
spaces,  and  to  set  up  a  condition  of  septicaemia  as  in  the  more  serous 
inflammation  described  above. 

Septiccemia,  or  the  passage  of  micro-organisms  into  the  blood,  with 
all  the  results  of  such  a  passage  —  the  condition  which  sundry  French 
observers  have  described  as  inflammation  of  the  blood  —  is  dealt  with 
in  another  article.  In  septicaemia  we  pass  beyond  the  local  response  to 
injury,  we  deal  with  a  state  of  general  systemic  disturbance.  Never- 
theless certain  phases  of  the  septicaemic  condition  throw  light  upon  the 
inflammatory  process. 

In  the  first  place,  it  is  of  interest  to  note  that  when  the  infective 
micro-organisms  and  their  products  are  within  the  vessels  they  fail  to 
induce  the  cardinal  symptoms  of  inflammation.  They  do  not  lead  to 
exudation  of  fluid  from  the  blood  or  to  wide-spread  diapedesis  of  leuco- 
cytes. The  stimulus,  whatever  it  be,  which  leads  to  these  phenomena  at 
the  point  of  invasion  is  no  longer  called  into  activity  when  the  noxa  is 


74  SYSTEM   OF  MEDICINE 

within  the  circulatory  apparatus.  This  is  the  reverse  of  what  might  be 
expected  if  the  inflammatory  process  were  primarily  due  to  a  modification 
of  the  endothelium  of  the  vessel  walls  by  the  irritant,  a  modification  pas- 
sively permitting  the  exudation  and  passage  outwards  of  the  leucocytes. 

The  statement  that  infective  micro-organisms  and  their  products 
circulating  within  the  blood  fail  to  induce  inflammatory  changes,  would 
seem  to  need  modification  when  the  development  of  metastatic  abscesses 
is  taken  into  account.  But  a  study  of  the  mode  of  production  of  these 
abscesses  shows  that  the  statement  still  holds.  Such  abscesses  originate 
round  emboli  of  pyogenic  micro-organisms  in  the  capillaries.  Sundry 
cocci  are  arrested  in  the  capillary,  proliferate  and  fill  the  vessel.  It  is 
only  when  a  minute  vessel  is  thus  occluded  that  the  abscess  process 
begins,  that  is  to  say,  when  by  this  occlusion  the  vessel  has  become 
extravascular  ;  and  Avhile  it  is  true  that,  primarily,  the  arrest  of  patho- 
genic microbes  within  the  capillaries  is  often  associated  with  a  small 
accumulation  of  intravascular  leucocytes  and  with  degenerative  changes 
in  the  vascular  endothelium,  the  metastatic  abscess,  as  such,  forms  not 
by  accumulation  of  leucocytes  in  the  occluded  vessel,  but  around  it ; 
the  leucocytes  emigrating  from  surrounding  capillaries. 

Inflammatory  Fever.  —  In  the  second  place,  through  this  study  of 
advancing  inflammation  it  is  of  interest  to  trace  the  very  close  relation- 
ship that  exists  between  inflammation  and  fever.  Besides  the  local 
changes  here  described,  local  injury  is  accompanied  by  systemic  dis- 
turbances.    These  may  be  slight  or  grave. 

Take,  for  instance,  progressive  abscess  formation,  or  follow  the 
development  of  a  malignant  carbuncle  in  man.  At  first  the  reaction 
is  purely  local,  but  very  soon,  long  before  any  of  the  micro-organisms 
are  capable  of  detection  in  the  blood,  there  is  exaltation  of  temperature 
and  a  slight  febrile  state,  the  fever  becoming  more  and  more  evident  as 
the  local  process  becomes  more  and  more  extensive,  until  with  the 
detection  of  the  microbe  in  the  blood  the  most  severe  fever,  with  con- 
stitutional disturbance,  sets  in.  Local  inflammation,  then,  without  any 
other  possible  explanation  than  either  the  nervous  irritation  to  which 
it  may  give  rise,  or  the  passage  into  the  general  circulation  of  the 
soluble  products  of  bacterial  growth  and  tissue  destruction,  or  both, 
may  lead  to  the  development  of  the  febrile  state.  How  large  a  share  is 
played  by  these  two  possible  factors  it  is  difficult  to  say.  That 
bacterial  products  injected  into  the  circulation  lead  to  the  rapid  pro- 
duction of  the  febrile  state  we  have  ample  evidence  ;  but  whether  these 
act  directly  by  inducing  increased  cellular  activity,  or  indirectly  by 
stimulating  the  cerebral  centres,  we  cannot  absolutely  say.  As  yet  we 
have  little  accurate  knowledge  of  the  parts  played  by  the  nervous 
system  in  the  development  of  the  febrile  state.  This,  however,  may 
safely  be  declared,  that  the  more  we  study  the  continued  fevers  the  more 
do  we  discover  that  these  commence  by  a  local  inflammatory  disturbance. 
The  continued  fevers  are  the  continuance,  or  rather  the  extension,  of  a 
primarily  localised  inflammatory  lesion.     [Vide  art.  on  "Fever."] 


INFLAMMA  TION  75 


Summary  of  the  Facts  thus  far  brought  forward. 

The  main  facts  gathered  thus  far  concerning  the  inflammatory  pro- 
cess, and  the  conclusions  to  be  drawn  therefrom,  may  now  be  placed  in 
order  before  I  discuss  in  detail  the  various  factors  in  the  process.  They 
are  — 

1.  Injury,  when  it  is  not  so  widespread  and  severe  as  to  lead  to  the 
death  of  the  individual,  is  followed  by  a  reaction  on  the  part  of  the 
organism. 

2.  In  unicellular  organisms  the  continued  vitality  of  the  individual 
after  injury,  and  in  mxulticellular  organisms  the  vitality  of  the  indi- 
vidual cells,  are  dependent  primarily  upon  the  persistence  of  the 
nucleus ;  if  this  be  destroyed  or  removed  the  rest  of  the  cell  is  incapa- 
ble of  complete  restitution  and  continued  groAvth. 

3.  In  unicellular  organisms  the  reactive  process  is  twofold,  and  con- 
sists of  (a)  destruction  or  removal  of  the  irritant ;  destruction  being 
brought  about  by  a  process  of  intracellular  digestion,  removal  by  extru- 
sion of  the  irritant :  (b)  new  growth  of  the  organism. 

4.  This  response  to  injury  on  the  part  of  unicellular  organisms  is 
essentially  reparative. 

5.  In  multicellular  organisms,  with  division  of  labour  among  the 
constituent  cells  of  the  individual,  there  is  a  separation  of  functions ; 
the  twofold  reaction  to  local  injury  is  yet  more  clearly  marked;  but 

(a)  The  destruction  or  removal  of  the  irritant  is  in  the  main  accom- 
plished by  the  wandering  cells  of  mesoblastic  origin. 

(6)  The  new  growth  to  replace  the  tissue  destroyed  by  the  irritant 
proceeds  in  the  main  from  the  fixed  cells  of  the  tissue. 

6.  Ascending  the  scale  of  multicellular  organisms,  a  division  of 
labour  and  differentiation  of  function  is  discoverable  among  the  wander- 
ing mesoblastic  cells.  Whereas  in  the  lower  forms  of  the  Metazoa  one 
type  of  leucocyte  alone  is  present,  in  the  higher  forms  two  or  more 
varieties  can  be  distinguished  which  possess  different  properties  and 
act  differently  towards  irritants  introduced  into  the  system. 

7.  According  to  the  nature  of  the  irritant  causing  the  injury,  the 
leucocytes  are  actively  attracted  in  greater  or  less  numbers  to  the 
region  of  injury,  surround  the  irritant,  and  remove  or  destroy  it  by 
means  very  similar  to  those  employed  by  unicellular  organisms.    Where 

'  the  irritant  is  present  in  the  form  of  discrete  particles,  there  some  at 
least  of  the  leucocytes  may  incorporate  the  particles,  and  remove  them 
or  destroy  them  by  a  process  of  digestion.  Others  of  the  leucocytes  in 
the  higher  Metazoa  never  act  thus  as  phagocytes ;  nevertheless  they  are 
equally  attracted  to  the  focus  of  inflammation,  and  jjresumably  tend  to 
counteract  the  irritant  by  some  other  (extracellular)  means. 

8.  While  to  the  wandering  cells  appears  to  be  allotted  the  main 
duty  of  removing  deleterious  and  irritant  matters,  certain  of  the  fixed 
cells  of  the  organism,  notably  the  endothelial  cells  of  the  vessels,  can 
also  exert  these  functions. 


76  SYSTEM  OF  MEDICINE 

9.  Among  the  very  large  number  of  Metazoan  forms  in  wMch  no 
complete  vascular  system  is  present,  this  attraction  of  the  leucocytes  to 
the  region  of  injury  is  at  first  the  sole  response  to  injury.  At  a  later 
period  proliferation  of  the  fixed  cells  occurs  in  the  neighbourhood  of 
the  injury. 

10.  Among  the  higher  Metazoa,  in  which  there  is  a  well-developed 
vascular  system,  the  determination  of  leucocytes  to  the  region  of  irrita- 
tion still  continues,  and  is  in  fact  markedly  aided  by  the  participation 
of  the  vessels  in  the  inflammatory  process. 

11.  The  vascular  phenomena  in  inflammation  may  be  regarded  as 
serving  two  main  purposes  —  (a)  the  pouring  out  of  increased  fluid  into 
the  injured  area ;  (6)  the  afilux  and  diapedesis  of  leucocytes. 

12.  Even  in  the  highest  Metazoa,  possessing  fully-developed  vascular 
systems,  the  response  to  injury  in  a  non- vascular  area,  such  as  the 
cornea,  may  be  associated  with  no  change  in  the  surrounding  vascular 
areas,  but  purely  with  a  determination  to  the  injured  area  of  leucocytes 
already  free  in  the  surrounding  tissues. 

13.  The  second  phase  of  the  inflammatory  process,  that  of  tissue 
repair,  but  very  rarely  occurs  without  evidence  of  previous  migration 
of  leucocytes  and  exudation  from  the  congested  vessels. 

14.  A  comparative  study  leads  inevitably  to  the  conclusion  that  the 
determination  of  leucocytes  to  the  region  of  injury  is  the  most  constant 
and  most  characteristic  early  response  to  injury  recognisable  through- 
out the  Metazoa,  and  that  it  must  be  regarded  as  the  most  important 
factor  in  the  flrst  stage  of  the  inflammatory  process.  The  vascular 
phenomena  noticeable  in  the  higher  Metazoa  must  be  regarded  as  a 
second  and  highly  important  factor  of  later  development  and  adjuvant. 
New  tissue  formation  is  the  prominent  characteristic  of  the  later  stages 
of  the  process. 

15.  As  among  the  Protozoa,  so  in  the  Metazoa,  the  response  to 
injury  is  consistently  an  attempt  to  repair  the  injury. 

This  general  survey  of  the  response  to  injury  throughout  the  animal 
kingdom  demonstrates  most  clearly  that  the  same  broad  principles,  the 
same  methods  of  defence  and  repair  on  the  part  of  the  organism,  are 
called  into  activity  from  the  lowliest  forms  to  the  highest ;  that,  in  fact, 
no  line  can  be  drawn  to  separate  one  set  of  phenomena  as  truly  inflam- 
matory from  another  set  which,  while  also  a  response  to  injury,  are  non- 
inflammatory. Although  it  is  true  that  the  term  inflammation  implies 
a  reddening  and  congestion  of  the  vessels,  we  find  upon  closer  exam- 
ination that  this  reddening  and  congestion  is  not  the  fundamental  but  a 
superadded  feature  in  the  process  of  repair  of  injury  —  a  feature  super- 
added as  the  organism  advances  in  its  place  in  the  animal  kingdom. 
Thus  if  we  are  to  comprehend  the  process  satisfactorily  we  must  pass 
beyond  the  narrower  acceptation  of  the  term. 

Having  thus  sketched  broadly  the  general  phenomena  of  the  inflam- 
matory process,  it  will  be  well  now  to  describe  in  fuller  detail  the  factors 
of  this  process  among  the  higher  vertebrata,  and  to  bring  together  the 


INFLAMMA  TION  77 


more  important  results  of  the  study  of  the  respective  functions  of  the 
wandering  cells,  the  vessels,  the  fixed  cells,  and  the  nervous  system 
in  inflammation. 


PAET  II.  —  The  Factors  in  the  Inflammatory  Process 

Chapter  1.  —  The  Part  played  by  the  Leucocytes 

■  The  Leucocytosis  of  Inflammation.  —  As  I  have  already  shown,  there 
is  more  than  one  form  of  leucocyte  in  the  mammalian  organism, 
and  the  several  forms  evidently  possess  different  attributes,  and  act 
differently  in  the  reaction  to  injury.  Inasmuch  as  these  forms  have 
been  variously  classified  —  so  variously,  in  fact,  that  it  is  often  far  from 
easy  to  collate  the  various  descriptions,  and  to  discuss  the  forms  distin- 
guished by  one  observer  in  the  terms  of  another  —  it  is  necessary  to 
give  the  chief  classifications  of  them,  and, their  relations. 

The  first  to  discriminate  between  the  forms  of  white  corpuscles  in 
the  blood  was  Wharton  Jones  so  long  ago  as  1846.  He  drew  a  dis- 
tinction between 

A.  Granule  cells      i  T;inely  granular. 

j  Coarsely  granular. 

B.  "Nucleated"  cells  —  Kon-granular. 

His  observations,  together  with  those  of  Rindfleisch  in  1861  and 
1863,  were  confirmed  and  advanced  by  Max  Schultze,  who  made  out  the 
following  forms :  — 

1.  Small  round  cells  with  round  nucleus  and  little  clear  protoplasm. 

2.  Larger  cells  with  round  nucleus  a'nd  more  clear  protoplasm. 

3.  Cells  with  finely  granular  protoplasm,  and  one,  two,  or  more  nuclei. 

4.  Cells  with  coarse  granules  in  the  protoplasm. 

The  distinctions  drawn  were,  so  far,  purely  morphological ;  and  very 
little  notice  was  taken  of  these  varieties  for  a  long  period  until  Ehrlich, 
in  a  notable  series  of  papers  extending  from  1878  to  1887,  drew  atten- 
tion to  the  fact  that  the  wandering  cells  of  the  organism  react  diversely 
towards  the  diffef  ent  aniline  dyes  and  possess  diverse  tinctorial  affinities 
indicating  chemical  differences  in  the  nature  of  certain  constituents 
of  the  cell  bodies.  The  granules  of  the  previous  observers  were  found 
to  be  variously  affected  by  the  dyes  employed ;  they  were  shown  not  to 
be  fatty,  but  —  as  Ehrlich  put  it  —  of  the  nature  of  a  glandular  excre- 
tion ;  ^  and  comparing  the  effects  of  the  two  groups  of  aniline  colours 
—  that  in  which  the  dye  is  associated  with  the  acid  constituent  of  the 
salt,  and  that  wherein  the  dye  forms  the  base  (the  "  acid  "  and  ''  basic  " 

1  J.  Weiss  has  studied  the  micro-chemical  reactions  of  the  eosinophilous  granules, 
and  conolndes  that  they  are  of  albuminoid  nature  ;  as  they  were  found  not  to  be  digested 
in  gastric  juice  he  would  ally  them  with  the  nucleins. 


SYSTEM  OF  MEDICINE 


aniline  dyes  respectively)  —  he  made  out  tlie  existence  of  five  forins  of 
granulation  associated  with  as  many  varieties  of  wandering  cells.  His 
table  of  cells  according  to  their  granulation  is  as  follows :  — 

0.  Granulation  —  Eosinophile.  —  Cells  frequently  in  horse's  blood,  present  con- 

stantly in  small  numbers  in  human  blood  ;  numerous  in  medulla  of 
bones  of  rabbits,  dogs,  guinea-pigs,  etc.  Stain  deeply  with  acid  aniline 
dyes.     Granules  large  and  coarse. 

/3.  Granulation  —  Amphophile.  —  Cells  frequent  in  rabbits  and  guinea-pigs  in 
blood  ;  present  also  in  medulla  of  bones.  Stain  both  with  acid  and  basic 
dyes.     Granules  fine. 

7.  Granulation  —  Basophile. — Large  cells  found  in  the  connective  tissue, 
from  the  frog  upwards,  "  Mastzellen  "  ;  in  blood  of  man  only  in  cer- 
tain cases  of  Leucsemia.  Stain  only  with  basic  dyes.  Granules 
coarse. 

5.  Granulation  —  Fine  Basophile.  —  The  "mononuclear"  leucocyte  of  human 
blood.     Granulation  fine.     Stain  with  basic  dyes. 

c.  Granulation  —  Neutrophile. — The  most  frequent  ?eucocyte  of  human 
blood,  "  polynuclear."  Stain  only  in  neutral  dyes  —  not  in  acid  or 
basic. 

While  Ehrlich  and  his  pupils,  and  Rieder,  have  done  much  to  throw 
light  upon  the  relative  numbers  of  the  leucocytes  possessing  these  different 
granulations  in  different  diseases,  they  have  accomplished  little  in  dis- 
covering the  origin  of  the  various  forms,  their  functions,  or  their  relation- 
ships. We  owe  the  first  satisfactory  studies  upon  the  properties  of  the 
different  forms  to  Metschnikoff,  who,  at  an  early  period  in  his  long- 
continued  and  wonderful  series  of  researches  upon  Phagocytosis,  made 
out  that  the  different  wandering  cells  of  the  body  act  differently  towards 
microbic  and  other  foreign  particles  introduced  into  the  organisms.  Thus 
he  was  led  to  draw  a  distinction  between  — 

1.  Lymphocytes  —  immature  leucocytes. 

2.  Large  hyaline  cells,  mononuclear,  phagocytic,  "macrophages."^ 

3.  Smaller  neutrophile  cells,  polynuclear,  "  microphages." 

4.  Eosinophile  leucocytes  —  not  phagocytic.^ 

Quite  recently  the  admirable  researches  of  Prof.  Sherrington,  and  of 
Dr.  Kanthack  and  Mr.  Hardy,  have  appeared  which,  starting  on  the 
groundwork  laid  down  by  the  older  observers,  have  made  a  notable 
advance  in  the  determination  of  the  function  of  the  various  forms  of 
wandering  cells  in  inflammatory  and  other  conditions.    The  observations 

1  While  acknowledging  that  a  certain  amount  of  convenience  attends  the  employ- 
ment of  these  terras,  "  macrophage"  and  "  microphage,"  I  cannot  but  agree  with  Pro- 
fessor Burdon-Sanderson  that  they  are  utterly  barbaric. 

2  While  this  article  was  passing  through  the  press,  M.  Mesnil,  apupil  of  Metschnikoff, 
has  stated  that  eosinophilous  cells  can  occasionally  act  as  phagocytes.  The  statement  is 
contrary  to  Metschnikoff's  previous  observations  and,  I  may  add,  contrary  to  general 
experience.  Until  further  confirmatory  observations  have  been  made,  I  am  not  prepared- 
to  accept  the  statement. 


INFLAMMA  TION 


79 


of  Kanthack  and  Hardy  are  especially  full,  and  I  shall  have  occasion  to 
refer  continually  to  their  results.  In  the  meantime  it  may  be  said  that 
they  materially  simplify  the  classification  given  by  Ehrlich,  by  dividing 
the  leucocytes  thus  :  — 


2'.  Finefy  grSar^^  }  ^^^yP^ile  cells.     Staining  with  acid  dyes. 

Coarsely  granular  1  ^        ,  .,        ,,        ci.  •   •  -xi   1      •    j 

Finely  granular     |  ^asophile  cells.     Staming  witn  basic  dyes. 


2 
3 
4. 

6.  Hyaline  cells. 
6.  Lymphocytes. 


Their  coarsely  granular  oxyphile  cells  are  the  eosinophile  cells  of 
most  writers ;  their  finely  granular  are  the  neutrophile  and  amphophile 
of  Ehrlich.  They  prove  conclusively  that  Ehrlich's  neutral  stain  is  in 
no  sense  to  be  regarded  as  such,  but  must  be  considered  as  an  acid  dye. 

It  is  now  possible  to  collate  these  various  classifications,  and  in  this 
way  to  begin  to  study  the  functions  of  the  various  forms  with  a  clear 
appropriation  of  the  terms  employed  in  the  following  paragraphs. 


Collation  of  the  different  Classifications  of  the  Varieties  of  Leucocytes. 


Kanthack  and  Hardy. 

Ehrlich, 

Metschnikoff. 

Max  Schultze. 

Wharton  Jones. 

Lymphocyte. 

Lymphocyte. 

Lymphocyte. 

Small  round  cell  I. 

[Nod -granular 

Hyaline  cell. 

Macrophagocvte. 

Large  round  cell  IL 

i     nucleated  cells. 

Coarsely  granular 

Eosinophile  cell. 

Eosinophile  cell. 

Cells  with  coarsely 

Granule  cells, 

oxyphile. 

granular     proto- 
plasm. 

coarsely  granular. 

Finely  granular  j 
oxyphile.           1 

Neutrophile  K^jj^ 

Microphagocyte. 

Cells    with    finely 

Granule  cells,  finely 

Amphophile  f 

granular     proto- 

granular. 

plasm. 

Coarselj'  granular 

Basophile  cell  ^v1th 

basophile. 

V    granulation. 

Mastzellen. 

Finely     granular 

Basophile  cell  with 

Cells    with    finely 

?  Granule  cells,  finely 

basophile. 

6  granulation. 

granular     proto- 

granular. 

plasm. 

Lymphocyte.  —  Immature  leucocyte  ;  round  nucleus  deeply  staining  ;  scanty  pro- 
toplasm ;  increased  in  number  after  food ;  diminished  after  starvation  ; 
indistinguishable  from  small  elements  of  lymphoid  tissue.  Not  phagocytic  ; 
variable  in  number ;  not  amoeboid ;  may  form  up  to  30  per  cent  of  the 
leucocytes  present  in  human  blood. 

Hyaline.  CM.  —  Round  or  kidney-shaped  nucleus  of  slight  staining  power ; 
abundant  protoplasm ;  hyaline ;  non-granulated ;  actively  amoeboid  and 
phagocytic  ;  rare  in  blood  (2  per  cent)  ;  abundant  in  ccelomic  fluid. 
Nuclei  have  been  seen  to  undergo  mitosis. 

Coarsely  Granular  Oxyphile. — Large  horseshoe-shaped  nucleus  (in  man);  rela- 
tively large  spherules  in  protoplasm  ;  highly  refractive ;  staining  deeply  with 
acid  aniline  dyes ;  abundant  in   ccElomic  fluid,  in  serous  cavities,  in  inter- 


go  SYSTEM   OF  MEDICINE 


stices  of  areolar  tissue  (K  and  H),  and  in  bone  marrow  (Ehrlich)  ;  rare  in 
blood  (2-4  per  cent)  ;  amoeboid  ;  non-phagocytic. 

Finely  Granular  Oxyphils.  —  Smaller  than  last  (in  man)  ;  nucleus  branching  or 
polymerous,  staining  deeply;  granules  very  small  and  spherical;  feeble 
oxyphile  reaction  (Ehrlich's  amphophile  reaction  in  rabbit,  neutrophile  in 
man,  etc.).  Abundant  in  blood  (20-70  per  cent  of  all  leucocytes)  ;  absent 
from  ccelomic  fluid  ;  actively  amoeboid  and  phagocytic.  The  most  common 
form  of  pus  cell. 

Coarsely  Granular  Basophile.  —  When  found  free  in  ccelomic  fluid,  round  nucleus 
staining  very  feebly  ;  spherules  large  and  numerous,  stain  with  basic  dyes 
—  somewhat  similar  cells  are  found  stationary  in  connective  tissue  spaces  — 
absent  from  human  blood  in  health  ;  nou-phagocytic. 

Finely  Granular  Basopliile.  —  Spherical;  smallest  of  the  wandering  cells  ;  tri- 
lobed  nucleus  ;  clear  cell  substance  containing  great  numbers  of  fine  baso- 
phile  dots.  Found  in  human  blood  in  small  numbers  (1-5  per  cent)  ;  increased 
after  meals. 

From  this  description  of  the  character  of  the  various  forms  of  leuco- 
cytes (for  which  I  am  largely  indebted  to  Kanthack  and  Hardy)  it  will 
be  seen  that  certain  forms  are  characteristically  present  in  the  circulating 
blood,  namely,  the  finely  granular  oxyphile  and  the  finely  granular  baso- 
phile ;  others  in  the  body  fluid,  namely,  the  coarsely  granular  oxyphile 
and  coarsely  granular  basophile;  while  the  lymphocytes  and  hyaline  cells 
are  common  to  both  fluids.  It  must  be  added  that  the  eosinophile,  or 
coarsely  granular  oxyphile,  are  also  present  in  small  numbers  in  the 
healthy  human  blood :  it  occurs  in  larger  numbers,  however,  in  diseased 
conditions  which  do  not  come  within  the  scope  of  this  article. 

Of  the  origin  and  relationship  of  these  diverse  cells  we  still  know 
very  little.  As  Gull  and  has  pointed  out,  the  blood  of  the  embryo  is 
entirely  free  from  white  corpuscles.  The  exact  period  at  which  each 
form  makes  its  first  appearance  has  not  yet  been  studied,  although  in 
all  probability  such  a  study  would  throw  a  flood  of  light  upon  the  origin 
of  the  different  orders  of  cells. 

The  most  that  we  can  say  with  fair  certainty  is  that  the  lymphocytes, 
while  representing  the  larval  form  of  leucocytes  in  general,  are  in  the 
main  derived  from  lymphoid  tissue ;  that  some  of  them  develop  into  the 
hyaline  cells  (for,  as  Sherrington  and  others  have  noted,  every  gradation 
is  observable  between  these  two  forms) ;  and  that  what  appears  to  be  an 
immature  eosinophile  cell  can  often  be  detected  in  the  peritoneal  fluid, 
as  also  an  immature  coarsely  granular  basophile  cell  (Kanthack  and 
Hardy).  Beyond  this  we  have  not  at  present  advanced.^  Ehrlich's  sug- 
gestion that  the  eosinophile  cells  are  derived  from  the  bone  marrow  may 

II  quite  understand  that  sundry  observers  regard  all  the  various  forms  of  leucocytes 
as  modifications  one  of  another.  It  is  true  that  all  embryologically  have  the  same  origin  ; 
so,  for  example,  have  the  corpuscles  of  cartilage  and  bone,  yet  this  does  not  make  carti- 
lage and  hone  one  tissue.  Everard,  Gulland,  Ruffer,  Demoor  and  Massart,  state  that  all 
transitions  are  observable  between  the  various  forms ;  I  cannot  but  think  that  the  methods 
of  staining  employed  by  these  observers  were  insufficient  for  these  wide  conclusions.  It 
is  interesting  to  note  that  these  observers,  like  Kanthack  and  Hardy,  found  Ehrlich's 
*mphophile  and  neutrophile  cells  to  stain  with  eosin,  i.e.  to  be  oxvnhile. 


INFLAMMA  TION  8i 


be  partially  true,  but  not  entirely  ;  inasmuch  as  it  is  difficult  to  correlate 
the  preponderance  of  these  cells  in  the  body  fluid  with  so  special  and 
local  an  origin.  Nor  can  the  recent  observation  of  Siawcillo,  that 
eosinophile  cells  are  abundant  in  the  ray  which  possesses  neither  bone 
nor  bone  marrow,  be  regarded  as  favourable  to  Ehrlich's  hypothesis. 
And  again,  the  observations  of  Metschnikoff  and  his  pupils  render  it 
eminently  probable  that  some,  at  least,  of  the  large  hyaline  cells  are 
derived  not  from  lymphocytes,  but  from  proliferating  endothelial  cells 
of  the  lymph  and  blood-vessels  and  of  serous  surfaces.  Finally,  it  is 
noticeable  that  the  cells  with  multilobate  nucleus  (the  finely  granular 
oxyphile),  the  commonest  of  the  haemal  leucocytes,  are  not  to  be  recog- 
nised in  lymphoid  tissue :  yet,  as  Sherrington  has  pointed  out,  certain 
of  their  peculiarities,  notably  the  contorted  shape  of  the  nucleus,  may  be 
regarded  as  acquired,  inasmuch  as  if  they  be  allowed  to  remain  at  rest 
in  the  living  state  outside  the  body  the  nuclei  become  more  spherical. 

Of  these  varieties  of  wandering  cells  not  all  have,  so  far,  been  found 
to  bear  a  part  in  the  inflammatory  process  :  but  certain  forms  appear  to 
have  distinct  functions  therein :  these  are  the  finely  granular  oxyphile 
(neutrophile),  the  coarsely  granular  oxyphile  (eosinophile),  and  the 
hyaline  cells. 

A  word  should  here  be  said  concerning  the  cells  of  later  development, 
appearing  as  a  result  of  inflammation  —  giant-cells,  Ranvier's  cells,  and 
Gluge's  corpuscles.  Of  these  the  last  are  evidently  leucocytes  of  the 
hyaline  type  which  have  taken  up  the  fatty  products  of  tissue  degenera- 
tion; the  second — colossal  cells  breaking  down  with  great  ease — are  of 
doubtful  origin.  Giant-cells  would  seem  to  be  of  more  than  one  variety ; 
some  appear  to  be  due  to  aberrant  cell  growth,  wherein  the  nuclei 
undergo  division  without  the  protoplasm  of  the  cell  body  following  suit. 
The  characteristic  giant-cells  of  tuberculosis  and  chronic  inflammation 
may  now  be  said  with  fair  certainty  to  be  plasmodia,  in  all  respects  com- 
parable to  the  masses  of  fused  cells  seen  to  form  in  the  lower  animals 
around  foreign  bodies,  and  by  Kanthack  and  Hardy  around  masses  of 
bacteria  in  the  lymph  of  frogs  outside  the  body.  The  recent  observations 
of  Borel  and  of  Duenschmann  strongly  support  this  opinion. 

Phagocytosis. — In  the  case  of  a  very  large  number  of  pathogenic  micro- 
organisms (so  large  aTnumber  that  merely  to  enumerate  them,  with  the 
names  of  the  observers  and  of  the  animals  upon  which  the  observations 
have  been  conducted,  makes  a  list  so  long  that  in  the  bibliographical 
table  at  the  end  of  this  article  I  give  only  the  more  important  references, 
and  not  nearly  the  complete  list),  after  inoculation  into  the  organism, 
a  very  considerable  proportion  are  to  be  discovered,  sooner  or  later, 
within  wandering  cells  which  have  collected  in  the  region  of  inocula- 
tion. I  have  already  mentioned  more  than  one  case  of  this  nature  in 
discussing  the  comparative  pathology  of  inflammation.  Evidently  under 
certain  conditions  one  of  the  functions  of  certain  of  the  leucocytes  is  to 
attack  and  incorporate  bacteria.  The  leucocytes  having  these  properties 
are  more  especially  the  finely  granular  oxyphile  (where  the  injection  has 
VOL.  I  a 


82 


SYSTEM   OF  MEDICINE 


been  into  a  neighbourhood  richly  supplied  with  vessels),  the  hyaline  cells 
chiefly  where  the  microbes  have  found  an  entry  into  the  body  cavity. 
It  is,  for  instance,  the  finely  granular  oxyphile  cell  which  is  found  in 
overwhelming  numbers  in  an  extending  subcutaneous  abscess,  and  these 
are  seen  to  contain  great  numbers  of  the  micrococci. 

The  conditions  leading  to  this  phagocytosis  have  been  very  fully 
worked  out  by  Metschnikoff.  He  has  amply  demonstrated  that  the 
microbes  can  be  taken  up  in  a  living  condition.  Thus,  if  the  Vibrio 
Metschnikovi  (a  form  closely  allied  to  the  cholera  spirillum)  be  inocu- 
lated into  the  anterior  chamber  of  the  eye  of  an  immunised  animal,  within 
a  very  few  hours  phagocytes  are  discovei-ed  filled  with  the  small,  slightly 
curved  vibriones.     If  now  one  such  cell  be  isolated,  placed  in  a  drop  of 


cf 


<£-' 


yO. 


Fig.  1.  —  Resolution  of  acute  infectious  disease  (relapsing  fever),  spleen  pulp  of  monkey  (Macacus 
erythr.),  showing  (u)  raicrophage,  multinuclear,  with  incepted  spirochaetes ;  {h)  solitary,  and  (c) 
forming  dense  tangle,  {d  d)  nuclei  of  splenic  tissue  (Zeiss,  ^'g  ocular  4;  x  1515  diam.).  —  [Metsch- 
nikotr  (51).  ] 


broth  upon  a  coverslip,  made  into  a  hanging  drop  preparation  and  exam- 
ined under  the  microscope,  it  is  seen  that  the  broth  causes  the  death  of 
the  leucocyte;  while  with  time,  and  favourable  temperature,  the  microbes 
proliferate  rapidly,  and  completely  fill  the  corpuscle  until  it  disinte- 
grates; whereupon  they  proceed  to  multiply  in  the  surrounding  fluid. 
This  seizing'  and  incorporation  of  microbes  does  not  then  necessarily 
lead  to  their  death.  In  certain  cases  of  acute  disease  there  may  be 
abundant  phagocytosis,  and  the  disease  progress  nevertheless ;  the 
phagocytes  being  destroyed  by  the  products  of  the  incorporated  organ- 
isms. This  is  the  case  in  mouse  septicaemia,  in  swine  erysipelas,  and 
(as  has  been  shown  quite  recently  by  Gabritchewski)  in  diphtheria.  As 
M.  Roux  remarks  :  "lis  ont  fait  de  leur  mieux  en  englobant  les  microbes, 
mais  ceux-ci  se  sont  adaptes  an  milieu  interieur  des  cellules,  et  ils  ont 
triomphes."  ^ 

iRoux. —  Trans.  Internal.  Congress  of  Hygiene,  London,  1891,  ii.  p.  120. 


INFLAMMA  TION 


83 


In  other  less  acute  diseases,  such  as  gonorrhoea;   and  in  chronic 
maladies  of  a  tubercular  nature  —  in  tuberculosis,  leprosy,  and  glanders 

the  bacilli  may  in  certain  stages  be  found  within  the  cells  and  rarely 

free  in  the  lymph  spaces,  they  appear  to  be  almost  parasitic,  after  the 
manner  of  the  microspheera  previously  referred  to  as  infesting  the  amceba. 


Fig.  2.  — Two  giant-cells,  seen  under  high  magnification  (x  1515  diam.)  from  a  rodent,  the  spermophile, 
inoculated  with  tuberculosis,  to  show  stages  in  the  destruction  of  the  bacilli.  «,  unaltered 
bacillus ;  6,  bacillus  staining  badly,  and  with  greatly  thickened  capsule  ;  e,  bacillus  granular  and 
breaking  up  ;  c^e,  "shadows."  —  [Metschnikoff  (51).] 

In  these  cases  it  would  seem  as  though  the  toxic  properties  of  the 
microbes  and  the  antagonising  powers  of  the  cells  were  nearly  balanced. 
In  tuberculosis,  for  instance,  it  is  not  unusual  to  find  in  the  giant-cells 
some  bacilli  which  evidently  are  undergoing  degenerative  changes,  stain- 
ing poorly  and  irregularly,  or  but  faintly  traceable  as  unstained,  translu- 
cent shadows,  while  elsewhere  they  are  apparently  proliferating  despite 
their  intracellular  position.^ 

1  It  is,  however,  un.safe  to  declare  in  all  cases  that  because  a  micro-organism  con- 
tinues to  stain  well  therefore  it  was  living  at  the  moment  the  preparation  was  taken  and 


54 


SYSTEM   OF  MEDICINE 


And  this  equality,  or  almost  equality  of  the  resisting  powers  of  cells 
and  microbes,  may  explain  the  chronic  nature  of  the  diseases  above  men- 
tioned. Nevertheless,  in  general,  it 
may  be  stated  that  there  is  some  rela- 
tionship to  be  recognised  between  the 
amount  of  phagocytosis  and  the  viru- 
lence of  the  microbe ;  the  more  virulent 
the  microbes  the  less  the  proportion  of 
them  taken  up  by  the  cells ;  aud,  as 
Kanthack  and  Hardy  have  pointed  out, 
the  longer  the  time  before  the  phago- 
cytes come  into  action.  As  is  the  case 
in  the  unicellular  organisms,  so  in  the 
wandering  cells  of  higher  animals  the 
process  of  destruction  of  the  included 
microbes  can,  under  suitable  condi- 
tions, be  seen  to  be  digestive.  Sev- 
eral observers  have  seen  the  anthrax 
bacillus,  in  frogs  and  other  animals, 
wholly  or  in  part  surrounded  by  a 
vacuole  developed  within  the  leucocyte ;  and,  as  an  evident  result,  the 


Fig.  3.  —  Phagocytes,  macrophage  and  micro- 
phage,  to  show  stages  of  digestion  and 
destruction  of  bacilli,  from  spleen  and  eye 
respectively  of  white  rat  with  anthrax.  In 
i,  part  of  the  bacillus  is  unaffected,  but  a 
vacuole  has  formed  around  the  other  part, 
which  further  has  now  lost  the  power  of 
taking  the  stain.  In  2,  various  stages  are 
seen,  the  bacilli  passing  through  the  granu- 
lar badly  staining,  to  the  vacuolated  un- 
stained, until  finally  but  faint  "shadows" 
are  observable  (Zeiss  ^,  oc.  3).  —  [Metsch- 
mkoff(51).] 


Fig.  4. — Anthrax  of  pigeon  (an  animal  but  slightly  susceptible  to  the  disease)  to  show  stages  of 
destruction  of  bacilli  by  phagocytes.  1  and  2,  macrophages:  i,  from  exudation  from  eye  of  re- 
fractory bird  ;  2,  from  muscle  of  region  of  inoculation  of  bird  that  succumbed  ;  3,  A,  5,  micro- 
phages  —  all  from  eye  twenty-seven  hours  after  inoculation  ;  a  a,  unaltered  bacilli ;  b^  b^  b^,  bacilli 
becoming  more  and  more  degenerated  and  Indistinct ;  c  c,  debris  of  bacilli  (Zeiss  xj,  ocular  3) .  — 
[Metschnikoflf(51).] 

portion  so  surrounded  has  been  seen  to  become  swollen  and  fainter  when 
stained,  until  it  has  undergone  a  veritable  digestion  and  dissolution. 
As   with   the   lower   organisms,    so   with   the   wandering   cells    of 


fixed  by  heat.  Thus  in  pneumonia  after  the  crisis  a  fair  number  of  diplococci  may  be 
found  within  the  leucocytes  of  the  expectorated  contents  of  the  alveoli,  and  these  may 
stain  perfectly  well ;  yet  it  may  be  impossible  to  gain  a  single  growth  of  the  diplococcus 
.from  the  same  material. 


INFLAMMA  TION  85 


the  higher,  there  is  an  evident  attraction,  or  chemiotaxis,  whereby 
these  cells  pass  towards  the  microbes  and  their  products;  and  this 
chemiotaxis  would  also  seem  in  general  to  be  in  the  inverse  ratio  of 
the  virulence  of  the  microbes.  I  say  in  general,  for  with  chemiotaxis  as 
with  phagocytosis  there  appear  to  be  exceptions  to  any  iinif orm  law ;  and 
cases  can  be  brought  forward — of  diphtheria,  for  example — in  which  the 
leucocytes,  instead  of  being  repelled,  are  attracted  in  great  numbers  to 
the  region  of  inoculation  of  a  most  virulent  bacillus. 

The  chemiotactic  properties  of  the  wandering  cells  have  been 
especially  studied  by  Pekelharing,  Leber,  Massart  and  Bordet,  and  by 
Gabritchewski. 

Of  the  results  obtained  by  these  observers  the  most  important  are 
that  leucocytes  are  variously  attracted  towards  variojis  substances.  Thus 
Leber  found  that  the  introduction  into  the  system  of  finely-powdered 
copper  and  various  compounds  of  mercury  caused  an  abundant  collection 
of  the  wandering  cells  around  the  particles,  while  powdered  gold,  silver 
and  iron  exerted  no  such  attraction.  Gabritchewski  and  A.  Schmidt 
showed  that  the  products  of  bacterial  growth  in  general  possessed  chemio- 
tactic properties  yet  more  powerful  than  simple  chemical  compounds. 
While  the  degree  of  positive  chemiotaxis  is  found  to  vary  within  wide 
limits,  the  examples  brought  forward  of  negative  chemiotaxis  exerted  by 
bacterial  products  have  so  far  been  very  few — so  few  as  to  support  the 
contention  of  Dr.  Kanthack,  that  it  is  very  doubtful  whether  any  microbes 
by  their  products  actually  repel  the  leucocytes,  though  they  are  capable 
of  causing  the  rapid  destruction  of  the  attracted  leucocytes,  and  so  of 
rendering  the  area  around  the  microbes  relatively  free  from  wandering 
cells. 

A  very  good  study  of  the  action  of  bacteria  of  different  degrees  of 
virulence  can  be  made  by  repeating  an  experiment  of  Metschnikoff .  The 
rabbit  is  an  animal  susceptible  to  the  growth  within  its  tissues  of  the 
bacillus  of  anthrax.  As  is  well  known,  there  are  various  means  whereby 
the  virulence  of  this  microbe  can  be  diminished ;  so  that  if  cultures  of 
the  "  attenuated  "  bacillus  be  inoculated  into  susceptible  animals,  these, 
instead  of  causing  a  fatal  disease,  induce  but  a  transient  local  inflam- 
matory disturbance,  acccfmpanied  by  fever,  and  followed  by  complete 
recovery.  If  now  a  small  quantity  of  a  virulent  culture  of  the  bacillus 
be  inoculated  into  the  one  ear  of  a  rabbit,  and  an  equal  quantity  of  an 
attenuated  culture  into  the  other,  the  results  are  very  instructive. 
Within  twenty-four  hours  it  can  be  noticed  that  an  acute  inflammation 
has  been  induced  in  both  ears ;  in  both  the  vessels  round  the  seat  of 
inoculation  are  greatly  congested,  but  whereas  at  the  seat  of  inoculation 
of  the  virulent  organism  there  is  a  serous  inflammation  so  intense  that 
the  skin  is  raised  and  separated  from  the  subjacent  tissues  by  a  clear, 
transparent,  reddish  fluid  which  also  infiltrates  the  deeper  tissues,  in 
the  other  ear  there  is  not  nearly  the  same  amount  of  swelling  and  serous 
exudation ;  the  region  of  inoculation  is  more  opaque  and  solid.  Upon 
more  minute  examination  the  serous  fluid  in  the  first  ear  is  found  to 


86  SYSTEM  OF  MEDICINE 

contain  relatively  very  few  leucocytes ;  the  firmer  mass  in  the  second  is 
composed  of  a  huge  aggregation  of  leucocytes  [yid.  art.  "Anthrax"]. 

Evidently,  therefore,  the  relative  number  of  leucocytes  migrating, 
and  the  quantity  of  serum  exuded,  depend  very  largely  upon  the  inten- 
sity of  the  irritant;  and  by  the  intensity  of  the  irritant,  and  the 
behaviour  of  the  leucocytes,  the  forms  of  the  inflammatory  process  may 
be  classified. 

But  to  the  subject  of  classification  I  shall  refer  later.  In  the  meantime 
it  is  well  to  sum  up  the  theory  of  phagocytosis  as  upheld  by  Metsch- 
nikoff  and  those  who  see  in  this  phenomenon  the  all-important  factor  in 
inflammation  and  the  repair  of  injury  (as  also  in  the  production  of 
immunity),  in  order  that,  having  put  clearly  forward  the  tenets  of  those 
upholding  the  theor«^,  I  may  the  more  readily  state  wherein  lies  the 
strength  and  wherein  the  weakness  of  the  doctrine. 

The  theory  of  phagocytosis  as  set  forth  in  Metschnikoff's  later  writings 
may  be  summed  up  in  the  following  theses :  — 

1.  That  certain  of  the  leucocytes  present  in  the  blood  and  lymph, 
notably  the  finer  granular  oxyphile  or  neutrophile,  and  the  large 
hyaline,  are  capable  under  certain  conditions  of  taking  up  bacteria  which 
have  gained  entry  into  the  system. 

2.  That  in  addition  to  these  the  splenic  corpuscles,  the  cells  form- 
ing the  endothelium  of  capillaries,  and  sundry  other  fixed  cells  of  meso- 
blastic  origin,  possess  the  same  property,  although  they  exert  it  to  a  less 
extent. 

3.  That  these  phagocytes  seize  upon  and  destroy  living  and  active 
microbes  under  certain  conditions. 

4.  That  the  more  virulent  the  microbe  the  less  the  tendency  for  the 
leucocytes  above  mentioned,  and  for  the  other  fixed  cells,  to  take  up  the 
bacteria.  The  less  virulent  the  microbe  the  more  extensive  the  phago- 
cytosis. 

5.  That  in  addition  to  this  power  on  the  part  of  certain  cells  (the 
phagocytes)  to  take  up  and  destroy  certain  bacteria,  another  factor 
has  to  be  called  in  to  explain  why  the  wandering  cells  of  the  body 
migrate  towards  the  focus  or  foci  where  the  micro-organisms  have 
gained  an  entry  into  the  body.  This  factor  is  the  "  chemiotaxis " 
exerted  by  the  products  of  bacterial  growth,  and  by  some  other  substances, 
such,  for  example,  as  the  products  of  death  of  tissue  and  of  wandering  cells ; 
and  experimentally  also  certain  chemical  irritants  as,  for  example,  turpen- 
tine and  mercury.  In  the  case  of  the  virulent  microbes  the  leucocytes 
are  not  attracted  to  the  focus  of  infection.  There  is  a  "  negative " 
chemiotaxis,  and  thus,  in  the  absence  of  phagocytosis,  the  proliferation  of 
the  microbes  takes  place  without  hindrance ;  whereas  the  less  virulent 
microbes  and  their  products  attract  the  leucocytes,  they  exert  a  positive 
chemiotaxis,  so  that  there  is  a  migration  of  leucocytes  through  the 
capillary  and  venous  walls  to  the  focus  of  infection,  and  the  leucocytes 
taking  up  the  microbes  tend  to  arrest  the  infective  process. 

6.  That   the   leucocytes   may  become   accustomed   and   eventually 


INFLAMMA  TION  87 


attracted  to  substances  from  which  at  first  they  were  repelled,  and  thus 
a  negative  may  be  transformed  into  a  positive  chemiotaxis. 

7.  That  the  cells,  having  once  acquired  positive  chemiotactic  pro- 
perties in  relation  to  the  products  of  any  specific  microbe,  retain  and 
transmit  these  properties  through  a  series  of  cell  generations,  the  length 
of  which  varies  according  to  the  microbe,  the  extent  of  the  primary 
reaction,  and  the  idiosyncrasies  of  the  individual. 

8.  That,  consequently,  the  cure  of  zymotic  or  mycotic  disease, 
whether  localised  or  general,  and  immunity  also,  are  mainly  brought 
about  by  the  activity  of  special  cells  (the  phagocytes),  and  are  primar 
rily  dependent  upon  the  attraction  existing  between  these  cells  and  the 
products  of  bacterial  metabolism. 

9.  The  process  of  inflammation  is  essentially  the  endeavour  on  the 
part  of  the  organism  to  promote  the  migration  of  leucocytes,  and  to 
aid  the  inclusion  and  destruction  of  the  irritant.  "The  essential  and 
primordial  element  of  a  typical  inflammation  is  a  reaction  of  phagocytes 
against  the  irritant  {agent  nuisihle)P  (14)  Or,  more  fully,  "inflamma- 
tion is  to  be  regarded,  on  the  whole,  as  a  phagocytic  reaction  of  the 
organism  against  irritants,  —  a  reaction  which  at  times  is  accomplished 
by  the  wandering  cells  alone,  at  times  with  the  aid  of  the  vascular 
(fixed)  phagocytes,  or  with  that  of  the  nervous  system." 

10.  That  in  rare  cases  bacteria  may  be  affected  if  not  destroyed 
by  extracellular  action,  by  substances  derived  from  the  leucocytes  and 
dissolved  in  the  surrounding  lymph. 

In  the  terms  of  this  theory,  then,  phagocytosis  is  the  all-important 
factor  in  the  inflammatory  process,  the  vascular,  exudative,  nervous  and 
other  phenomena  being  auxiliary  means  whereby  the  phagocytic  pro- 
perties of  the  wandering  and  fixed  mesodermal  cells  may  be  brought 
more  fully  into  action:  the  determination  of  leucocytes  that  I  have 
described  is  almost  entirely  to  be  attributed  to  an  endeavour  on  the 
part  of  these  cells  to  take  up  and  destroy  the  irritant. 

It  is  necessary  now  to  ask  to  what  extent  this  doctrine  is  to  be 
accepted.  Certainly  phagocytosis  is  a  factor  in  the  inflammatory  pro- 
cess—  no  antagonist  of  this  doctrine  nowadays  is  prepared  to  deny 
this  —  but  does  it  occupy  the  all-important  position  arrogated  to  it 
by  Metschnikoff  ?  Metschnikoff  himself  admits  that  there  are  certain 
wandering  cells  —  the  coarsely  granular  oxyphiles  —  which  never  act  as 
phagocytes.  When  powers  so  great  are  found  to  belong  to  one  set  of 
leucocytes,  is  it  likely  that  another  set,  which  is  also  especially  attracted 
to  the  inflammatory  focus,  is  absolutely  devoid  of  either  bactericidal  or 
antitoxic  function  ?  Or,  to  approach  the  matter  from  another  stand- 
point, let  us  take  a  case  supplied  recently  by  Gabritchewski  from 
Metschnikoif' s  laboratory.  If  a  guinea-pig  be  rendered  refractory  to 
the  bacillus  of  diphtheria,  and  if  the  vulva  be  cauterised  and  infected  by 
a  virulent  culture  of  this  bacillus,  there  results  a  necrosis  of  the  surface 
layers.  On  the  free  surface  of  the  necrosed  region  lie  the  proliferating 
microbes;  apposed  to  the  under  surface  of  the  necrosed  area  is  a  large 


SYSTEM  OF  MEDICINE 


collection  of  migrated  leucocytes.  In  about  three  days  the  necrosed 
tissue  sloughs  off,  and  recovery  and  repair  ensue.  But  in  this  process 
little  phagocytosis  is  observable.  The  phagocytosis  is  evidently  not 
commensurate  with  the  extent  of  the  inflammation ;  and  if,  as  Metschni- 
koff  urges,  the  leucocytes  are  the  all-important  factor,  their  powers  of 
defence  must  here  include  something  beyond  the  incorporation  of  the 
micro-organisms.  The  same  additional  something  would  seem  to  be 
wanted  to  explain  the  healing  of  abscesses. 

A  crucial  test  of  the  importance  of  phagocytosis  has  been  devised  by 
Baumgarten,  and  repeated,  with  like  results^,  by  Sanarelli.  If  microbes 
be  placed  in  an  animal  which  has  normally  the  power  of  withstanding 
the  growth  of  such  microbes;  and  if,  further,  they  be  so  placed  (in 
bags  of  filter  paper,  celloidin,  or  pith)  that  the  leucocytes  cannot  attack 
them,  although  the  body  fluids  can  easily  bathe  them,  then,  if  Metschni- 
koff  be  right,  the  microbes  ought  to  flourish  unaffected.  Baumgarten 
and  Sanarelli  found  that  this  is  not  so,  that  the  microbes  are  destroyed 
despite  the  absence  of  phagocytes ;  but  Metschnikoff,  repeating  these 
experiments,  obtained  diametrically  opposite  results.  Both  Baumgarten 
and  Sanarelli  are  capable  observers  although  it  is  true  that  the  former 
by  the  very  violence  of  his  attack  upon  Metschnikoff  has  materially 
weakened  his  position.  It  is,  however,  difficult  to  explain  away  their 
positive  results,  or  to  arrive  at  a  conclusion  other  than  that  under  certain 
conditions  the  microbes  may  be  destroyed  without  being  ingested. 

The  Humoral  Theory. — The  conception  that  there  is  some  agency 
besides  phagocytosis  pure  and  simple  has  led  bacteriologists,  in  the 
study  of  phenomena  of  inflammation  and  immunity,  to  engage  in  a  very 
remarkable  series  of  experiments.  Although  some  of  them  have  failed 
to  establish  a  satisfactory  theory  of  immunity,  they  have  led  to  results 
of  such  high  importance  as  the  discovery  of  the  s'erum  treatment  of 
diphtheria  and  tetanus.  The  majority  of  these  researches,  indeed, 
bear  especially  upon  the  production  of  immunity,  and  only  secondarily 
upon  the  inflammatory  process.  It  is  unnecessary  for  me,  therefore,  to 
describe  them  in  detail ;  it  will  suffice  if  I  indicate  the  direction  taken 
by  the  more  important  among  them. 

First  in  order  of  time  may  be  mentioned  Nuttall's  observations. 
In  an  attempt  to  repeat  Metschnikoff's  researches  upon  the  destruc- 
tion of  the  anthrax  bacillus,  this  observer  noticed  that  if  he  placed 
a  fine  canula  containing  a  fresh  culture  of  attenuated  anthrax  bacilli  in 
the  tissue  of  a  rabbit's  ear,  there  resulted  in  sixteen  hours  a  rich  cellular 
exudation;  but  phagocytosis  appeared  not  to  reach  its  maximum  for 
twenty-two  hours,  and  even  then  half  of  the  bacilli  lay  free  and  not  taken 
up  by  cells ;  and  he  found,  further,  that  the  free  bacilli  showed  involu- 
tion and  degeneration  to  the  same  extent  as  did  the  ingested.  This  led 
him  to  study  the  effect  of  blood  serum,  defibrinated  blood  and  lymph  upon 
the  bacilli,  and  he  discovered  that  these  fluids  had  a  remarkably  rapid 
action,  destroying  great  numbers  within  a  very  few  hours.  Moritz, 
Traube,  Von  Fodor  and  others,  had  previously  recognised  this  rapid 


INFLAMMA  TION 


destruction  of  micro-organisms  in  the  living  blood,  but  Nuttall's  very 
full  research  appeared  to  show  conclusively  that  the  bacteria-destroying 
power  resided  largely  in  the  serum,  and  that  in  inflammation  the  exuded 
fluid  rather  than  the  leucocytes  brought  about  the  destruction  of  the 
microbes. 

These  observations  were  confirmed  and  extended  by  Nissen,  Behring, 
and  Buchner,  and  a  most  valuable  series  of  contributions  (see  article  on 
the  "General  Pathology  of  Infection")  have  been  made  by  Hankin, 
Buchner,  Vaughan,  Tizzoni  and  Cattani,  Behring,  and  others,  upon  the 
nature  and  properties  of  the  substances  to  be  derived  from  the  blood 
serum  of  animals  either  naturally  immune  to  certain  diseases,  or  rendered 
immune  by  one  or  other  procedure.  What  is  more,  it  has  been  rec- 
ognised that  two  orders  of  siibstances  are  recognisable:  one  capable 
of  destroying  pathogenetic  microbes,  the  other  not  destroying  them,  but 
rendering  their  products  inert. 

It  would  thus  at  first  sight  appear  that  in  these  discoveries  there  is  a 
direct  contradiction  to  the  theory  of  phagocytosis.  Yet  upon  further 
study  this  is  found  not  to  be  the  case. 

As  was  shown  by  Nuttall,  at  the  commencement  of  these  studies,  the 
blood  serum  removed  from  the  body  acts  far  more  rapidly  and  energeti- 
cally than  do  the  blood  plasma  and  lymph  within  the  body.  The  dis- 
parity of  action  between  the  two  is  remarkable.  Thus  Lubarsch  has 
shown  that  in  order  to  kill  a  rabbit  by  anthrax,  by  injection  into  the 
circulating  blood,  at  least  16,000  virulent  bacilli  of  the  disease  must  be 
introduced:  a  smaller  number  produces  only  a  transient  disturbance. 
That  is  to  say,  the  whole  circulating  blood  can  only  destroy  less  than 
16,000  bacilli  at  a  time.  On  the  other  hand,  one  cubic  centimeter  (15 
minims)  of  rabbit's  blood  serum  can  in  a  few  minutes  kill  an  equal  or 
even  greater  number. 

The  Cellulo-Humoral  TJieory.  —  If  the  serum  and  if  the  blood  plasma 
contain  bactericidal  substances,  these  must  in  all  likelihood  be  developed 
by  certain  cells,  and  thus  at  bottom  the  humoral  theory  must  be  cellular ; 
and  the  very  fact  of  the  great  increase  in  the  bactericidal  properties 
of  the  blood  immediately  on  its  withdrawal  from  the  body,  must  suggest 
that  in  the  changes  which  occur  in  the  extravascular  blood  there  is  a 
liberation  and  solution  of  bactericidal  substances.  Now  the  first  and 
foremost  of  these  changes  is  the  breaking  down  of  the  leucocytes 
as  the  blood  begins  to  clot.  It  may  therefore  be  that  this  breaking 
down  of  the  leucocytes,  with  liberation  of  their  contents,  is  capable  of 
explaining  the  increased  bactericidal  action  of  defibrinated  blood  and 
blood  serum. 

That  the  leucocytes  contain  bactericidal  substances  was  first  demon- 
strated by  Dr.  Hankin,  who  obtained  from  the  lymphatic  glands  and 
spleens  of  animals  immune  to  anthrax  (dogs  and  cats),  a  proteid  of  the 
nature  of  a  globulin  identical  with  ])r.  Halliburton's  cell  globulin  /?,  and 
having  a  bacteria-killing  power  similar  to  that  possessed  by  blood  serum. 
In  later  observations  upon  the  rat  he  showed  that  there  was  a  relationship 


90  SYSTEM  OF  MEDICINE 

between  the  amount  and  activity  of  these  "  defensive  proteids  "  and  the 
power  of  resistance  of  the  animal  to  the  disease.  Thus  Hankin  showed 
that  in  animals  possessing  the  power  of  destroying  bacilli,  the  organs 
containing  the  largest  collections  of  leucocytes  yielded  notable  quantities 
of  a  bacteria-destroying  substance. 

For  the  last  few  years  I  have  steadily  urged  this  view,  and  observa- 
tion after  observation  is  proving  it  to  be  correct.  Recently  Buchner  has 
shown  that  if  sterilised  emulsions  of  the  gluten  of  wheat  be  injected  into 
the  pleural  cavity  of  a  dog  and  rabbit,  its  presence  leads  to  the  pouring 
out  of  an  aseptic  exudation  peculiarly  rich  in  leucocytes,  and  this  exuda- 
tion is  more  bactericidal  than  is  the  blood  and  serum  of  the  animal. 
Further,  Victor  C.  Vaughan  is  led  to  the  conclusion  that  the  bactericidal 
action  is  associated  with  the  leucocytes  by  his  discovery  that  from 
blood  serum  a  nuclein  (or  nucleinic  acid)  can  be  separated  —  a  body,  that 
is,  which  so  far  has  been  found  exclusively  in  connection  with  nucleated 
cells.  This  nuclein  is  either  itself  bactericidal,  or  has  a  bactericidal 
substance  in  intimate  association  with  it ;  and  Vaughan's  observations 
and  conclusions  have  been  substantiated  by  the  later  and  independent 
researches  of  Kossel  upon  nucleinic  acid. 

Further  confirmation  of  the  correctness  of  these  views  —  that  the 
bactericidal  action  of  the  blood  serum  is  due  to  the  breaking  down  of  the 
leucocytes — has  been  supplied  from  the  laboratory  of  Denys  at  Louvain. 
Denys  and  Havel  have  shown  that  the  blood  and  exudations  of  the  dog, 
freed  from  leucocytes  either  by  filtration  or  by  centrifugal  action,  lose 
their  bactericidal  action,  regaining  it  when  the  leucocytes  are  reintro- 
duced. Van  der  Velde  induced  an  exudation  rich  in  leucocytes  by 
injecting  into  the  pleural  cavities  of  rabbits  sterilised  cultures  of  the 
pyococci,  and  killing  the  animals  at  various  periods.  Centrifugalising 
the  pleural  fluid,  he  found  that  the  older  the  exudation,  and  the  richer  it 
had  been  in  wandering  cells,  the  more  powerful  its  bactericidal  action, — 
this  being  out  of  all  proportion  to  the  bactericidal  action  of  the  blood 
serum  removed  at  the  same  time  and  similarly  centrifugalised. 

But  more  convincing  proof  has  been  gained  by  a  study  of  the  leuco- 
cytes in  action.  Even  in  1887  Ribbert,  in  his  studies  upon  the  fate 
of  spores  of  various  species  of  aspergillus  and  mucor  inoculated  into  the 
anterior  chamber  of  the  rabbit's  eye,  had  found  that  two  stages  of  reaction 
were  recognisable :  at  first  the  spores  and  developing  hyphal  filaments 
became  surrounded  by  dense  clusters  of  leucocytes,  which  remained  in 
apposition  to,  but  did  not  ingest  the  micro-organisms.  Nevertheless 
they  appeared  to  bring  about  a  weakening  and  lowering  of  vitality  on 
the  part  of  the  spores  and  filaments,  so  that  after  a  time  other  cells 
could  manifest  their  phagocytic  activity  and  take  them  up.  Ribbert,  it 
is  true,  attributed  the  lowering  of  vitality  to  the  walling  in  ("  Wallbil- 
dung")  by  the  leucocytes,  and  consequent  lack  of  nutrition ;  but  the  fact 
remains  that  he  demonstrated  a  preparatory  extracellular  action  upon 
the  micro-organisms  by  the  leucocytes. 

Altogether  the  fullest  and  most  important  studies  upon  this  extra- 


INFLAMMA  TION  91 


cellular  action  have  been  those  of  Kanthack  and  Hardy.  In  their  first 
communication  to  the  Royal  Society  these  observers  showed  (and  their 
experiment  can  be  repeated  without  difficulty)  that  if  a  drop  of  frog's 
lymph  be  placed  upon  a  coverslip,  with  the  addition  of  a  few  anthrax 
bacilli,  and  this  preparation  be  suspended  in  a  moist  chamber,  an  ex- 
amination extending  over  four  or  five  hours  reveals  the  following  suc- 
cession of  changes : — 

1.  The  coarsely  granular  oxyphile  cells  are  strongly  attracted  to  the 
bacilli :  they  move  towards  them,  and  apply  themselves  to  their  surface  ; 
their  protoplasm,  ordinarily  sluggish,  exhibits  quick  streaming  move- 
ments. Next  the  eosinophile  granules  are  discharged,  and  the  bacilli 
begin  to  show  signs  of  degeneration.  During  this  stage  the  hyaline 
cells,  the  phagocytes  proper,  remain  quiescent,  and  are  not  even  at- 
tracted towards  the  bacilli. 

2.  The  hyaline  cells  proliferate  and  eventually  approach  the  masses 
of  oxyphile  cells  surrounding  the  bacilli ;  they  fuse  with  these  —  forming 
a  Plasmodium  around  the  chains  —  and  for  the  next  hour  or  two  nothiug 
can  be  clearly  made  out  as  to  the  action  of  individual  cells. 

3.  The  first  stage  in  the  dissolution  of  the  mass  is  the  separation 
and  wandering  away  of  the  oxyphile  cells  ;  next,  the  hyaline  phagocytes 
containing  remnants  of  the  bacilli  within  vacuoles  slowly  break  apart. 

4.  A  third  set  of  cells,  with  basophile  granules,  is  observed  to 
approach  during  this  last  period;  as  to  their  functions  Kanthack 
and  Hardy  are  a  little  doubtful. 

Here,  then,  we  have  clear  evidence  of  division  of  labour  among  the 
wandering  cells  of  the  frog :  the  coarsely  granular  oxyphile  cells  act  as 
unicellular  glands  discharging  or  excreting  their  granules,  and  these 
granules  dissolving  appear  to  exert  a  deleterious  action  upon  the  bacilli, 
in  consequence  of  which  the  hyaline  cells  are  now  capable  of  ingesting 
them.  I  may  add  that  occasionally  the  coarsely  granular  cells  may  be 
seen  to  act  when  not  in  immediate  apposition  to  the  microbes  ;  the  num- 
ber of  granules  in  a  cell  may  diminish,  and  at  the  same  time  neighbour- 
ing bacilli  manifest  signs  of  partial  dissolution.^ 

Continuing  their  research  Kanthack  and  Hardy  have  demonstrated 
these  distinctions  in  the  function  of  the  different  forms  of  leucocytes 
throughout  the  vertebrata  up  to  man.  They  have  shown  that  in  general 
the  hyaline  cells  act  as  the  phagocytes  of  the  lymphatic  and  coelomic 
system ;  the  finely  granular  oxyphile  (neutrophile  and  amphophile)  as 
the  phagocytes  of  the  haemal  system ;  while  the  coarsely  granular 
oxyphile  (eosinophile)  when  present  possess  excretory  functions. 

If  capillary  chambers  filled  with  bacilli  or  their  products,  or  some 
irritant  such  as  nitrate  of  silver  or  turpentine,  were  placed  under  the 
skin,  or  in  the  peritoneal  cavity,  and  allowed  to  remain  there  for  periods 

1  Mesnil,  in  a  long  and  often  suggestive  work,  which  appeared  while  this  article  was 
in  the  press,  contradicts  these  observations  of  Kanthack  and  Hardy.  Apparently  he 
never  once  attempted  to  repeat  their  procedure,  never  once  attempted  the  simple  methods 
necessary  to  confirm  their  results.     His  criticism  must  therefore  be  relatively  valueless. 


92  SYSTEM  OF  MEDICINE 

up  to  twenty-four  hours,  they  were  found  to  contain  a  multitude  of  cells, 
chiefly  of  the  coelomic  type.  If  the  irritant  were  situated  in  such  a 
position  as  to  appeal  to  the  blood-vessels  of  a  vascular  membrane  rather 
than  to  the  cells  of  the  connective  tissue  spaces,  then  the  cells  were  those 
of  the  haemal  system.  In  both  cases  in  the  earliest  stages  there  was 
usually  found  a  preponderance  of  the  coarsely  granular  oxyphile  cells. 
Even  in  cutaneous  blisters  induced  upon  themselves,  while  the  main  mass 
of  cells  present  in  the  serous  exudation  were  the  finely  granular  oxyphile 
of  haemal  origin,  the  coarsely  granular  were  always  more  abundant  rela- 
tively to  the  others  than  in  the  blood.  The  rate  of  accumulation  was 
found  to  vary  according  to  the  irritant.  Thus,  comparing  the  action  of 
the  virulent  B.  anthracis  and  the  harmless  B.  ramosus  upon  rabbits  and 
guinea-pigs,  it  was  seen  that  if  cultures  of  these  two  forms  were  placed 
within  capillary  tubes  and  introduced  into  the  peritoneal  cavity,  with  the 
former  only  the  coarsely  granular  oxyphile  found  its  way  into  the  tubes 
(even  after  seven  hours) ;  whereas  with  the  latter  enormous  numbers  of 
the  hyaline  phagocytes  had  invaded  the  chambers  within  two  and  a  half 
hours.  In  the  former  case  also  the  total  number  of  invading  cells  of  all 
kinds  was  very  much  less  than  in  the  latter  case ;  and  there  was  clear 
evidence  of  the  abundant  disintegration  and  dissolution  of  many  of  the 
cells.  This  destruction  of  a  certain  number  of  cells  occurred,  whatever 
the  nature  of  the  microbe  introduced  into  the  system  ;  and,  as  these 
observers  point  out,  it  must  profoundly  alter  the  chemical  constitution 
of  the  plasma,  and  may  therefore  play  an  important  part  in  the  struggle 
with  the  bacilli.  They  observed  phenomena  of  the  same  nature  as  those 
of  the  frog's  lymph,  when  they  placed  anthrax  bacilli  in  hanging  drops 
of  human  blister  fluid  and  examined  the  preparations  upon  the  warm 
stage,  noticing  here  also  the  rapid  diminution  of  the  granules  of  the 
eosinophile  cells. 

Finally,  it  must  be  added  that  Metschnikoff  (while  misunderstanding 
wholly  the  drift  of  these  last-mentioned  researches)  has  recently  admitted 
that  the  wandering  cells  are  capable  of  exerting  an  extracellular  activity 
upon  the  bacteria.  Certain  observations  of  R.  Pfeiffer  had  revealed  that, 
under  certain  conditions,  when  guinea-pigs  have  been  rendered  highly 
refractory  to  the  spirillum  of  cholera,  these  microbes  when  injected  into 
the  peritoneal  cavity  are  rapidly  modified,  becoming  swollen  and  spheri- 
cal before  any  phagocytosis  has  time  to  come  into  play ;  and  this  alteration 
was  explained  by  Pfeiffer  as  due  to  the  fluid  secreted  by  the  peritoneal 
cells  following  upon  the  inoculation.  Without  detailing  Metschnikoff's 
criticism  of  the  value  of  these  observations,  it  will  suffice  to  say  that, 
carefully  repeating  them,  he  discovered  that  five  minutes  after  such 
injection  the  leucocytes  in  the  peritoneal  fluid  —  "  polynuclear,"  mononu- 
clear, and  eosinophilous  —  were  surrounded  by  a  layer  of  spirilla,  while 
the  lymphocytes  and  red  corpuscles  were  entirely  free  from  any  such 
surrounding.  Here  in  the  immediate  neighbourhood  of  the  wandering 
cells,  the  short,  curved  bacillary  forms  could  be  seen  to  have  undergone 
the  transformation  into  globules.    Metschnikoff  further  recognised  a  clear 


INFLAMMA  TION  93 


zone,  evidently  of  exuded  liquid,  between  the  leucocytes  and  the  sj)irilla. 
Whether  this  be  a  true  secretion,  or  an  accompaniment  of  the  death  of 
the  cells,  he  is  not  at  present  prepared  to  say. 

In  this  way  Metschnikoff  admits  that,  besides  phagocytosis,  an  extra- 
cellular action  of  the  wandering  cells  does  occur ;  so  that  now  the  only 
point  of  paramount  importance  to  be  agreed  upon  is  the  extent  to  which 
the  extracellular  activity  is  manifested  intra  vitam.  Metschnikoff  at 
present  holds  that  it  plays  a  very  secondary  part  compared  with  jjhago- 
cytosis  ;  others,  like  Buchner  in  Germany,  Denys  in  Belgium,  Kanthack 
and  Hardy  in  England,  hold  that  its  part  is  of  high  importance.  Person- 
ally, while  holding  that  phagocytosis  has  been  conclusively  proved  to  be 
of  singularly  high  importance,  I  cannot  but  see  in  this  extracellular  action 
of  active  and  of  disintegrating  leucocytes  an  adjuvant  to  the  former  factor, 
and  one  which  under  certain  conditions  is  even  of  greater  value  to  the 
organism  in  its  attempt  to  neutralise  microbic  and  other  irritants. 
Whether  the  fixed  tissue  cells  of  the  body  have  similar  "  extracellular  " 
action  upon  living  irritants,  or  not,  is  a  matter  that  has  not  yet  been 
ascertained.     There  are  indications  that  this  may  be  so. 

Summary.  —  Thus,  to  sum  up  the  facts  gathered  together  in  this 
chapter,  the  chief  results  of  recent  researches  into  the  functions  of  the 
"wandering  cells,  as  they  affect  our  knowledge  of  the  inflammatory 
process,  would  seem  to  be  the  following :  — 

1.  That  in  the  higher  animals  there  are  several  forms  of  leucocytes. 

2.  That  a  distinction  can  be  made  out  in  the  distribution  of  the 
various  forms,  some  being  characteristic  of  the  blood,  others  of  the  con- 
nective tissue  spaces  and  of  the  coelom  and  coelomic  fluid  in  general. 

3.  That  the  forms  of  cells  accumulating  during  the  inflammatory 
process  consequently  vary  according  to  the  region  of  injury. 

4.  That  a  variation  is  to  be  made  out  also  in  the  rate  of  accumula- 
tion of  the  different  forms  of  cells :  the  coarsely  granular  oxyphile 
(eosinophilous),  which  in  the  main  are  pre-existent  in  the  connective 
tissue  spaces,  being  attracted  sooner  than  the  finely  granular  oxyphile 
(neutrophile  haemal)  and  the  hyaline  (coelomic)  respectively. 

5.  That  a  further  distinction  is  to  be  made  out  in  the  mode  of  action 
of  these  cells :  the  coarsely  granular  oxyphile  never  act  as  phagocytes, 
"but  possess  excretory  properties  ;  the  hyaline  and  finely  grantilar  oxy- 
phile are  characteristically  phagocytic. 

6.  That  the  accumulation  of  leucocytes  is  due  in  part  to  migration, 
in  part  to  proliferation  in  situ. 

7.  That  under  certain  conditions  (what  these  are  and  what  their 
relative  importance  have  yet  to  be  more  fully  v/orked  out)  the  phago- 
cytes are  capable  of  directly  incorporating  pathogenetic  bacteria.  The 
main  conditions  would  seem  to  be  the  possession  by  the  bacteria  of 
relatively  weak  irritant  or  pathogenetic  properties,  and  by  the  organism 
of  relatively  strong  powers  of  resistance. 

8.  That  under  other  conditions  (where,  for  example,  the  microbes  are 
endowed  with  fuller  irritant  properties,  or  the  constitutional  resistance  is 


94  SYSTEM   OF  MEDICINE 

lower)  phagocytosis  may  be  preceded  by  an  excretory  process  on  the 
part  of  certain  cells,  notably  the  coarsely  granular  oxyphile,  whereby 
apparently  the  vitality  and  irritant  properties  of  the  microbes  undergo 
a  diminution.  Here  again  we  are  as  yet  ignorant  of  the  exact  value  of 
all  the  factors  leading  to  active  intervention  of  these  excretory  cells. 

9.  That  the  bactericidal  and  antitoxic  action  of  the  blood  serum  and 
body  fluids  outside  the  body  is  due  to  the  liberation  into  these  fluids  of 
bactericidal  and  antitoxic  substances  step  by  step  with  the  disintegration 
of  the  leucocytes. 

10.  That  clearly  this  liberation  of  bactericidal  and  antitoxic  sub- 
stances by  excretion  from  living  cells,  and  by  disintegration,  does  not 
obtain  to  the  same  extent  in  the  fluids  within  the  living  body ;  never- 
theless it  does  occur,  more  especially  as  the  result  of  irritation,  and 
its  occurrence  is  fitted  to  explain  those  cases  in  which  the  amount 
of  phagocytosis  observable  is  not  co-extensive  with  the  disappearance 
of  the  microbic  irritants. 

11.  That  where  the  bacteria  are  endowed  with  great  virulence,  there 
the  wandering  cells  migrating  to  the  region  are  both  fewer  in  numbers, 
and,  being  killed,  undergo  dissolution  to  a  very  considerable  extent. 
This  dissolution  may  in  itself,  by  the  liberation  of  bactericidal  substances 
into  the  inflammatory  exudation,  hinder  the  proliferation  of  the  microbes 
to  a  greater  or  less  extent.  If,  however,  the  dissolution  be  unaccom- 
panied by  a  massing  of  active  leucocytes  peripherally  around  the  region 
of  irritation,  then  the  microbic  irritants  may  be  carried  away  from  the 
inflammatory  focus,  and  induce  generalised  disease. 

To  complete  this  summary  I  will  here  add  other  conclusions  deduced 
from  a  study  of  the  later  stages  of  inflammation  and  discussed  in  a  later 
chapter  ("  Upon  the  part  played  by  the  fixed  Cells  in  the  Inflammatory 
Process  "),  viz. :  — 

12.  In  the  later  stages  of  inflammation  the  growing  fibroblasts  may 
often  be  seen  to  contain  leucocytes  in  process  of  digestion.  Presumably, 
therefore,  a  certain  number  subserve  nutrition. 

13.  Others  are,  in  certain  cases,  recognisable  in  the  lymph-spaces 
outside  the  inflammatory  focus,  containing  the  debris  of  dead  tissue. 
Emigration  can  therefore  occur  as  well  as  immigration. 

14.  The  process  of  development  of  wandering  into  fixed  cells  has 
been  observed  ;  but  this  is  the  exception,  not  the  rule. 

15.  The  contrary  process  of  development  of  wandering  cells  from 
degenerating  tissue  (muscle  fibres)  has  also  been  recorded  by  more  than 
one  observer. 

Chapter  2. — The  Inflammatoet  Exudation 

Whenever  injury  to  the  tissues  leads  to  vascular  dilation  there  is 
an  increased  effusion  of  plasma  from  the  blood.  The  extent  of  this 
effusion  varies  greatly;  it  varies  with  the  tissue  affected,  the  state 
of  the  organism,  and  the  quality  and  nature  of  the  irritant.     Pense 


INFLAMMA  TION 


95 


tissue  permits  of  little  exudation,  while  loose  vascular  tissue,  under  the 
action  of  an  irritant  of  no  great  intensity,  may  undergo  great  exudative 
swelling.  There  is,  for  instance,  a  peculiar  liability  in  serous  and 
cutaneous  surfaces  (or  more  truly  in  subserous  and  dermal  layers),  when 
inflamed,  to  manifest  abundant  exudation.  Their  vascularity  and  the 
slight  external  resistance  would  appear  to  explain  this  liability.  There 
is  not  the  same  tendency  to  abundant  exudation  from  mucous  surfaces 
save  where,  as  in  the  alveoli  of  the  lungs,  the  epithelium  is  reduced  to 
a  single  layer  of  delicate  flattened  cells ;  on  the  other  hand  there  is  a 
marked  tendency  towards  serous  infiltration  and  swelling  of  the  sub- 
mucosa.  That  some  general  state  of  the  organism  is  a  factor  concerned 
is  seen  when  virulent  anthrax  bacilli  are  inoculated  subcutaneously  into 
an  ordinary  rabbit  and  into  one  that  has  been  rendered  immune :  in  the 
former  the  exudation  is  of  a  serous  nature,  in  the  latter  little  fluid  is 
exuded  from  the  vessels.  The  effect  of  the  quality  of  the  irritant  is 
observable  upon  comparison  of  the  results  of  inoculation  of  various 
microbes.  Some  cause  little  exudation  of  fluid.  These  are  in  general 
of  low  pathogenic  quality,  but  not  always ;  certain  virulent  microbes 
(such  as  those  of  tetanus)  lead,  when  inoculated,  to  relatively  little 
effusion  of  fluid  from  the  vessels.  On  the  other  hand,  it  may  be  stated 
definitely  that  where  in  a  moderately  dense  tissue  the  injection  of  a  pure 
culture  of  a  micro-organism  leads  to  well-marked  exudation,  the  micro- 
organism is  of  high  virulence^ 

Can  any  meaning  be  ascribed  to  this  effusion  ?  Is  it  an  attempt 
at  increased  nutrition  in  the  injured  region  ?  It  has  been  sug- 
gested, in  accordance  with  Virchow's  theory  of  inflammation,  that 
the  injury,  stimulating  the  surrounding  fixed  cells,  leads  to  increased 
local  metabolism ;  and  that  the  exudation  is  a  means  of  bringing  to  the 
region  the  increased  nourishment  demanded  by  the  increased  cellular 
activity.  But  inasmuch  as  exudation  is  most  marked  in  those  cases 
where  there  is  most  profound  and  rapid  cell  destruction,  and  again  at 
the  early  stage  of  the  inflammatory  reaction,  when  evidences  of  growth 
and  proliferation  of  the  fixed  cells  of  the  region  may  be,  and  most  often 
are,  wholly  wanting,  this  view  can  scarcely  be  upheld.  Yet  at  a  later 
period  of  the  process,  and  again  in  chronic  inflammation,  the  overgrowth 
of  the  connective  tissue  cells  would  appear  to  stand  in  close  relationship 
to  the  over-nutrition  caused  by  the  continued  dilation  of  the  vessels  and 
the  pouring  out  of  excessive  lymph  into  the  tissues.  There  is,  appar- 
ently, a  close  relationship  between  the  increased  exudation  and  inflam- 
matory hyperplasia. 

That  the  exudation  exerts  a  "flushing  out"  action  is  very  evident  in 
many  cases.  Thus  the  inflammation  induced  by  plunging  an  animal's  leg 
into  hot  water  is  accompanied  by  great  increase  in  the  amount  of  lymph 
obtainable  from  the  efferent  lymphatics  of  the  part.  It  is  shown  also  by 
the  presence  of  streptococci  in  the  lymph  channels  outside  the  area  of 
acute  inflammation  in  erysipelas,  by  the  frequent  implication  of  the 
nearest  lymph  glands  in  suppurative  disturbances,  and  by  the  appearance 


96  SYSTEM  OF  MEDICINE 

of  lesions,  due  to  the  direct  action  of  bacterial  products,  in  organs 
far  removed  from  the  focus  of  bacterial  proliferation  in  such  diseases  as 
diphtheria  and  tetanus,  wherein,  as  a  rule,  the  bacteria  remain  strictly 
localised.  It  is  clear  that  the  exudation  into  an  inflamed  area  can  accom- 
plish a  removal  of  irritant  matters.  It  is  clear  also,  from  more  than  one 
of  the  examples  given  above,  that  a  process  which  may  be  beneficial  to 
the  region  of  injury  may  be  harmful  to  the  system  as  a  whole. 

It  is  interesting  to  note  that  this  effect  of  flushing,  in  part  beneficial, 
in  part  harmful,  has,  if  I  may  so  express  it,  gained  a  certain  amount  of 
recognition  on  the  part  of  the  organism.  Where  the  irritant  can  be  con- 
veyed to  the  exterior  an  abundant  exudative  inflamiuation  generally 
occurs  —  an  abundant  flushing;  where  it  can  be  conveyed  into  one  of 
the  body  cavities  the  same  holds  good ;  but  here  a  mechanism  is  often 
called  into  action  whereby  the  exudate  with  its  contained  irritants  is  held 
within  the  serous  cavity  for  days  and  weeks  after  all  signs  of  active 
inflammation  have  subsided.  The  organism,  that  is  to  say,  would  seem 
to  restrain  its  drainage  to  the  general  lymphatic  system.  Where  the 
irritant  is  merely  the  product  of  tissue  change  the  profuse  exudate  is 
rapidly  conveyed  away;  where,  on  the  other  hand,  the  injury  is  of 
bacterial  origin,  the  passage  of  lymph  from  the  focus  of  inflammation, 
is,  generally  speaking,  not  nearly  so  free ;  it  is  of  thicker  consistency 
and  drains  away  slowly.  In  short,  as  I  have  already  indicated,  where 
the  microbe  is  not  too  virulent  a  cellular. rather  than  a  serous  inflamma- 
tion is  produced ;  and  in  place  of  abundant  flushing  an  increased  anti- 
bacterial and  antitoxic  action  of  the  exuded  lymph  comes  into  play. 

But  besides  this  "  flushing  out "  effect  the  exudation  subserves 
another  purpose,  namely,  dilution  of  the  irritant  and  reduction  of  its 
injurious  properties,  so  that  it  acts  with  lessened  force  upon  the  tissues, 
and  permits  the  wandering  cells  to  be  attracted  to  the  region  where  they 
may  exert  their  functions.  Where  a  comparatively  mild  physical  irritant 
leads  to  abundant  exudation  the  flushing  out  action  appears  to  be  in  the 
ascendant,  where  microbic  irritants  cause  great  local  inflammatory 
oedema,  judging  from  the  less  extensive  lymph  flow  from  the  region,  the 
diluent  action  must  be  regarded  as  the  more  important.  I  have  already 
pointed  out  that  a  relation  may  be  traced  between  the  intensity  of 
bacterial  irritation  and  the  extent  of  the  exudation.  In  short,  there 
may  be  great  exudation  under  two  apparently  opposed  conditions :  in 
the  presence  of  comparatively  mild  physical  irritants,  and  in  that,  of 
severe  bacterial  irritants.  In  the  former  case  it  more  especially  sub- 
serves removal,  in  the  latter  dilution  of  the  poison. 

The  fundamental  distinction  between  the  inflammatory  exudation  and 
ordinary  lymph  is  its  richness  in  proteids.  Whether  we  regard  lymph 
as  a  filtrate  pure  and  simple  from  the  blood,  or,  with  the  majority  of 
modern  physiologists,  follow  Heidenhain  in  regarding  it  as  the  result  of 
a  selective  filtration,  it  is  eminently  probable  that  in  inflammation  the 
exudate  approaches  in  its  composition  more  nearly  to  the  blood  plasma 
than  does  ordinary  lymph.     The  dilatation  of  the  capillaries,  the  conse- 


INFLAMMA  TIOIV 


97 


quent  thinning  of  the  endothelial  layer  with,  it  may  be,  the  opening 
of  some  lacunae  between  the  individual  cells,  and  the  direct  action  of 
the  irritant  upon  these  cells,  may  all  be  expected  to  aid  the  transudri- 
tion.  In  this  way  the  amount  of  proteid  matter  in  the  lymph  may  be 
increased.  But  equally  important  must  be  the  addition  of  proteids  due 
to  the  breaking  down  of  leucocytes  and  tissue  cells.  I  have  already 
discussed  this  destruction  of  the  cells,  and  need  not  here  give  the  evi- 
dence of  its  occurrence. 

In  addition  to  the  proteids  the  inflammatory  lymph  may  contain 
other  substances  worthy  of  more  than  passing  note.  Of  these  the  more 
important  are  ferments,  the  results  of  proteolysis  (notably  fibrin  and 
its  precursors,  and  peptones),  and  in  many  cases  mucin,  together  with 
bactericidal  substances,  and,  where  bacteria  are  present,  the  products 
of  their  growth. 

The  presence  and  amount  of  these  substances  depend  largely  upon 
the  intensity  and  character  of  the  inflammation.  Thus  the  total  quantity 
of  proteids,  and  the  proportion  of  fibrin,  albumin,  and  globulin  present, 
vary  within  wide  limits.  The  following  table  ^  of  observations  made  by 
Dr.  Halliburton  shows  well  this  variation  in  proteids,  and  the  difference 
existing  between  inflammatory  exudations  and  dropsical  effusions  :  — 


Pleural  Fluid  from 

Sp.  Gr. 

Perceutage  Quantity  of 

Total 
Proteid. 

Fibrin. 

Serura- 
g-lobulin. 

Serum- 
albumin. 

Acute  pleurisy,  Case  1 
,,      ■  Case  2 
,,             ,,         Case  3 
Hydrothorax         .         .  1 
Average  of  three  cases  j 

1023 
1020 
1020 

1014 

5-123 

3-4371 

52018 

1-7748 

0-016 
0-0171 

0-1088 

0-0086 

3-002 

1-2406 

1-76 

0-6137 

2-114 

1-1895 

3-330 

1-1557 

Between  the  amount  of  fibrin  present  in  exudations  and  the  amount 
of  peptones  there  is  an  inverse  ratio.  Peptones  are  especially  devel- 
oped in  connection  with  suppurative  inflammation;  and  the  more  an 
inflammation  tends  to  be  suppurative  the  greater  is  the  breaking  down 
of  the  fibrin,  as  also  of  fixed  and  wandering  cells,  and  the  more  evident 
the  production  of  peptones,  until  in  chronic  abscess-formation  of  fair 
extent  the  peptones  pass  into  the  general  circulation,  and  are  excreted 
and  recognisable  in  the  urine. 

Into  the  discussion  of  the  mode  of  formation  of  fibrin  I  need  not  en- 
ter here,  intimately  connected  as  the  subject  is  with  the  inflammatory 
process.  The  greater  text-books  of  Physiology  enter  exhaustively  into 
the  matter.     Suffice  it  to  say  that,  as  in  the  blood,  a  direct  relationship 

'  The.se  figures  are  thoroughly  in  accord  with  those  of  other  analyses  by  Reuss, 
llofrnann,  Mehu,  and  Letulle. 

VOL.    r  H 


SYSTEM   OF  MEDICINE 


is  made  out  between  the  breaking  down  of  leucocytes  and  the  develop- 
ment of  this  substance  in  inflammatory  exudations. 

It  is  in  connection  with  inflammation  affecting  serous  and  epithelial 
surfaces  ^  that  fibrin  is  most  clearly  recognisable,  forming,  it  may  be, 
thick  coatings  of  the  badly-named  ''inflammatory  lymph"  over  the  in- 
flamed surfaces.  This  deposit  is  in  all  respects  comparable  to  the  forma- 
tion of  thrombi  in  the  blood-vessels.  Here,  as  there,  the  deposit  occurs 
only  when  the  endothelium  has  undergone  destruction  and  the  roughened 
sub-endothelial  tissues  are  exposed.  And  here  also  the  fibrin  may  be 
deposited  either  in  filamentous  or  homogeneous  and  hyaline  form  accord- 
ing to  circumstances. 

Leaving  out  of  account  coagulation-necrosis  as  not  occurring  in 
direct  connection  with  exudates,  it  may  be  said  that  similar  fibrin  for- 
mation is  frequently  recognisable  in  connection  with  primary  inflamma- 
tion of  parenchymatous  tissues. - 

The  beneficial  effects  of  fibrin  formation  in  serous  cavities  have  been 
rendered  abundantly  manifest  by  the  increase  in  abdominal  surgery.  No 
one  who  has  followed  any  considerable  number  of  operations  for  appendici- 
tis can  have  failed  to  remark  how,  in  case  after  case,  despite  the  intricacy 
of  the  abdominal  coils  and  their  mobility,  the  strongly  irritant  matter  pro- 
duced by  gangrene  of  the  appendix,  or  oozing  through  perforations  in  it, 
is  restricted  within  a  relatively  small  space  by  the  surrounding  fibrinous 
adhesions  which  form  rapidly  between  the  intestinal  loops.  By  this  means 
alone  the  peritonitis  is  restricted  and  "  regional,"  instead  of  being  general- 
ised from  the  onset.  Even  when  inflammation  (as  in  pericarditis)  affects 
the  whole  extent  of  a  serous  cavity,,the  layer  of  fibrin  acts  as  a  protective 
coat  closing  the  lymphatic  stomata,  hindering  the  free  absorption  of  the 
morbid  material  by  the  lymph  and  blood-vessels,  and  filtering  bacteria 
out  of  such  fluid  as  does  find  its  way  through  to  the  tissues  beneath.  It 
is  not  a  little  remarkable  to  call  to  mind  how  case  after  case  of  purulent 
pericarditis  or  purulent  pleurisy  may  be  examined  in  which,  despite  the 
intense  suppurative  disturbance  in  the  serous  cavity,  the  tissues  at  the 
other  side  of  the  deposit  of  fibrin  —  the  myocardium  or  the  lung  tissue 
—  show  little  or  no  tendency  to  abscess  formation.  Let  there  be  primary 
abscess  formation  or  gangrene  in  the  lung,  and  perforation  of  the  pleura 
and  hydrothorax  may  supervene ;  pleurisy,  however  intense,  does  not 
lead  to  this  unless  complicated  by  other  disease.  Let  there  be  primary 
or  metastatic  abscess  in  the  myocardium,  then  there  maybe  aneiirysm  and 
rupture  of  the  heart ;  yet  such  rupture  produced  by  extension  inwards  of  a 
purulent  pericarditis  is  of  the  utmost  rarity.  Let  there  be  inflammation 
originating  in  the  submucosa  of  the  intestines,  as  in  enteric  fever,  and 

1  Of  epithelial  surfaces,  more  especially  those  covered  by  a  single  cell  layer,  as  notably 
the  pulmonary  alveoli. 

2  Where  there  are  abundant  and  distensible  lymph  channels  there  extensive  clotting 
may  be  seen  in  the  lymph.  This  is  peculiarly  well  marked  in  the  contagious  pneumonia 
of  cattle  (contagious  pleuro-pneumonia).  In  acute  inflammation  of  various  organs,  by 
appropriate  methods  of  staining,  similar  formations  of  threads  of  fibrin,  often  starting 
from  cells  as  centres,  may  be  observed  in  the  tissue  spaces. 


INFLAMMA  TION  99 


perforation  may  result ;  general  peritonitis,  while  often  due  to  perfora- 
tion, never  —  so  far  as  I  can  call  to  mind  —  directly  induces  that  event. 
In  all  these  cases  the  natural  protective  layer  of  the  serous  surface  is 
removed  or  gravely  injured  at  a  very  early  stage  ;  and  the  layer  of  fibrin, 
replacing  the  serous  endothelium,  forms  an  effective  barrier.  I  may  add 
that  the  mucin,  extruded  so  as  to  form  a  layer  over  inflamed  mucous 
surfaces,  presents  a  similar  protective  action. 

Passing  now  to  the  ferments  and  ferment-like  bodies  present  in 
the  exudate,  I  may  briefly  state  that  these  are  not  only  generated  and 
excreted  by  the  pathogenetic  bacteria  present,  but  are  liberated  by  the 
breaking  down  of  the  wandering  cells.  Abundant  evidence  of  the  exist- 
ence of  bacterial  ferments  capable  of  acting  upon  proteids,  gelatine, 
sugars,  etc.,  is  supplied  by  the  study  of  the  growth  of  these  microbes 
outside  the  body.  That  ferments  also  originate  fl'om  the  wandering 
cells  has  been  demonstrated  by  Leber,  who,  placing  pieces  of  copper  in 
the  anterior  chamber  of  the  eye,  thereby  produced  a  purulent  collection 
devoid  of  microbes,  and  showed  that  the  exudate  was  capable  of  digest- 
ing proteid  matter. 

It  would  seem,  therefore,  that,  more  especially  in  pyogenetic  inflam- 
mation, the  removal  of  dead  tissue  cells  and  dead  leucocytes  may,  to  a 
large  extent,  be  due  to  the  action  of  the  inflamm'atory  exudations,  apart 
from  any  phagocytic  action  on  the  part  of  living  active  cells ;  although 
this  also  comes  often  into  play. 

Of  the  bactericidal  substances  present  in  the  inflammatory  exudate 
I  have  already  treated.  Here  I  need  only  repeat  that  the  researches  of 
Kanthack  and  Hardy,  of  Denys,  and  lastly  of  Pf eiff er  and  Metschnikoff, 
fully  prove  that  substances  capable  either  of  destroying  microbes  or  of 
hindering  their  growth  are  present  therein. 

Summary.  —  To  sum  up  what  is  known  concerning  the  inflammatory 
exudate,  it  may  be  said  — 

1.  That  the  exudate  varies  in  amount  and  in  character  with  (a)  the 
nature  and  intensity  of  the  irritant,  (6)  the  condition  of  the  organism, 
(c)  the  region  of  irritation. 

2.  That  while  it  undoubtedly  augments  the  nutrition  of  the  affected 
region,  increased  nutrition  at  the  early  stage  of  an  acute  inflammatory 
process  would  not  seem  to  be  of  benefit  or  to  play  any  important  part. 
At  a  later  stage  and  in  chronic  inflammation  the  increased  nutrition  in 
all  probability  aids  the  hyperplasia. 

3.  That  in  many  cases  the  exudate  exerts  a  beneficial  action  by 
flushing  out  the  injured  area. 

4.  That  the  exudate  plays  an  important  part  in  diluting  the  irri- 
tant. 

5.  That  the  development  of  fibrin  in  certain  inflammatory  exudates 
is  associated  with  the  breaking  down  of  the  wandering  cells,  and  is  of 
manifest  benefit  in  so  far  as  it  circumscribes  the  inflamed  area,  and 
yjrevents  the  passage  of  morbid  material  outwards. 

G.    That  the  exudate  may  possess  digestive  functions,  causing  the  pro- 


SYSTEM  OF  MEDICINE 


duction  of  peptones  ;  the  ferments  being  developed  from  the  cells  alone 
when  the  exudate  is  aseptic,  from  these  and  the  microbes  together  where 
pathogenetic  microbes  are  present. 

7.  That  the  exudate  may  further  contain  substances,  generated  by 
the  cells,  capable  of  hindering  bacterial  growth,  and  of  destroying 
pathogenetic  microbes. 

Chapter  3.  —  The  Part  played  by  Blood-Vessels 

The  study  of  the  action  and  function  of  the  leucocytes  in  inflamma- 
tion has  profoundly  modified  our  conception  of  the  inflammatory  process. 
When  the  leucocytes  were  regarded  as  purely  passive  agents,  and  their 
diapedesis  as  purely  secondary  to  modified  conditions  of  the  blood  cur- 
rent and  of  the  vascular  walls,  the  theory  of  Cohnheim  was  that  most 
generally  accepted.  And  this  theory  regarded  the  changes  in  the  vessels 
as  of  the  first  importance.  Thus  it  was  that  for  several  years  our  atten- 
tion was  mainly  concentrated  upon  the  determination  of  the  various 
changes  of  the  vessel  walls,  and  of  the  mechanism  whereby  these  changes 
were  brought  about.  Nowadays  less  attention  is  directed  to  this  side  of 
the  inflammatory  process,  and  it  may  be  said  that  during  the  last  ten 
years  little  advance  has  been  made  in  determining  the  mechanism  of  the 
dilatation  that  accompanies  inflammation. 

The  subject,  indeed,  is  beset  with  difficulties.  It  is  most  difficult 
to  observe  the  changes  that  occur  in  the  cells  forming  the  endothelium 
of  the  congested  vessels  ;  we  are  still,  for  instance,  far  from  being  sure 
whether  the  opinion  of  Arnold  is  correct,  namely,  that  the  leucocytes, 
and,  it  may  be,  a  large  portion  of  the  exuded  plasma,  find  their  way  out 
through  the  dilated  stomata  between  the  endothelial  cells ;  or  whether 
the  leucocytes  pass  directly  through  these  cells  as  one  soap  bubble  may 
be  passed  through  another.  And  when  we  come  to  discuss  whether  the 
inflammatory  exudation  be  a  filtration,  or  whether,  on  the  other  hand,  it 
be  more  of  the  nature  of  an  excretion,  or  what  may  be  termed  a  selective 
filtration  —  certain  components  of  the  blood  plasma  being  permitted  to 
pass  through,  while  others  are  withheld  —  we  are  met  with  the  difficulty 
that,  of  the  extravasated  leucocytes,  a  varying  proportion  undergo  rapid 
destruction  and  dissolution.  Thus,  in  analysing  the  inflammatory 
serum,  we  are  not  dealing  simply  with  the  extravasated  fluid,  but  with 
a  fluid  which  in  addition  contains  proteid  and  other  constituents  derived 
largely  from  broken-down  white  corpuscles,  and  in  part,  it  may  be,  from 
the  modified  cells  of  the  inflamed  area. 

Though  Arnold's  observations  upon  the  altered  condition  of  the 
vascular  endothelium  in  inflammation  appear  at  first  very  convincing, 
upon  further  study  they  seem  at  most  to  indicate  that  with  dilation 
of  the  vessels  there  is  an  increase  in  the  size  of  the  spaces  between  the 
endothelial  cells.  They  do  not,  however,  prove  that  these  are  other  than 
virtual  spaces  filled  with  intercellular  substance ;  and  indeed  Arnold 
himself  came  eventually  to  the  conclusion  that  some  such  substance  was 


INFLAMMA  TION 


present  filling  them.  The  fact  that  viscid,  gelatinous  substances  injected 
into  the  circulation  may  be  detected  passing  through  these  stigmata  is 
not  a  proof  that  the  spaces  are  actual ;  all  it  proves  is  that  the  walls 
are  weaker  in  these  regions :  it  must  be  remembered  that  increased 
force  and  increased  intravascular  pressure  are  necessary  to  promote  the 
passage  of  the  injected  mass  along  the  vessels.  The  passage  of  the  mass 
through  the  walls  may  therefore  be  an  "  artefact." 

There  is  this  further  difficulty  in  the  assumption  that  these  are  actual 
spaces  —  that  in  acute  inflammation  the  exuded  fluid  in  general  contains 
a  smaller  quantity  of  proteids  than  does  the  blood  plasma.  It  is  true, 
no  doubt,  that  the  stigmata  are  so  small  they  may  possibly  act  like  the 
pores  of  a  filter,  and  consequently  may  not  permit  the  free  passage  of 
certain  constituents  of  blood  plasma.  Yet,  granting  all  this,  if  the  same 
principles  be  in  action  as  those  governing  the  ordinary  (non-inflamma- 
tory) transudation,  we  must,  with  Heidenhain,  be  inclined  to  regard  the 
endothelium  as  playing  not  a  passive,  but  an  active  role.  To  enter  into 
the  large  subject  of  the  nature  of  lymph  would  be  to  pass  too  far  afield; 
recent  researches,  on  the  whole,  favour  the  view  that  the  inflammatory 
exudation  is  not  a  mere  filtrate,  but  is  the  result  of  a  selective  activity 
on  the  part  of  the  endothelial  cells. 

We  have  not  a  little  evidence  that  these  cells  play  an  important  part 
in  the  vascular  phenomena  of  inflammation.  To  their  power  of  taking  up 
microbes  and  acting  as  phagocytes  I  have  already  referred ;  into  their 
connection  with  the  slowing  of  the  blood  stream  I  shall  enter  later. 
Here  I  would  point  out  that-  microscopically  these  cells  can  be  seen  to 
alter  during  the  inflammatory  process;  they  become  enlarged  and 
project  into  the  lumen  of  the  smaller  vessels,  and  in  my  experience  this 
enlargement  affects  not  only  the  cell  bodies,  but  also  the  nuclei,  which 
at  the  same  time  would  seem  to  contain  more  chromatin  and  to  stain 
more  intensely.  In  cases  of  chronic  inflammation  the  enlargement  is 
followed  by  proliferation,  notably  in  the  arterioles  and  capillaries,  —  a 
process  which  may  lead  to  the  ultimate  occlusion  of  these  small  vessels. 
And  in  acute  inflammation,  according  to  numerous  observers,  mitosis  is 
to  be  seen  occurring  in  these  endothelial  cells  at  an  earlier  period  than 
in  the  surrounding  tissues. 

A  further  and  very  important  process  intimately  connected  with  the 
proliferation  of  the  endothelium  of  the"  capillaries  is  the  formation  of 
new  vessels  as  the  result  of  continued  inflammation.  It  is  true  that 
Eindfleisch  and  others  have  described  this  as  being  brought  about  by 
vaso-formative  cells  situated  externally  to  the  vessels ;  and  that  others 
have  advanced  so  far  as  to  suggest  that  there  are  cells  in  the  newly- 
forming  granulation  tissue  which  become  hollowed  out  and  gain  attach- 
ment to  the  pre-existing  capillaries  in  a  manner  wholly  similar  to  that 
observable  in  the  vascular  zone  of  the  chicken  embryo.  I  have  sought 
for  such  intracellular  developinent,  V)ut  never  have  I  seen  the  slightest 
indication  thereof ;  nor  again  have  I  been  able  to  discover  cells 
arranging  themselves  after  the  method  described  by  liindfleisch  in 


SYSTEM  OF  MEDICINE 


columns  or  parallel  rows  preparatory  to  the  passage  of  blood  between 
them  and  to  the  formation  of  a  capillary. 

The  search  for  the  earliest  signs  of  new  capillaries  is  a  matter  of 
peculiar  difficulty.  I  will  not  peremptorily  state  that  Rindfleisch  mis- 
took an  arrangement  of  cells  not  unf  requently  seen  in  granulation  tissue 
for  stages  in  the  development  of  new  vessels.  I  will  only  say  that  my 
own  observations  coincide  with  those  of  Arnold,  and  of  the  majority  of 
those  who  have  more  recently  studied  the  question,  and  lead  me  to  regard 
the  formation  of  new  capillaries  as  originating  from  the  endothelium  of 
the  vascular  loops  already  in  existence. 

The  first  step  in  the  process  is  often  recognisable,  in  cases  of  pleurisy 
and  pericarditis,  in  the  projection  of  loops  of  pre-existing  capillaries 
beyond  the  line  which  indicates  where  the  serous  endothelium  used  to 
be,  and  into  the  fibrinous  clot  now  adherent  to  the  sub-endothelial  layer. 
Such  loops  are  markedly  distended,  and  "  point,"  as  it  were,  at  right 
angles  to  the  denuded  surface.  A  similar  pointing  or  giving  way  of  the 
wall  along  the  convex  margin  of  the  loop  is  also  to  be  made  out  not 
unfrequently  in  newly-developed  capillaries.  In  these  there  is  not,  as 
might  be  expected,  a  thinning  of  the  endothelium  along  this  outer  mar- 
gin, but  certain  of  the  cells  on  the  contrary  appear  large  and  active.  At 
times  a  small  sharp  protrusion  of  the  vessel  wall  can  be  detected  in  the 
region  of  pointing.  This  is  best  seen  in  the  capillaries  that  are  them- 
selves but  newly  formed,  and  composed  of  nothing  but  a  layer  of  endo- 
thelial cells.  In  this  layer  the  protrusion  can  be  made  out  to  be  in 
direct  continuity  with  the  endothelial  cells  of  the  region.  At  first  it 
is  solid,  but  in  the  later  stages  it  can  be  seen  to  be  nucleated,  and  to  be 
growing  by  proliferation  of  the  endothelial  cells  which  thus  jut  out- 
wards. Even  before  any  further  change  is  noticeable  in  this  projection 
from  the  capillary  wall  it  may  be  seen  to  be  united  with  a  similar  pro- 
cess originating  from  a  neighbouring  vascular  loop.  Finally,  it  would 
appear  that  the  joined  processes  become  hollowed  out,  and  thus  are 
developed  into  fully-formed  capillary  loops.  It  seems  impossible  to 
make  precise  observations  on  the  phenomena  of  new  vascular  formation 
in  its  successive  stages.  I  can  but  state  that  these  appear  to  be  the 
steps  of  the  process.  By  what  means  the  new  vascular  projections  join 
together  to  form  loops  we  are  ignorant.  Metschnikoff  suggests  that 
there  must  be  an  attraction  between  the  neighbouring  projections  —  a 
chemiotaxis  —  leading  them  to  come  into  apposition;  this,  however,  is 
no  more  than  a  suggestion.  That  they  do  join  is  very  clear  to  those  who 
have  studied  granulation  tissue,  or  have  observed  the  vascular  network 
connecting  the  previously  separated  surfaces  of  a  wound. 

A  further  function  of  the  vessel  walls  is  to  be  seen  in  the  slowing  of 
the  blood  current.  It  is  difficult,  and  in  fact  impossible,  to  explain  this 
slowing  by  altered  diameter  of  the  arteries  and  veins.  The  alterations 
observed  in  the  diameters  of  the  vessels  of  the  inflamed  area  are  such  as, 
acting  alone,  would  led  to  increased  rate  of  flow.  Nor  again  is  the 
apparent  amount  of  exudation,  and  of  lymph  flow  from  the  affected 


I 


INFLAMMATION  ■  103 


part,  sufficient  to  make  it  probable  that  (as  Wharton  Jones  first  suggested) 
the  slowing  is  in  the  main  due  to  the  concentration  of  the  blood,  relative 
diying  of  the  corpuscles,  and  consequent  increase  of  friction  :  while  this 
may  be  an  adjuvant  we  must,  I  think,  tind  some  more  potent  factor. 
What  this  factor  is  was  pointed  out  long  ago  by  Lister,  who,  in  1858, 
noticed  that  coincident  with  the  slowing  of  the  blood  stream,  the  cor- 
puscles move  sluggishly  along  the  vessel  wall  as  though  attracted  by  it. 
Lister  essayed  to  prove  this  by  an  experiment  performed  previously  by 
Weber.  He  ligatured  a  frog's  leg,  then  irritated  a  portion  of  the  web  by 
a  little  mustard,  and  found  that,  although  the  blood  current  had  ceased, 
there  was  nevertheless  an  accumulation  of  corpuscles  in  the  vessels  of  the 
irritated  area,  the  corpuscles  gliding  into  the  affected  region  and  becom- 
ing adherent  there.  Other  observers  have  shown  that  this  accumulation 
is  not  due  to  increased  adhesiveness  of  the  red  corpuscles,  inasmuch  as 
similar  slowing  and  stasis  may  be  induced  if  the  blood  of  the  frog's  leg 
be  replaced  by  milk  and  the  web  irritated.  In  this  case  there  is  a 
gradual  slowing  of  the  stream  of  milk  and  accumulation  of  the  fatty 
globules  in  the  inflamed  area.  While  in  Lister's  experiment  the  transu- 
dation of  the  plasma  might  explain  the  accumulation  of  the  corpuscles, 
in  this  latter  instance,  as  in  ordinary  inflammation,  the  observed  transuda- 
tion is  insufficient  to  account  for  the  accumulation  and  slowing.  Although 
I  cannot  accept  his  experiment  as  conclusive,  I  am  forced  to  concur  with 
Lister  to  this  extent,  that  in  inflammation  the  endothelium  of  the  vessel 
walls  becomes  altered,  the  cells  becoming  enlarged.  With  this,  as  evi- 
denced by  the  conduct  of  the  white  corj)uscles,  they  become  more 
adhesive,  and  this  adhesiveness  with  the  associated  increased  friction 
between  the  vascular  walls  and  contents  I  regard  as  the  first  factor  in 
bringing  about  the  slowing  of  the  blood  stream.  Let  the  current  once 
accelerated  be  rendered  slower  by  this  increased  friction,  then  transu- 
dation may  accentuate  the  accumulation  of  corpuscles. 

Summary.  —  While  there  is  very  much  yet  to  be  learned  concerning 
the  part  played  by  the  blood-vessels  in  inflammation,  and  while  our 
present  knowledge  of  this  branch  of  the  subject  can  only  be  regarded 
as  very  imperfect,  the  following  may,  I  think,  safely  be  said  to  epitomise 
what  is  known  at  the  present  time  :  — 

(1)  That  the  vascular  walls,  and  more  especially  the  endothelial  cells 
lining  the  capillaries,  play  an  active  and  not  a  passive  part  in  the  in- 
flamed area. 

(2)  These  cells  have  the  power  of  throwing  out  pseudopodia  and 
of  taking  up  non-motile  bacteria. 

(3)  They  are  larger  and  more  prominent  during  inflammation  than 
they  are  under  conditions  of  health. 

(4)  From  them  are  developed  the  new  vascular  loops  in  cases  of 
more  chronic  inflammation. 

(5)  They  would  seem  to  become  more  adhesive  in  inflammation,  and 
by  this,  in  the  first  place,  to  lead  to  the  adhesion  of  the  leucocytes  and 
red  corpuscles  to  their  walls. 


I04  SYSTEM   OF  MEDICINE 

(6)  Similarly  they  would  seem  to  cause  an  increased  resistance  to  the 
passage  of  the  blood  current,  and  in  this  way  tend  to  slow  the  rate  of 
blood  flow. 

(7)  The  slowing  of  the  stream  may  further  be  aided  by  the  passage 
through  the  walls  of  increased  amounts  of  fluid  from  the  blood. 

(8)  It  is  impossible  by  analysis  of  the  inflammatory  exudation  to 
determine  whether  this  be  a  mere  filtrate  or  be  the  result  of  a  selective 
activity  of  the  endothelium.  On  the  whole,  taking  into  account  the 
observations  made  upon  ordinary  lymph,  the  latter  would  appear  the 
more  probable. 

Other  properties  of  the  blood-vessels  in  respect  of  inflammation  will 
be  better  discussed  in  a  later  section  in  connection  with  the  discussion 
of  the  part  played  by  the  nerves. 

Chapter  4.  —  On  the  Passage  of  Corpuscles  out  of  the  Vessels 

By  his  researches,  Cohnheim  (18G7)  forcibly  attracted  the  attention  of 
pathologists  to  the  diapedesis  of  leucocytes  in  inflammation  —  a  process 
which  had  already  been  described  years  before  by  Addison  (1843)  and 
Waller  (1846)  in  England ;  and  yet  earlier  (though  without  grasp  of  the 
connection  between  the  diapedesis  and  inflammation)  by  Dutrochet,  in 
France  (1828).  Cohnheim  recognised  the  amoeboid  nature  of  the  leuco- 
cytes, and  saw  that  once  outside  the  vessels  they  moved  actively,  but 
eventually  he  could  not  discover  that  their  penetration  of  the  vessel  walls 
was  anything  but  passive ;  and  this  failure  on  his  part  to  recognise  the 
true  nature  of  diapedesis  confirmed  him  yet  more  strongly  in  the  view 
that  the  all-important  factors  in  the  inflammatory  state  were  the  changes 
in  the  vessel  walls,  and,  it  may  truly  be  said,  arrested  his  advance 
towards  a  fuller  comprehension  of  the  subject. 

It  must  be  acknowledged  that  there  is  much  which  would  seem  to 
support  this  view  of  the  passivity  of  the  leucocytes.  No  one  is  pre- 
pared to  attribute  active  movements  to  the  red  corpuscles,  nevertheless 
in  inflammation  a  certain  number  of  these  escape  through  the  vessel 
walls.  In  the  inflammation  affecting  some  organs,  notably  the  lungs, 
the  number  effecting  a  passage  is  very  considerable.  If,  then,  the  red 
corpuscles  emerge  passively,  why  should  not  the  emergence  of  the  white 
be  passive  also  ?  Add  to  this  the  very  important  observations  made  by 
Cohnheim,  that  where  the  circulation  is  arrested  by  compression  of  the 
artery  there  diapedesis  ceases.  This,  if  invariably  true,  would  seem  to 
indicate  that  when  once  by  cha^iges  in  the  vessel  the  leucocytes  adhere 
to  the  wall,  the  further  passage  through  that  wall  is  due  to  the  vis  a 
tergo  of  the  blood  pressure. 

This,  however,  is  not  a  safe  deduction  to  draw  from  the  experiment  re- 
ferred to.  When  the  artery  of  an  inflamed  area  is  compressed  the  stoppage 
of  the  blood  stream  not  only  reduces  the  pressure,  but  also  affects  the 
quality  of  the  blood  and  the  conditions  of  the  vessel  walls  ;  moreover,  it 
must  profoundly  affect  the  vitality  and  activity  of  the  contained  leucocytes. 


IN  FLAM  MA  TION  105 


These  considerations  alone  render  the  experiment  valueless  as  a  proof  of 
the  passive  nature  of  the  diapedesis.  Again  the  passage  outwards  of  red 
corpuscles  does  not  occur  in  the  earliest  stages  of  reaction  to  irritation ; 
it  never  precedes  the  diapedesis  of  the  leucocytes  (save  where  there  is 
gross  injury),  but  follows  it.  A  capillary  or  small  vein  in  the  inflamed 
frog's  web,  for  example,  may  be  seen  wholly  filled  with  corpuscles,  the 
peripheral  zone  being  quite  annihilated,  and  numerous  red  corpuscles 
lying  in  immediate  contact  with  the  walls  ;  nevertheless  at  first  leucocytes 
only  are  seen  to  emigrate.  This  difference  must  be  due  to  some  special 
property  of  these  cells.  The  leucocytes  in  the  blood  stream  are  not 
necessarily  globular  passive  agents,  but  they  are  capable  of  independent 
movement.  Leber,  in  his  long  series  of  studies,  has  pointed  out  that  if, 
with  due  precautions,  a  hooked  glass  tube  (closed  at  its  outer  end  where 
it  catches  into  the  incision  in  the  wall)  be  inserted  into  a  large  vein 
no  thrombosis  may  be  set  up  around  the  intravascular  portion,  and  yet, 
upon  removal,  a  large  collection  of  leucocytes  may  be  found  in  the  tube, 
attracted  by  a  drop  of  mercury  placed  within  it,  with  normal  salt  solu- 
tion. (Mercury  is  a  substance  which  within  the  tissues  leads  to  an 
accumulation  of  leucocytes.)  Here,  then,  there  must  be  active  attrac- 
tion and  active  movement  of  the  leucocytes  within  the  blood  stream. 
And  Lavdowsky  has  described  very  exactly  what  other  observers  had 
also  noted,  namely,  that  in  inflammation  the  leucocytes  in  the  outer  zone 
of  the  blood  stream  do  not  simply  adhere  passively  to  the  wall,  but  move 
backwards  and  forwards  before  they  attach  themselves  and  emigrate,  as 
though  seeking  for  a  point  of  less  resistance.  At  times  this  movement 
is  in  a  direction  opposite  to  that  of  the  blood  current. 

If,  then,  both  within  and  without  the  vessels,  the  leucocytes  can  be 
actively  amoeboid,  it  is  strange  that  they  should  be  passive  in  the  pro- 
cess of  diapedesis  which  to  the  eye  has  so  characteristically  amoeboid 
an  appearance. 

As  above  stated,  the  compression  of  the  artery  passing  to  an  in- 
flamed area  is  in  most  cases  sufficient  to  arrest  diapedesis  in  that  area, 
and  I  have  suggested  that  this  arrest  may  be  due  to  the  altered  envi- 
ronment of  the  leucocytes.  Now,  if  an  embryonic  form  be  taken,  in 
which  the  tissues  would  seem  to  possess  greater  inherent  vitality  coupled 
with  less  sensibility,  the  arrest  does  not  necessarily  occur.  Thus, 
Metschnikoff  has  noted  that  diapedesis  of  the  leucocytes  can  be  fol- 
lowed in  the  tadpole's  tail  after  the  animal  has  been  curarised  to  such 
an  extent  that  the  heart  has  ceased  to  beat  and  the  blood  in  the  capil- 
laries has  been  brought  to  a  standstill. 

It  is  evident,  therefore,  that  with  our  present  knowledge  we  must 
regard  the  diapedesis  of  the  leucocytes  as  an  active  migration,  and  must 
look  upon  the  blood  pressure,  the  disposition  of  the  blood  stream,  and 
the  altered  condition  of  the  endothelium  of  the  dilated  vessels  as  adju- 
vants in  the  process.  The  slowing  of  the  blood  stream  and  the  diminished 
j)ressuro  in  the  inflamed  capillaries  render  it  more  easy  for  the  leucocytes 
to  accumulate  close  to  the  vessel  wall ;  the  dilation  of  the  vessels  and 


io6  SYSTEM   OF  MEDICINE 

consequent  thinning  of  the  walls,  with  the  opening,  perhaps,  of  larger 
spaces  of  cement  substances  or  stigmata  between  the  individual  endo- 
thelial cells,  render  it  more  easy  for  the  leucocytes  to  accomplish  the  pas- 
sage ;  but  the  movement  from  within  the  capillaries  to  the  tissue-spaces 
outside  is  an  active  process  due  to  amoeboid  movement  of  the  leucocytes 
themselves.  The  continuity  of  the  vessel  wall  once  destroyed,  other 
cells  —  red  corpuscles  —  may  be  pressed  passively  through  the  walls. 

If  this  view  be  accepted,  we  are  bound  to  look  beyond  Cohnheim's 
limit  of  changes  in  the  vessel  wall  for  the  stimulus  Avhich,  originating  in 
the  area  of  irritation,  acts  upon  the  vessel  wall  and  the  leucocytes  in 
contact  with  it ;  and,  having  first  set  up  changes  in  the  former,  so  reacts 
upon  the  latter  that  they  emigrate ;  or,  to  put  it  in  other  words,  are  at- 
tracted out  of  the  capillaries  towards  the  focus  of  irritation.  It  has 
already  been  shown  that  the  movement  of  wandering  cells  in  the  tissue  is 
due  to  the  attraction  of  a  diffusible  product  of  bacterial  growth  and  of 
tissue  change,  and  of  sundry  organic  and  inorganic  materials  —  a  force  to 
which  the  name  of  positive  chemiotaxis  has  been  given.  This  chemiotaxis 
must  be  invoked  to  explain  the  active  emigration  of  the  leucocytes  from 
the  capillaries,  and  again  to  explain  its  cessation  under  other  conditions. 
Thus,  while  the  exposed  mesentery  of  a  frog  is  a  tissue  in  which  diape- 
desis  can  be  observed  with  facility  under  ordinary  conditions,  if  it  be 
washed  with  a  weak  solution  of  quinine  the  leucocytes  in  the  vessels 
remain  globular,  cease  to  adhere  to  the  walls,  and  do  not  emigrate.  This 
fact,  first  noted  by  Binz,  has  been  confirmed  by  several  observers,  among 
whom  Disselhorst  made  out  also  that,  if  these  same  leucocytes  be  re- 
moved from  the  vessels,  they  exhibit  their  usual  amoeboid  movements. 
The  quinine  has  not  paralysed  them,  as  Binz  supposed ;  but,  as  Metsch- 
nikoff  pointed  out,  it  has  neutralised  the  previous  positive  attraction,  a 
negative  or  repulsive  chemiotaxis  being  brought  into  play.  It  is  diffi- 
cult to  see  how  the  above  facts  can  be  otherwise  explained. 

The  Adew  that  diapedesis  is  an  active  process  gains  further  siipport 
from,  and  at  the  same  time  explains  certain  interesting  observations 
made  by,  Bouchard,  Roger,  and  Buffer.  These  observers  have  independ- 
ently shown  that  in  sundry  instances  the  results  of  local  injection  of  viru- 
lent cultures  are  greatly  modified  if,  shortly  before  or  coincidently,  the 
microbes  and  their  products  are  introduced  into  the  circulation.  Thus, 
as  Buffer  points  out,  a  drop  of  the  culture  of  the  bacillus  pyocyaneus  in- 
ocfilated  into  the  anterior  chamber  of  the  rabbit's  eye  leads  ordinarily 
to  a  great  migration  of  leucocytes  —  to  an  acute  purulent  inflammation. 
If,  however,  the  toxins  produced  by  this  microbe  have  previously  been 
injected  into  the  circulating  blood,  no  accumulation  of  leucocytes  follows 
inoculation  into  the  eye.  Dr.  Buffer  has  also  extended  most  suggestively 
certain  observations  of  Boger.  Subcutaneous  or  intramuscular  inocula- 
tion of  the  rabbit  with  the  bacillus  of  symptomatic  anthrax  leads  to  the 
production  of  a  local  abscess  with  extensive  accumulation  of  leucocytes. 
After  simultaneous  injections  of  fluid  containing  virulent  bacilli  and 
their  products  into  the  vein  of  the  ear  and  the  muscles  of  the  hind  leg, 


INFLAMMA  TION  107 


E-uffer  found  the  rabbit  dead,  within  fifteen  hours,  with  a  huge  tumour 
in  the  inoculated  limb.  Here,  upon  examination,  the  muscle  fibres 
were  found  widely  separated  by  exudation  fluid,  in  which  there  had  been 
great  multiplication  of  the  bacilli ;  but  leucocytes  were  entirely  absent. 
In  both  of  these  cases  we  have  therefore  diapedesis  and  determination 
of  leucocytes  following  the  purely  local  action  of  the  toxin ;  want 
of  diapedesis  and  absence  of  leucocytes  when  the  toxin  at  the  same 
time  circulates  in  the  blood  stream.  If  any  large  proportion  of  the 
leucocytes  which  find  their  way  to  a  focus  of  irritation  emerge  from  the 
blood  stream,  these  divergent  results  are  only  to  be  explained  by  some 
theory  which  is  capable  of  reconciling  the  difference  in  the  action  of  the 
leucocytes  when  they  are  circulating  in  normal  and  toxin-containing 
blood  respectively. 

Now,  the  results  in  these  two  cases  are  entirely  consonant  with  what 
we  know  concerning  the  sensitiveness  and  reaction  to  stimuli  not  only 
of  unicellular  organisms,  but  also  of  the  higher  animals.  Organisms, 
whether  lowly  or  of  most  complex  development,  only  perceive  and  react 
to  alteration  in  their  environment  when  the  alteration  exceeds  a  definite 
ratio.  Thus,  as  Pfeffer  has  pointed  out,  a  motile  bacterium  (the  "  B. 
termo  ")  is  attracted  towards  solutions  of  peptone  :  if  it  be  already  in  a 
peptone  solution,  in  order  for  it  to  be  attracted  towards  and  move  into 
a  more  concentrated  solution,  this  last  must  be  five  times  as  strong  as  is 
the  former.  The  only  possible  explanation  that  I  can  see  of  the  above 
observations  of  Buffer  and  Roger  is  that  the  passage  and  want  of  passage 
of  the  leucocytes  out  of  the  vessels  depends  upon  the  ratio  of  diffusible 
bacterial  products  present  in  the  blood  stream  and  in  the  tissues  respec- 
tively. Where  the  products  are  localised  at  one  focus  in  the  tissues, 
the  leucocytes  are  attracted  out  of  the  unaltered  blood,  and  there  is 
active  diapedesis  ;  where  there  was  already  a  solution  of  the  bacterial 
products  in  the  blood,  the  ratio  of  difference  between  the  percentage 
amount  of  toxin  in  blood  and  tissue  may  be  insufficient  to  stimulate  the 
leucocytes  ;  no  diapedesis  then  ensues. 

As  is  well  shown  in  the  experiment  with  symptomatic  anthrax,  the 
presence  of  the  bacillus  and  its  products  in  the  circulating  blood  did  not 
prevent  inflammation  at  the  region  of  local  injection  ;  inflammation  and 
exudation  were  abundantly  manifest  — there  was,  in  fact,  a  more  extensive 
exudation  than  ever.  The  irritant  —  that  is  to  say,  the  toxic  products 
of  the  bacilli  —  at  the  point  of  injection  was  in  no  wise  hindered  from 
exerting  effects  upon  the  fixed  cells  of  the  vessel  walls,  and  promoting 
all  the  changes  in  calibre  and  condition  of  the  walls  and  in  the  blood 
stream  characteristic  of  inflammation.  But  with  vascular  changes,  if 
anything  more  prominent  than  in  the  case  where  local  inoculation  alone 
had  been  practised,  the  leucocytes  stayed  within  the  vessels  :  now  the 
only  cause  to  which  we  can  attribute  this  abstention  of  the  cells  from 
emigration,  is  lack  of  attraction  —  certainly  not  lack  of  vascular  change 
or  lack  of  blood  pressure. 

Summary.  —  I  am  thus  led  to  the  following  conclusions  regarding 


io8  SYSTEM  OF  MEDICINE 

the   passage   of  cells   out    of    the    blood    stream    into    an    inflamed 
area :  — 

1.  The  diapedesis  of  the  leucocytes  is,  as  the  name  implies,  an  active 
and  not  a  passive  ];)rocess ;  it  is  due  to  active  amoeboid  movements  on 
the  part  of  the  cells. 

2.  The  stimulus  leading  to  diapedesis  is  that  of  positive  chemiotaxis. 
It  is  the  attraction  exerted  upon  the  leucocytes  by  the  diffusible  sub- 
stances associated  with  the  irritant. 

3.  Irritants,  if  themselves  diffusible,  or  the  diffusive  substances 
developed  while  the  irritants  are  within  the  tissues,  are  capable  of  two 
separate  actions  :  one  direct  upon  the  vessel  walls,  leading  to  vascular 
changes  ;  the  other  through  the  walls  upon  the  leucocytes,  whereby 
emigration  may  be  induced. 

4.  These  two  actions  need  not  (and  frequently  do  not)  manifest  them- 
selves pari  passu. 

5.  In  relation  to  diapedesis,  the  dilation  of  the  vessels,  the  altered 
rate  of  blood  stream,  the  altered  disposal  of  the  corpuscles  in  the  stream, 
and  the  modified  endothelium,  may  all  be  regarded  as  adjuvants. 

6.  The  passage  of  red  blood  corpuscles  from  the  blood-vessels  into 
the  inflamed  area  is  passive,  due  to  the  blood  pressure  and  to  lack  of  con- 
tinuity of  the  vessel  walls.  Such  lack  of  continuity  is  afforded  in  many 
instances  by  the  migration  of  the  leucocytes  through  the  walls. 

Chapter  5.  —  Ox  the  Part  played  by  the  Nervous  System 

If  the  vascular  changes  in  inflammation  were  due  to  reflex  influences 
proceeding  from  the  central  nervous  system,  and  Avere  in  fact  controlled 
by  the  centres  in  the  brain  and  spinal  cord  (as  has  been  held  by  the 
supporters  of  neuro-humoral  theories)  then,  in  the  first  place,  there 
should  be  a  rapid  and  almost  immediate  response  on  the  part  of  the 
vessels  of  any  region  on  the  introduction  of  an  irritant.  But  this  is 
not  by  any  means  constantly  to  be  observed.  Thus,  as  Cohnheim 
pointed  out,  if  croton  oil  be  rubbed  upon  a  rabbit's  ear  more  than  an  hour 
may  elapse  before  the  first  beginnings  of  hypersemia  can  be  detected  ; 
yet  the  inflammation  eventiially  set  up  may  be  very  intense.  In  the 
second  place,  section  of  all  the  nerves  passing  to  any  region  of  the 
body  should  have  this  effect,  that  injury  in  the  region  in  question  should 
be  unaccompanied  by  the  ordinary  vascular  reaction.  But  this  is  not  the 
case.  Divide  all  the  nerves  which  supply  a  rabbit's  ear  for  example,  and 
then  injure  that  ear,  either  by  heat,  cold,  or  inoculation  of  pathogenetic 
micro-organisms,  and  inflammation  manifests  itself  with  all  the  stages 
recognisable  in  an  ear  with  intact  nerve-supply.  The  vascular  changes 
which  accompany  inflammation  can  occur  then  independently  of  any 
central  nervous  influences. 

We  can  proceed  farther,  and  state  that  regions  deprived  of  their 
nerve-supply  are  peculiarly  prone  to  inflammatory  changes.  But  this 
liability  to  inflammatory  disturbances  in  such  regions  is  not  directly  due 


INFLAMMA  TIOJV  109 


to  the  destruction  of  vaso-motor  tracts  and  the  cutting  off  of  central 
influences  from  the  vessels  of  the  part,  but  is,  it  would  seem,  immediately 
connected  with  the  loss  of  sensation.  Divide  the  ocular  branch  of  the 
fifth  nerve  of  a  rabbit,  and,  if  the  eye  be  not  protected,  ulceration  and 
necrosis  of  the  cornea  manifest  themselves  in  the  course  of  a  few  days. 
Protect  the  eye,  either  by  bringing  the  lids  together  or  by  placing  a 
shade  over  it  in  such  a  way  that  dust  and  foreign  particles  are  prevented 
from  settling  upon  the  surface,  and  no  such  ulcerative  disturbance  mani- 
fests itself.  Erom  this  it  is  clear  that  the  primary  cause  of  the  inflam- 
mation is  not  any  trophic  change  in  the  region,  but  is  the  lack  of  sensa- 
tion, whereby  irritant  substances  are  permitted  to  gain  a  lodgment  upon 
the  outer  surface  without  any  attempt  being  made  to  remove  them. 
That,  in  addition,  there  is  a  lowered  vitality  in  parts  deprived  of  their 
nerve-supply,  and  that  this  renders  those  parts  a  more  favourable  seat 
for  inflammatory  disturbances  is  more  than  probable;  nevertheless,  this 
would  not  seem  to  be  the  primary  cause  of  the  increased  liability  to 
inflammation.     [Vide  art.  on  "Nutritional  Retrogressive  Changes."] 

This,  then,  in  the  first  place,  is  clearly  recognisable — that  the  vascular 
changes  accompanying  inflammation  can  occur  independently  of  central 
nervous  influences.  Hence  it  follows  that  there  must  be  a  peripheral 
nervous  mechanism  controlling  the  vessels.  It  remains,  therefore,  to 
determine  the  nature  of  this  peripheral  mechanism :  is  it  wholly  under 
the  guidance  of  peripheral  nerve  cells  situated  in  the  vessel  walls,  or 
is  it,  in  part  at  least,  idiopathic  ?  In  the  present  state  of  our  knowledge 
the  answer  to  this  question  must  be  guarded.  The  more  carefully  the 
innervation  of  the  various  regions  is  studied,  the  more  clearly  is  it 
demonstrated  that  throughout  all  the  tissues  of  the  body  there  exists 
a  wonderfully  fine  and  complicated  network  of  nerve  filaments  with 
occasional  isolated  ganglion  cells.  Yet  proof  is  wanting  that  this  system 
in  connection  with  the  vessels  is  sensorimotor.  Indeed,  so  far  as  regards 
the  heart  and  ventricular  muscle  (which  may  be  looked  upon  as  the 
region  of  the  vascular  system  wherein  the  motile  portion  of  the  walls 
has  become  specially  developed),  the  researches  of  Romberg  and  His  lead 
rather  to  the  conclusion  that  the  peripheral  iiervous  system  subserves 
sensation  alone. 

Dr.  H.  J.  Berkley's  careful  series  of  researches  recently  brought 
together  in  a  Johns  Hopkins  Hospital  Report  (jSTeurology  II.,  1894) 
throws  much  light  upon  the  termiiiation  of  the  nerves  in  various  organs, 
and  upon  the  relation  of  these  nerves  to  the  vessel  walls.  Berkley 
finds  in  connection  with  the  ventricular  muscles  a  dense  network  of  nerve 
filaments,  with  small  bulbous  terminations  upon  the  individual  fibres. 
These  observations,  it  must  be  admitted,  tend  to  weaken  the  belief  in  the 
idiomuscular,  or,  more  truly,  idioneural  action  of  the  heart  muscle. 

At  the  same  time,  the  more  the  activity  of  the  various  tissues  is 
studied,  the  more  fully  it  is  seen  that  many  cells  retain  what  may  be 
termed  reminiscences  of  an  earlier  and  more  embryonic  condition  in 
which  their  functions  were  varied  and  less  specialised.     There  is  an 


SYSTEM  OF  MEDICINE 


inherent  probability  that  the  endothelial  cells  can  react  directly  to  stim- 
uli, and  that  they  are  capable  of  idiopathic  contraction  and  expansion 
on  appropriate  stimuli.  We  have  seen  that  these  cells  are  capable  of 
taking  up  microbes,  and  thus  seem  to  exhibit  an  independent  activity 
similar  to  that  observed  in  the  amoeba  or  the  wandering  phagocyte.  If 
these  cells,  then,  are  capable  of  throwing  out  pseudopodia,  and  thus  of 
enclosing  non-motile  bacteria,  are  they  not  capable  of  contracting  and 
expanding,  as  a  whole,  according  to  the  stimulus  of  altered  environ- 
ment ?  As  a  matter  of  fact,  such  contractility  of  the  endothelial  walls 
of  the  capillaries  has  been  demonstrated  by  Klebs  and  Severini.  I  can- 
not but  conclude,  then,  that  the  endothelium  of  the  capillaries  is  to  some 
extent  self -regulative  or  neuro-muscular.  It  is  quite  possible  —  but 
''non-proven"  —  that  the  muscular  coats  of  the  smaller  arteries  are 
likewise  capable  of  self-regulation,  and  respond  directly  to  stimuli. 

This  view  —  that  the  vascular  phenomena  of  inflammation  can  occur 
independently  of  the  central  nervous  system  and  of  the  peripheral  nerves 
—  does  not  imply  that  the  nervous  system,  central  and  peripheral,  is 
without  its  influence  upon  the  process ;  far  from  it.  We  have  evidence, 
in  the  first  place,  that  the  state  of  the  vascular  walls  is  modified  after 
destruction  or  severance  of  the  nerves.  I  do  not  here  refer  only  to  the 
consequent  alterations  in  calibre  of  the  vessels,  but  also  to  the  changes 
in  other  properties.  Thus  Gergens,  and  to  a  less  extent  Riitimeyer, 
noticed  that  after  destruction  of  the  spinal  cord  the  blood-vessels  of  the 
frog  permit  a  larger  quantity  of  fluid,  and  even  particles  of  granular 
colouring  matter,  to  permeate  them. 

In  the  second  place,  we  have  evidence  that  the  central  nervous 
system  exercises  some  direct  influence  upon  the  inflammatory  process. 
From  Cohnheim  onwards  it  has  been  a  matter  of  common  observation 
that  when  all  the  nerves  of  a  part  have  been  severed,  the  stages  of  the 
process  succeed  each  other  Avith  greater  rapidity.  It  may  be  that  the 
modified  state  of  the  capillary  walls,  noted  in  the  preceding  paragraph, 
is  capable  of  accounting  for  this  fact,  and  that,  in  the  absence  of  central 
influences,  dilation  of  the  vessels  and  exudation  of  fluid  lead  to  the 
cardinal  symptoms  of  redness  and  swelling,  with  associated  changes  in 
the  tissue,  at  an  earlier  period. 

Of  the  part  played  by  the  different  sets  of  nerves  the  external  ear  of 
the  rabbit  again  furnishes  an  excellent  study.  This  part  has  a  double 
nerve-supply  through  the  auriculars  (major  and  minor)  passing  from 
the  cervical  plexus  and  the  sympathetic  branches  proceeding  from 
the  superior  cervical  ganglion :  stimulation  of  the  former  leads  to 
dilation  of  the  ear  vessels,  of  the  latter  to  contraction  of  the  same.  If, 
as  shown  by  Samuel,  the  sympathetics  be  divided  on  the  one  side, 
and  the  auricular  branches  upon  the  other,  the  ear  vessels  of  the 
former  side  become  widely  dilated,  and  those  of  the  latter  markedly 
constricted.  Under  these  conditions,  if  both  ears  be  subjected  to  the 
action  of  water  warmed  to  54°  C,  there  is  a  characteristic  difference  in 
their  reaction.      In  the  organ  deprived  of  sympathetic  influence  the 


INFLAMMA  TION 


congestion  and  hyperaemia  become  yet  more  pronounced:  an  acute 
inflammation  sets  in  which  proceeds  rapidly  to  recovery.  In  the 
opposite  ear,  with  its  constricted  vessels,  no  hyperaemia  is  set  up ; 
but  there  is  stasis,  and  gangrene  may  supervene.  These  results  have 
been  confirmed  by  Roger,  who,  taking  a  rabbit  and  dividing  the 
sympathetic  on  one  side  and  then  inoculating  both  ears  with  like 
quantities  of  a  culture  of  the  streptococcus  of  erysipelas,  found  that  the 
erysipelatous  process  manifested  itself  much  more  promptly  upon  the 
paralysed  side,  and  came  to  an  end  at  an  earlier  date.  The  reverse  was 
the  case  when  the  auriculars  of  the  one  side  ha.d  been  divided :  here  the 
process  was  of  slower  development  than  on  the  intact  side,  and  of  slower 
course,  resulting  in  mutilation  of  the  organ. ^ 

The  inference  to  be  drawn  from  these  observations  is  that  section  of 
all  the  nerves  passing  to  the  rabbit's  ear  permits  the  inflammatory  process 
to  run  a  more  rapid  course  ;  section  of  the  sympathetics  (vaso-constrictors) 
alone  has  the  same  effect ;  while  the  uncontrolled  action  of  the  sym- 
pathetics after  section  of  the  auriculars  (vaso-dilators)  hinders  or  prevents 
the  manifestation  of  the  ordinary  processes  of  inflammation,  and  by 
preventing  the  destruction  or  removal  of  irritant  matter  favours  necrosis 
of  the  tissues.  We  have  yet  to  learn  whether  these  results  are  capable 
of  a  general  application,  and  to  discover  how  far  they  are  borne 
out  by  clinical  observations  on  diverse  cases  of  localised  paralysis.  So 
far  as  they  go  they  afford  direct  evidence  of  the  power  of  the  central 
nervous  system  to  modify  the  course  of  the  inflammatory  process,  while 
they  demonstrate  admirably  how  potent  an  auxiliary  is  the  dilation  of 
the  vessels  in  the  inflammatory  process.  , 

Other  evidence  that  the  state  of  the  nerve-supply  of  a  region  influences 
the  manifestation  of  inflammation  is  afforded  in  sundry  neuropathies. 
In  all  of  these,  in  the  present  state  of  our  knowledge,  it  is  ditiicult  to 
trace  out  the  nervous  factors  associated  with  the  lesions  to  which 
I  refer.  Our  knowledge  of  the  respective  influences  of  trophic  and 
vaso-motor  nerves  is  far  too  limited  to  permit  us  to  say  more  than 
that  a  relation  exists  between  the  condition  of  the  nerve-supply 
of  the  affected  area  and  the  inflammatory  lesions  there  observable; 
that  in  a  certain  number  of  cases  inflammation  affecting  the  area  sup- 
plied by  one  branch  of  a  nerve  may  have  associated  with  it  definite 
inflammatory  disturbances  in  the  areas  supplied  by  other  branches  of 
the  same  nerve,  and  that,  similarly,  when  inflammation  affects  a  viscus, 
inflammatory  phenomena  may  be  sympathetically  developed  in  regions 
innervated  from  the  same  area  in  the  brain  or  spinal  cord.  I  have 
already  given  examples  in  support  of  the  first  statement :  the  familiar 
redness,  swelling,  heat  and  pain  of  the  side  of  the  face  which  may 
accompany  toothache  is  an  example  in  support  of  the  second,  while  the 
condition  of  labial  herpes  in  pneumonia  is  an  evidence  of  the  results  of 

1  Although  these  results  have  been  criticised  by  Samuel  and  other  observers,  upon  re- 
viewing carefully  the  whole  literature  of  the  subject,  I  cannot  but  think  that  the  above 
paragraxjh  represents  the  general  trend  of  more  recent  work. 


SYSTEM  OF  MEDICINE 


the  third.  Another  example  is  to  be  found  in  the  acute  nephritis,  which 
at  times  rapidly  follows  the  passage  of  a  catheter,  or  the  impaction  of  a 
stone  in  the  urethra.  It  is  not  unlikely  that  many  of  these  sympathetic 
inflammations  are  not  direct,  but  secondary.  Thus,  the  first  noticeable 
symptom  of  catheter  fever  is  suppression  of  the  urine.  Such  suppression 
might  be  brought  about  either  by  reflex  contraction  of  the  renal 
arteries,  or,  contrariwise,  by  reflex  great  dilatation  and  congestion  of  the 
vessels  of  the  kidneys.  If  it  be  caused  by  the  former  then  the  nephritis 
can  only  be  regarded  as  secondary,  and  as  due  to  the  injury  done  to  the 
organ  by  the  stoppage  of  its  blood-supply  for  some  little  time. 

From  the  multitude  of  the  factors  involved,  these  examples,  taken 
separately,  afford  at  most  only  a  great  probability  that  the  nervous 
system  can  directly  originate  inflammatory  changes.  There  is,  however, 
the  clearest  proof  that  the  nervous  system  does  possess  this  power,  and 
this  is  afforded  by  the  results  of  certain  observations  upon  hypnotic 
effects.  There  are  persons  susceptible  to  hypnotic  suggestion,  in 
whom  the  suggestion  that  a  red-hot  substance  has  been  placed  upon  the 
hand  will,  in  the  course  of  a  few  minutes,  lead  to  great  reddening  of  the 
part  supposed  to  have  been  burned,  and  this  reddening  may  be  followed 
by  great  local  exudation  and  swelling  —  in  fact,  by  all  the  symptoms 
of  acute  inflammation.  Here  then  actual  inflammatory  reaction  follows 
supposed  injury. 

It  is  unnecessary  to  do  more  than  point  out  the  light  that  this 
intervention  of  the  central  nervous  system  throws  upon  the  subject  of 
counter-irritation,  and  upon  the  modifications  of  the  course  of  inflamma- 
tions brought  about  by  idiosyneracy  of  the  individual. 

From  Avhat  has  been  said  in  the  preceding  paragraphs,  it  follows 
that :  — 

1.  Acute  inflammation  in  all  its  stages  may  proceed  regularly  in  the 
absence  of  all  centrifugal  nervous  influences. 

2.  The  vessels  of  an  injured  area  are  capable  of  reacting  apart  from 
central  influences ;  it  may  be  either  directly,  or  under  the  control  of  a 
peripheral  system  of  nerve  cells. 

3.  The  central  nervous  system  is  capable  of  modifying  the  process 
of  inflammation.  It  would  appear  that  when  the  vaso-dilators  alone  are 
called  into  action  the  successive  stages  of  the  process  are  accelerated. 
When  the  vaso-constrictors  alone  are  acting  the  process  is  retarded. 

4.  Centrifugal  impulses  alone,  apart  from  any  local  injury,  may 
originate  a  succession  of  phenomena  of  inflammation  in  a  part. 

5.  Hence,  in  all  probability  a  nervous  and  central  origin  must  be 
ascribed  to  some,  at  least,  of  the  sympathetic  inflammations  seen  to  occur 
in  areas  supplied  by  the  other  branches  of  a  nerve  supplying  a  part 
primarily  inflamed ;  and  again  in  areas  supplied  from  the  same  region  of 
the  brain  or  cord  as  the  inflamed  organ. 


INFLAMMA  TION  1 1 3 


Chapter  6.  —  On  the  Pakt  played  by  the  Cells  of  the  Tissues 

As  a  consequence  of  irritation  two  opposed  processes  may  be  mani- 
fested in  the  cells  of  the  affected  area,  —  changes  leading  to  impairment 
and  death,  and  changes  leading  to  overgrowth  and  proliferation ;  de- 
generation and  regeneration. 

Either  of  these  two  processes  may,  it  is  true,  be  wholly  wanting. 
In  very  acute  suppurative  disturbances,  destruction  of  the  tissue  cells 
and  the  steps  leading  to  destruction  may  be  the  only  recognisable 
changes.  Again,  in  the  first  stage  of  most  injuries,  whether  of  me- 
chanical, chemical  or  bacterial  nature,  degenerative  changes  are  wont 
to  take  the  lead.  On  the  other  hand,  there  are  irritants  so  mild  that 
little  or  no  cell  destruction  results  from  their  action ;  an  extreme 
example  of  this  category  of  inflammations  is  seen  in  those  epithelial 
overgrowths  commonly  known  as  "corns,"  due,  as  Sir  James  Paget 
pointed  out  in  his  lectures,  to  intermittent  pressure  and  irritation  of 
moderate  intensity.^  Other  examples  are  to  be  found  in  the  "  catarrhal  " 
inflammations,  in  which  there  is  marked  initial  overgrowth  and  prolif- 
eration of  the  cells  of  mucous  membrane ;  and  in  tuberculosis,  again,  in 
which  characteristically  the  earliest  effects  upon  the  pre-existing  cells, 
produced  by  the  presence  and  growth  of  the  tubercle  bacilli,  are  those 
of  enlargement  and  multiplication  —  necrotic  changes,  as  a  rule,  only 
appearing  at  a  much  later  stage.  Once  more,  in  the  later  healing  stages 
of  injuries,  cell  proliferation  may  be  in  the  field  alone.  Nevertheless, 
in  a  very  great  number,  if  not  in  the  majority  of  inflammations,  the 
two  processes  may  be  found  occurring  together  —  destruction  and 
degeneration  being  in  evidence  at  the  focus  of  irritation,  and  growth 
and  proliferation  tow^ards  the  boundary  zone,  where  the  irritant  is 
acting  in  a  less  concentrated  form. 

Although  the  two  processes  are  thus  so  frequently  associated,  it  will  be 
well,  for  the  orderly  review  of  our  subject,  to  consider  them  separately. 

Degeneration  of  the  Tissue  Cells. — Death  of  the  pre-existing  cells 
as  an  immediate  consequence  of  injury  cannot  be  regarded  as  one  of  the 
phenomena  of  the  inflammatory  process.  Immediate  death  of  the  cells 
may  be  a  result  of  injury,  and  the  disintegration  of  the  dead  cells  may 
in  itself  lead  the  way  to  all  the  symptoms  of  inflammation.    But  cessation 

lit  may  very  well  be  that  this  is  not  an  extreme  example.  Neoplasms  as  a  class, 
whether  malignant  or  benign,  not  improbably  develop  as  a  consequence  of  some  irritation 
liaving  an  intensity  just  sufficient  to  induce  cell  proliferation,  and  continued  for  a  time 
sufficiently  lo)ig  to  impress  upon  the  cells  of  the  affected  tissues  the  habit  of  rapid  multipli- 
cation. There  is  evidence  both  in  animal  and  vegetable  pathology  favouring  this  rela- 
tionship between  inflammation  and  neoplastic  growth. 

The  objection  may  be  raised,  with  considerable  force,  that  substances  which  lead  to 
cell-proliferation  are  stimuli  and  not  irritants,  and  that  a  line  should  be  dtawn  between 
inflammation  proper  and  overgrowth  the  result  of  irritation.  I,  for  one,  would  willingly 
make  this  difference,  but  while  it  is  easy  to  draw  the  line  in  certain  well-marked  ex- 
amples, in  others,  as  I  shall  proceed  to  show,  cellular  proliferation  is  so  essential  a  part 
of  the  whole  inflammatory  process  that  the  division  becomes  impossible. 

VOL.    1  I 


ii4  SYSTEM   OF  MEDICINE 

of  action  is  not  reaction,  nor  is  failure  response,  and  thronghout  this 
article  inflammation  lias  been  considered  as  the  reaction  following 
injury,  and  the  response  to  it.  Thus  immediate  death  of  tissue  cells  is 
resultant  and  not  reactive,  and  may  be  eliminated  from  the  category  of 
the  essential  phenomena  of  inflammation. 

The  same  is  to  some  extent  true  of  cell  degeneration,  but  not 
entirely.  While  it  is  impossible  nowadays  to  *accept  Virchow's  old 
view,  that  inflammation  is  essentially  a  process  characterised  by 
increased  nutritive  changes  in  the  cells  of  the  tissues,  it  remains  most 
probable  that  in  very  many  cases  irritation  induces  increased,  even  if 
perverted,  activity  of  certain  orders  of  cells.  The  proliferation,  swelling, 
and  more  or  less  rapid  degeneration  of  these  cells  cannot  be  wholly 
ascribed  to  the  toxic  influence  of  the  irritant,  but  must  in  part  be 
regarded  as  a  result  of  over-stimulation  and  overwork.  This  is  most 
noticeable  in  connection  with  catarrhal  and  parenchymatous  inflam- 
mations. In  parenchymatous  nephritis,  for  example,  such  as  that  set 
up  by  cantharidin  or  septic  infection,  the  cells  especially  affected 
are  those  whose  functions  are  especially  excretory  ;  and  their  degenera- 
tion would  appear  to  be  intimately  related  to  the  performance  of  their 
functions.  Such  degeneration,  preceded  or  accompanied,  as  it  so  fre- 
quently is,  by  excessive  proliferation,  may  truly  be  regarded  as  reactive, 
and  not  as  wholly  and  primarily  destructive. 

Of  the  degenerations  which  affect  the  tissue  cells  in  inflammation 
(and  often  at  the  same  time  the  leucocytes)  there  are  many  varieties ; 
in  fact,  according  to  the  na,ture  of  the  irritant,  one,  or  other,  or  all  the 
degenerations  affecting  the  tissues  in  different  pathological  conditions 
may  manifest  themselves,  save,  perhaps,  simple  atrophy  and  pigmental 
degeneration  (as  apart  from  pigmental  infiltration).  Most  commonly 
recognised  are  cloudy  and  fatty  changes,  but  mucoid  and  hydropic 
changes  are  far  more  frequent  than  is  generally  noted.  Even  so  special- 
ised a  change  as  amyloid  degeneration  has  been  observed  occurring 
locally  in  chronic  inflammations  —  as,  for  example,  in  gummata ;  while 
in  these  same  chronic  lesions  hyaline  degeneration  in  the  vessel  walls 
is  very  often  to  be  encountered. 

There  is  also  to  be  seen  in  inflammatory  disturbances  of  moderately 
acute  type  a  further  form  of  degeneration,  which  receives  a  passing 
mention  in  the  text-books,  it  is  true,  but  so  far  has  not  to  my  knowledge 
been  duly  treated  as  an  entity ;  nor  has  its  significance  been  fully  grasped. 
This  is  what  may  be  termed  *'  reversionary  "  degeneration.  It  is  to  be 
seen  affecting  tissues,  in  which  the  individual  components  in  the  fully- 
formed  state  are  not  single  cells,  but  cell  complexes  or  compounds.  Such 
compounds  are  the  voluntary  muscle  and  medullated  nerve  fibres, 
and,  as  Grawitz  has  pointed  out,  the  fat  cells  of  connective  tissue.^ 
These  are  formed  by  the  fusion  and  united  growth  of  several  cells ; 

1 1  here,  and  throughout  this  article,  leave  wholly  out  of  account  Grawitz's  "  slum- 
hering  cell  "  theory  —  a  theory  incapable  of  actual  proof,  and  at  variance  with  the  cell 
theory  upon  which  is  based  the  entire  superstructure  of  modern  biology. 


INFLAMMA  TION 


"5 


and  in  inflammation,  as  under  other  pathological  conditions,  the  de- 
generation of  the  cell-compound  as  a  whole  manifests  itself  by  a  certain 
amount  of  proliferation  of  the  nuclei  (of  the  muscle  fibre,  sheaths  of 
Schwann,  and  periphery  of  the  fat  cells  respectively),  protoplasm  can  be 
observed  to  accumulate  around  these  active  nuclei,  and  with  the  assump- 
tion by  the  component  cells  of  an  independent  existence  the  degeneration 
may  be  said  to  be  complete  —  that  is  to  say,  beyond  this  point  only  the 
shell  and  debris  of  the  original  compound  are  left  to  be  considered. 

All  these  degenerations  are  inevitably  associated  with  disturbance 
of  the  functions  of  the  affected  cells,  and  lead  to  their  death  if  the 
irritation  which  has  induced  them  be  continued.  But  death  is  not  the 
final  stage  to  be  considered.  The  ultimate  fate  of  the  necrosed  cells 
varies  according  to  the  situation  of  the  inflamed  area,  the  intensity  of 
the  irritation,  and  the  specific  character  of  the  irritant.  From  a  free 
surface  the  dead  material  may  be  freely  cast  off.  In  acute  suppurative 
inflammations,  whether  superficial  or  deep,  and,  in  general,  wherever 
there  is  an  abundant  determination  of  leucocytes,  there  obtains  a  diges- 
tion and  solution  of  the  necrosed  cells ;  and,  as  I  have  already  pointed 
out,  this  is  associated  with  the  development  of  peptones  and  albumoses, 
and  is  brought  about  largely  through  the  extracellular  action  of  the 
leucocytes.  When  there  is  a  large  area  of  cell  destruction,  with  well- 
developed  encystment  and  limitation  of  necrosis  by  granulation  tissue, 
there  the  solution  of  the  dead  material  and  subsequent  absorption  may 
be  incomplete,  and  a  fatty  debris  left  behind,  which  may  eventually 
become  infiltrated  with  lime  salts  (the  calcareous  degeneration  falsely 
so-called).  In  tuberculosis,  despite  the  presence  of  many  leucocytes  in 
the  immediate  vicinity,  the  dead  material  of  the  centre  of  the  tubercle 
undergoes  very  little  absorption,  but  remains  as  an  inspissated,  cheesy 
mass.  In  syphilis,  on  the  other  hand,  in  large  gummata,  while  there 
is  similar  death  of  the  central  cells  and  absence  of  removal,  fatty 
metamorphosis  does  not  occur  nearly  to  the  same  extent. 

Lastly,  although  very  little  is  known  about  the  subject,  attention 
must  be  drawn  to  the  fact  that  along  with  the  tissue  cells  the  inter- 
cellular matrix  undergoes  modifications  or  degenerative  changes  dur- 
ing inflammation.  Among  these,  in  all  probability,  is  to  be  classed  an 
increase  in  the  amount  of  intercellular  mucin,  a  mucoid  degeneration. 
The  inflammatory  exudate  is  in  many  cases  rich  in  mucin,  and  although 
our  knowledge  of  the  changes  in  the  matrix  is  scanty,  the  fact  that  the 
tissue  cells  in  general  show  little  evidence  of  storage  of  mucoid  or 
mucinogenous  material,  renders  it  probable  that  what  mucin  is  formed 
is  either  excreted  or  elaborated  between  the  cells.  Connective  tissue 
fibrils,  which  may  be  regarded  as  part  of  the  matrix,  undergo  dissocia- 
tion and  swelling,  and  eventually,  in  acute  inflammation,  disappear. 
In  chronic  disturbances  they  are  especially  prone  to  hyaline  change. 

Regeneration  of  the  Tissue  Cells;  Overgrowth  and  Proliferation.  —  In 
the  lower  animals,  as  we  know,  injury  and  actual  removal  even  of  a  large 
portion  of  the  body  may  be  followed  by  the  complete  reproduction  of 


ii6  SYSTEM   OF  MEDICINE 

the  lost  part.  In  man,  however,  this  reproduction  of  lost  tissue  is 
reduced  to  its  lowest  point ;  the  higher  the  tissue  the  less,  and  the 
less  perfect,  the  reproduction.  Speaking  generally,  the  tissues  which 
show  the  greatest  potentiality  for  reproduction  are  the  least  highly 
organised  —  those  composed  of  similar  units.  The  " connective  tissue" 
—  the  lowest  and  most  widely  distributed  —  retains  the  largest  powers 
of  proliferation  and  hyperplasia. 

In  ordinary  inflammation  hypertrophy  and  hyperplasia  of  the  con- 
nective tissue  cells  are  absent  at  the  focus  of  irritation.  Here  degen- 
eration is  predominant.  It  is  in  the  peripheral  zone,  away  from  the 
maximum  concentration  of  the  irritant,  that  (as  shown  in  case  after  case 
of  Leber's  long  series  of  studies  upon  injury  to  the  cornea),  the  con- 
nective tissue  cells  show  signs  of  enlargement  and  proliferation,  that 
they  become  more  swollen  and  prominent,  send  out  large  processes,  and 
may  exhibit  signs  of  active  mitosis.  It  may  be  urged  that  this  peri- 
pheral change  is  not  inflammatory,  but  associated ;  yet,  as  I  have  already 
hinted,  the  signs  of  cellular  regeneration  may  manifest  themselves  at  so 
early  a  stage  that  it  is  impossible  to  disconnect  them  from  the  process 
of  inflammation.  This  fact  has  been  brought  out  with  emphasis  in 
Ranvier's  interesting  series  of  studies  on  irritation  of  the  peritoneum  by 
weak  solutions  of  caustic  substances.  If  a  few  drops  of  a  0-3  per  cent 
solution  of  silver  nitrate  be  injected  into  the  abdominal  cavity  of  a  rab- 
bit or  guinea-pig  an  inflammation  is  set  up  which  lasts  for  some  days. 
At  the  end  of  twenty-four  hours  the  portions  of  the  serous  coat  of  the 
abdominal  contents  which  have  been  most  affected  are  found  denuded  of 
their  endothelium  —  the  cells  have  died  and  disappeared;  but  in  other 
regions,  less  strongly  affected,  the  endothelial  cells  present  the  reverse 
condition  of  overgrowth :  their  nuclei  are  swollen ;  the  protoplasm, 
instead  of  forming  a  flattened  plate,  is  swollen,  and  presents  stellate  pro- 
longations anastomosing  with  those  of  neighbouring  cells.  The  under- 
lying vessels  at  this  period  show  abundant  evidence  of  inflammation ; 
they  are  congested,  and  leucocytes  are  being  poured  out  into  the  mesen- 
teric network.  Within  forty-eight  hours  there  follows  upon  the  inflam- 
matory exudation  a  rich  development  of  fine  filaments  of  fibrin,  and  along 
sundry  of  these  filaments  the  enlarged  endothelial  cells  send  processes. 
Some  of  the  cells  become  enormous,  100  yu,  or  more  in  diameter.  In  this 
extension  of  the  cells  along  the  fibrinous  framework  we  have  probably 
the  commencing  formation  of  organised  adhesions.  The  endothelial  cells 
at  this  stage  have  become  so  modified  from  their  previous  quiescent  flat- 
tened state  that  even  outside  the  body  they  exhibit  amoeboid  movements. 

Up  to  this  time  no  signs  of  nuclear  division  manifest  themselves. 
According  to  Toupet,  working  under  Cornil,  it  is  not  until  the  fourth  day 
that  mitosis  is  recognisable  in  this  form  of  inflammation.  But  while 
inflammatory  congestion,  exudation  of  fluid,  and  diapedesis  of  leucocytes 
is  proceeding  actively,  the  modified  endothelial  cells  of  the  regions  that 
have  not  undergone  the  severest  injury  are  with  equal  activity  engaged 
m  what  it  is  difficult  to  regard  as  other  than  a  reparatory  process. 


INFLAMMA  TION  1 1 7 


As  Baumgarten  showed  in  his  studies  upon  the  development  of 
tubercles,  in  the  irritation  set  up  by  the  growth  of  the  B.  tuberculosis  in 
the  tissue,  a  like  overgrowth  with  proliferation  of  the  fixed  cells  occurs 
in  the  immediate  neighbourhood  of  the  bacilli  without  any  primary  evi- 
dence of  cell  degeneration.  It  is  true  that  of  late  the  researches  of  Borel 
have  thrown  doubt  upon  Baumgarten's  observations,  but  they  confirm 
the  earlier  researches  so  far  as  regards  the  mitosis  of  pre-existing  cells, 
and  the  absence  of  degeneration  of  these  in  the  earlier  stages  of  the 
tubercular  growth.  Borel  would  regard  all  the  large  epithelioid  cells 
of  the  tubercle  as  modified  leucocytes.  For  myself  I  cannot  admit  that 
he  has  proved  this,  careful  as  his  researches  seem  to  be ;  and  until  the 
leucocytic  nature  of  these  cells  be  firmly  established  I  am  inclined, 
with  the  majority  of  histologists,  to  regard  many  of  them  as  similar  in 
nature  and  origin  to  the  modified  cells  just  described  in  connection  with 
simple  inflammation. 

The  difiiculty  of  determining  the  origin  of  the  growing  cells  in 
inflammation  has  formed  the  greatest  trial  of  the  pathologist  throughout 
an  entire  generation,  and  yet  longer ;  nor  can  we  now  assert  without 
chance  of  dispute  what  cells  are  mainly  concerned  in  the  formation  of 
new  tissue. 

When  we  examine  newly-formed  granulation  tissue  we  can  distin- 
guish cells  of  more  than  one  type  —  (1)  small  round  cells  with  polylobu- 
lar  and  fragmented  nuclei,  (2)  other  cells  containing  oxyphil  granules,  (3) 
larger  cells  with  a  single  nucleus  and  a  relatively  large  quantity  of  proto- 
plasm, and  again  (4)  cells  of  varying  but  generally  large  size,  varying  in 
shape,  but  on  the  whole  having  the  appearance  of  spindle  cells  with  single 
oval  nucleus  and  abundant  protoplasm.     These  can  be  made  out  easily. 

The  first  two  forms  of  cells  are  clearly  leucocytes.  Further  study  of 
their  fate  shows  that  they  disappear ;  they  play  no  further  part  in  the 
organisation  of  the  tissue  save  that,  as  is  well  shown  by  Schelteraa  and 
Nikiforoff,  many  of  them  are  absorbed  by  the  growing  connective  tissue 
cells,  and  thus  would  seem  to  aid  in  their  nutrition.  The  last  form 
likewise  presents,  as  such,  no  difficulties.  These  are  fibroblasts  —  cells 
in  the  process  of  growth  into  connective  tissue.  But  what  is  their  rela- 
tionship to  the  previous  form,  —  to  the  round  mononucleated  cells  with 
fairly  abundant  protoplasm,  —  what  are  these  last,  and  what  in  short 
is  the  origin  of  the  fibroblasts,  —  is  it  from  leucocytes  or  from  pre- 
existing connective  tissue  cells  ?  Upon  this  most  difficult  question 
more  ingenuity  and  more  research  have  been  expended  than  upon  any 
other  part  of  this  well-worked  field  of  inflammation. 

There  can  be  no  doubt  nowadays  that  a  large  proportion  of  the  fibro- 
blasts in  granulation  tissue  are  developed  from  pre-existing  connective 
tissue  cells.  The  general  consensus  of  recent  researches  leads  de- 
cidedly in  this  direction ;  and  it  is  from  the  laboratory  of  Ziegler,  who 
by  his  classical  observations  led  pathologists  for  some  years  to  hold  the 
contrary  view,  that  the  studies  have  emanated  which  most  conclusively 
show  the  part  played  by  .the  connective  tissue ;  the  researches  of  Krafft, 


Ii8  SYSTEM   OF  MEDICINE 

Podwyssozki,  Coen,  Fischer,  and  Nikiforoff,  confirmed  and  strengthened 
by  the  researches  of  Arnold,  Marchand,  Keinke,  and  Sherrington,  all 
bring  forward  evidence  in  one  direction.  It  is  the  clearly  recognisable 
pre-existing  cells  of  the  tissue  —  connective,  endothelial*  and  epithelial 
—  which  show  most  constantly  the  signs  of  nuclear  division :  every 
stage  of  enlargement,  mitosis  and  cell  division,  can  be  made  out  in 
them.  Even  if  we  did  not  possess  the  information  afforded  by  nuclear 
changes,  the  fact  that  new  tissue  is  always  developed  in  the  immediate 
neighbourhood  of  pre-existing  tissue  would  in  itself  point  strongly  to 
this  same  conclusion. 

We  may  rest  assured  of  this  much.  But  can  we  advance  farther, 
and  state  that  all  newly-formed  connective  tissue  cells  originate  from 
the  pre-existing  cells  of  the  tissue,  and  that  none  of  them  are  derived 
from  wandering  cells  ?  In  the  present  state  of  our  knowledge  the 
answer  to  this  question  must  be  an  unhesitating  "  No."  If  we  base 
our  observations  upon  the  morphology  of  the  cells  in  granulation  tissue, 
Ave  find  that  with  our  present  methods  the  large,  round,  mononuclear 
cells  seen  therein  are  undistinguishable  on  the  one  hand  from  large 
hyaline  leucocytes,  on  the  other  from  one  stage  in  the  development  of 
fibroblasts.  If  we  examine  into  their  properties  we  find  that  they  act 
as  phagocytes  incorporating  the  multinuclear  leucocytes.  The  fibro- 
blasts, according  to  Nikiforoff's  careful  studies,  have  an  identical  action ; 
so  also,  according  to  Metschnikoff,  Kuffer,  Borel,  and  others,  have  the 
large  mononuclear  hyaline  leucocytes.  If  we  study  their  mode  of  divi- 
sion they,  like  the  connective  tissue  cells,  exhibit  indirect  or  nuclear 
division.  It  may  be  (as  has  been  more  than  once  suggested)  that  the 
large  mononuclear  hyaline  leucocytes  differ  from  the  other  forms  in 
being  of  endothelial  origin.  Were  this  so  a  path  would  be  found  out  of 
our  present  difficulty.  Certainly  the  most  that  can  now  be  said  is  that  it 
is  quite  possible  that  among  the  higher  animals  this  one  form  of  wan- 
dering cell  may  be  contributory  to  new  fibrous  tissue  formation,  quite 
possible  that  the  connective  tissue  cells  which  develop  as  a  result  of  in- 
flammation are  not  all  derived  from  the  pre-existing  cells  of  the  region.^ 

It  must  be  borne  in  mind  that  leucocytes,  endothelial,  and  connective 
tissue  cells  are  very  simple  forms  of  tissue,  that  they  are  all  of  like 
mesoblastic  origin,  and  thus  being  homogeneous,  may  be  more  variously 
modified,  without  impairment  of  activity,  than  more  highly  specialised 
cells.  I  must  here  add  that  in  lower  forms  —  in  the  tadpole's  tail, 
for  example  —  Metschnikoff  has  followed  day  by  day  the  transition  from 
leucocyte  into  typical  connective  tissue  cell,  and  that,  largely  in  conse- 
quence of  these  observations,  French  pathologists  hold  the  view  that  the 
leucocytes  enter  far  more  actively  into  new  tissue  formation  than  I  here 
recognise.     The  German  school,  with  the  exception  of  Arnold  (whose 

1  In  this  connection  may  be  mentioned  the  ohservations  of  Metschnikoff,  confirmed 
by  Barfurth,  and  more  recently  by  Dr.  Joseph  Griffiths,  which  show  that  in  the  deg^ener- 
ation  and  disintegration  of  muscle  fibres  (of  the  tadpole's  tail)  the  proliferated  nuclei  of 
the  fibres  become  the  nuclei  of  individual  wandering  cells*— leucocytes. 


IN  FLA  MM  A  TION  1 1 9 


views  correspond  on  the  whole  with  my  own),  has  with  Ziegler  passed 
over  to  the  opposite  camp  of  connective  tissue  only  from  connective 
tissue.  For  myself  I  have  carefully  sifted  the  evidence  adduced  by 
either  side.  What  is  said  above  gives,  I  believe,  the  estimate  of  the 
matter  for  the  time  being ;  while  what  follows  gives  in  brief  the  state 
of  our  knowledge  of  the  part  played  in  iniiammation  by  the  tissue  cells 
in  general. 

(1)  Two  series  of  changes  may  occur  in  the  cells  of  an  inflamed  tissue, 
which  may  be  included  under  the  terms  degeneration  and  regeneration 
respectively. 

(2)  The  extent  to  which  one  or  other  of  these  series  of  changes  pre- 
dominates varies  with  the  nature  and  intensity  of  the  irritant. 

(3)  Degeneration  and  death  of  the  tissue  cells  may  be  a  direct  and 
immediate  result  of  the  presence  of  the  irritant,  and  then  can  scarcely 
be  regarded  as  essential  phenomena  of  inflammation.  Or  they  may  be 
of  more  gradual  onset,  associated  with  evidence  of  over-stimulation  and 
increased  activity  of  the  cells. 

(4)  Fatty,  cloudy,  hydropic  and  mucoid  are  the  most  frequent  forms 
of  degeneration  affecting  the  tissue  cells  in  acute  inflammation  ;  hyaline 
in  chronic  ;  other  forms  are  rare. 

(5)  The  ultimate  fate  of  the  necrosed  cells  varies  as  the  situation, 
intensity  of  irritant,  and  specific  character  of  irritant. 

(6)  Cell-proliferation  is  so  constant  an  accompaniment  of  certain 
forms  of  inflammation  that  it  is  impossible  to  regard  this  as  an  adjunct 
and  not  as  an  essential  part  of  the  process. 

(7)  The  tissues  which  show  the  greatest  potentiality  for  reproduc- 
tion in  consequence  of  inflammation  are  those  which  are  least  highly 
organised. 

(8)  The  origin  of  fibroblasts  and  new  connective  tissue  cells  cannot 
be  regarded  as  entirely  determined,  but  this  much  would  seem  to  be 
clearly  demonstrated :  (a)  That  a  large  proportion  of  the  fibroblasts  are 
derived  from  pre-existing  connective  tissue  cells.  (yS)  That  in  lower 
forms  —  as,  for  example,  the  tadpole  —  leucocytes  can  be  seen  to  develop 
into  connective  tissue  cells,  (y)  It  is  quite  possible,  indeed  probable, 
that  in  the  higher  animals  one  form  of  wandering  cell,  the  large  hyaline 
mononuclear,  contributes  to  the  formation  of  new  fibrous  tissue. 

Chapter  7.  —  On  Fibrous   Hyperplasia  and  its  Relationship   to 

Inflammation 

The  succession  of  changes  from  embryonic  cells  to  fully-formed  tis- 
STie  can  best  be  studied  in  cases  where  there  has  been  a  relatively  large 
area  of  destruction  —  as,  for  example,  after  severe  burns,  or  excision  of 
organs  or  large  portions  of  organs ;  or  again,  where  inflammation  has 
been  of  a  chronic  character. 

If  healthy  granulation  tissue  be  examined,  the  process  of  growth  is 
seen  to  orit^inate  in  the  immediate  neighbourhood  of  if  not  in  direct 


SYSTEM  OF  MEDICINE 


connection  with  the  dilated  new  capillaries.  It  is  around  these  vessels, 
formed  of  little  more  than  a  single  layer  of  cells,  that  the  fusiform  fibro- 
blasts are  in  greatest  abundance.  At  a  later  stage,  in  regions  more  remote 
from  the  advancing  margin  of  the  granulations,  the  fibroblasts  have  a  more 
general  distribution  in  the  intercapillary  spaces,  and  are  more  elongated ; 
around  them  may  be  seen  the  earliest  wavy  fibres  of  white  connective 
tissue.  These  are  essentially  of  cellular  origin  —  as  much  so  as  is  the 
substance  of  striated  muscle  fibres.  The  elongated  fibroblasts  not  only 
break  or  extend  at  their  poles  into  fine  processes,  but  also  along  their 
sides  the  protoplasm  undergoes  modification  into  fine  parallel  fibrillae. 
With  the  continuance  of  this  change  the  cells  become  smaller  and 
smaller  until  little  is  left  but  the  attenuated  nuclei,  often  so  flattened 
and  narrow  as  to  be  scarcely  recognisable.  It  is  generally  accepted 
that  the  fibrillar  substance  contracts  with  increasing  age ;  certainly  the 
newly-forined  cicatricial  tissue  diminishes  greatly  in  volume,  and  with 
this  diminution  the  previous  great  vascularity  of  the  part  disappears ;  the 
capillaries  shrink  until  the  majority  become  completely  occluded.  Thus 
in  place  of  the  abundant,  soft  and  succulent  granulation  tissue,  rich  in 
cells,  blood-vessels  and  exuded  fluid,  there  is  eventually  a  firm,  shrunken, 
anaemic  mass  of  fibrous  tissue,  with  rare  flattened  nuclei,  rich  only  in 
closely-pressed  bundles  of  white,  semi-transparent  fibrils. 

Fibrous  hyperplasia  is  to  be  encountered  in  almost  every  tissue  of 
the  body  as  a  sequence  of  very  diverse  morbid  conditions.  To  speak  of 
it  in  any  case  as  "  fibroid  degeneration  "  is  a  misnomer.  The  overgrowth 
of  any  tissue,  however  lowly,  is  not  a  degeneration.  Fibrous  tissue  may 
and  often  does  become  the  seat  of  degenerative  processes,  notably  the 
hyaline;  but  that  is  another  matter.  To  regard  every  condition  of 
generalised  or  localised  fibroid  change  of  the  organs  of  the  body  as  a 
chronic  " — itis"  is  equally  erroneous,  until  we  have  proof  absolute  that 
connective  tissue  only  undergoes  excessive  growth  directly  or  indirectly 
under  the  stimulus  of  injury.  It  is  interesting  to  note  the  opposed 
tendencies  of  the  two  branches  of  our  profession  on  this  subject; 
the  surgeons  strive  to  restrict  the  idea  of  inflammation  to  acute  pyogenic 
disturbance,  the  physicians  to  extend  the  idea  so  as  to  include  all 
cases  of  chronic  progressive  "  fibrosis."  I  will  not  say  that  the  latter 
is  as  untenable  a  position  as  the  former,  for  it  is  a  matter  of  peculiar 
difficulty  and  delicacy  to  state  what  is  and  what  is  not  an  inflamma- 
tory fibrosis ;  after  all,  there  is  more  danger  of  being  tossed  about 
helplessly  in  the  Charybdis  of  including  too  little,  than  there  is  of 
striking  upon  the  Scylla  of  including  too  much  in  our  idea  of  inflam- 
mation. 

Here  I  wish  to  point  out  how  divergent  are  the  conditions  which 
lead  to  fibroid  hyperplasia,  and  to  draw  attention  to  the  fact  that  there 
is  reasonable  ground  for  not  classing  all  forms  under  the  one  common 
heading,  even  though  the  resulting  appearances  may  be  undistinguish- 
able  and  the  effects  the  same. 

Cicatricial  fibrosis  presents  little  difficulty ;  it  is  plainly  the  result  of 


INFLAMMA  TION 


inflammation ;  so  too  is  the  fibrous  overgrowth  upon  chronically  inflamed 
serous  surfaces.  Capsular  fibrosis  is  clearly  of  the  same  nature ;  it  is 
to  be  seen  around  foreign  bodies,  around  chronic  abscesses,  in  the 
walls  of  tubercular  cavities,  and  encapsulating  tubercles,  gummata,  and 
other  neoplasms  inflammatory  and  non-inflammatory.  Allied  to  these 
is  the  fibroid  replacement  in  old  infarcts  (including  that  following 
upon"  myomalacia  "  cordis).  Here,  stiidying  a  series  of  cases,  it  can  be 
made  out  that  the  necrosed  material  becomes  surrounded  by  a  zone 
of  inflammation,  and  that,  with  the  passage  of  leucocytes  into  the 
dead  area  and  absorption  of  the  effete  material,  there  is  soon  manifest 
a  new  connective  tissue  overgrowth  advancing  inwards  from  the  peri- 
phery. 

Among  the  generalised  scleroses  there  is  one  form  frequently  encoun- 
tered which  may,  without  hesitation,  be  regarded  as  the  accompaniment 
of  inflammation.  This  is  seen  well  in  the  general  interstitial  nephritis 
accompanying  subacute  and  chronic  parenchymatous  inflammation  of  the 
kidney.  Of  similar  nature  are  some  forms  at  least  of  hepatic  cirrhosis, 
difl'ase  syphilitic  cirrhosis,  the  diffuse  tubercular  cirrhosis  to  which  at- 
tention has  more  especially  been  drawn  by  French  pathologists,  and  an 
extensive  pericellular  cirrhosis  in  cattle,  which  I  have  of  late  been 
engaged  in  studying,  due,  it  would  seem,  to  the  abundant  multiplication 
of  a  diplobacillus  in  the  bile  capillaries  and  liver  substance.  Whatever 
be  the  immediate  cause  of  other  forms  of  cirrhosis,  overgrowths  of  fibrous 
tissue  would  appear  in  these  to  precede  atrophy  of  the  liver  cells,  and 
to  be  associated  with  the  presence  of  an  irritant. 

But  there  are  other  varieties  of  fibroid  growth  concerning  which  it 
is  less  easy  to  arrive  at  a  j  List  conclusion.  First  may  be  mentioned  the 
replacement  or  compensatory  fibroses.  An  excellent  example  of  this  is 
to  be  seen  in  the  sclerosis  of  well-defined  tracts  of  the  spinal  cord  follow- 
.  ing  destruction  of  the  ganglion  cells  governing  those  tracts,  or  sections 
of  the  fibres,  at  a  point  proximal  to  their  trophic  cells. 

The  fibrosis  in  these  cases  is  not  secondary  to  a  progressive  inflam- 
mation, but  to  a  simple  atrophy  of  the  nerve  fibres.  These  shrink,  and 
their  place  is  taken  by  fibrous  tissue.  Another  equally  instructive 
example  is  to  be  found  in  the  dystrophic  sclerosis  of  the  cardiac 
muscle  fibres  to  which  attention  has  been  called,  more  especially  by 
Drs.  Martin  and  Huchard.  This  occurs  in  certain  cases  of  arterio- 
sclerosis, and  is  best  seen  in  the  papillary  muscles,  the  fibroid  change 
occurring,  not  around  the  thickened  arterioles,  but  at  the  periphery  of 
the  area  supplied  by  each.  The  muscle  fibres  around  the  arterioles  are 
healthy ;  but  farther  away,  through  lack  of  nutrition,  they  have  atro- 
phied, and  their  place  is  taken  by  a  zone  of  fibrous  tissue  which  fre- 
quently manifests  hyaline  degeneration.  In  this  instance  the  morbid 
condition  of  the  arteries  is  in  itself  a  hindrance  to  active  dilatation  of 
the  vessels,  and  the  exhibition  of  the  ordinary  accompaniments  of  in- 
flammation. Indeed  this  peripheral  zone  is  singularly  free  from  leu- 
cocytes, yet  well-marked  sclerosis  appears  nevertheless. 


SYSTEM  OF  MEDICINE 


Can  these  be  regarded,  as  cases  of  inflammatory  fibrous  hyperplasia  ? 
According  to  our  definition  they  may  :  the  fibrosis  ensues  as  a  reaction  to 
injury.  It  is  legitimate  to  conceive  that  the  dying  and  atrophic  tissue 
elements  here,  as  in  the  grosser  condition  of  infarct,  act  as  irritants. 
But,  on  the  other  hand,  the  only  recognisable  evidence  of  inflamma- 
tion is  this  very  extension  of  cicatricial  tissue ;  and  even  this  is  strictly 
limited  in  amount,  being  just  sufficient  to  replace  the  dead  tissue,  and 
nothing  more. 

Active  hypersemia  is  not  a  prominent  characteristic  of  any  stage  in 
the  first  instance  cited  above,  and  is  throughout  absent  in  the  second. 
Still,  as  I  showed  in  an  earlier  portion  of  this  article  when  treating 
of  injuries  to  non-vascular  areas,  active  hypersemia  is  not  absolutely 
indispensable. 

Active  hypersemia  is  entirely  wanting  in  yet  another  form  of  fibrosis 
—  that  resulting  from  passive  congestion,  whether  of  the  blood  (as  in 
clubbed  fingers,  in  that  variety  of  cirrhosis  of  the  liver  which  may 
result  from  obstructive  lung  or  heart  disease,  and  in  the  spleen  of 
portal  obstruction),  or  of  the  lymph  (as  in  chronic  oedema,  sclerema, 
elephantiasis  and  macroglossia).  Is  this  to  be  regarded  as  an  inflam- 
matory fibrosis  ?  Everything  points  to  the  conclusion  that  connective 
tissue  cells  and  their  progenitors,  like  the  Chinaman  and  the  Polish  Jew, 
can  thrive  and  multiply  upon  a  pabulum  which  is  starvation  to  those 
of  a  higher  standard.  In  passive  congestion,  as  in  obstruction  to 
the  onward  flow  of  lymph,  there  results  undoubtedly  a  bathing 
of  the  tissues  with  increased  lymph.  Can  this  alone  account  for  the 
hyperplasia,  or  must  we  invoke  the  aid  of  the  irritation  or  stimulus 
of  retained  effete  matters  contained  in  the  lymph?  This  question  is 
one  that  is  most  difficult  to  answer.  Underlying  it  are  the  further  ques- 
tions whether  one  broad  explanation  can  be  found  to  apply  to  all  cases 
of  tissue  hyperplasia ;  and  whether  cell  growth  in  general,  under  physio- 
logical as  under  pathological  conditions,  is  due  to  increased  nutrition,  or 
to  stimulation  of  the  cells,  to  increased  physiological  activity  of  the 
same,  or  to  removal  of  pressure  and  other  conditions  preventing  growth, 
or  to  a  combination  of  all,  or  nearly  all  of  these.  This  last  question  at 
present  remains  unanswered.  In  the  examples  before  us  of  hyperplasia 
following  passive  congestion,  one  possible  factor,  that  of  removal  of 
pressure  from  the  cells,  is  absent :  and  we  are  narrowed  down,  I  think, 
to  two  of  the  possible  factors  named  above  —  relatively  increased  nu- 
trition, and  stimulation  by  efCete  matters.  If  it  were  shown  that  there 
are  states  in  which  stimulation  or  irritation  by  effete  matters  plays  no 
part  in  the  overgrowth  of  new  connective  tissue,  then  we  could,  I  think, 
safely  declare  that  forms  of  fibrous  hyperplasia  exist  which  cannot  come 
under  the  heading  of  inflammatory  fibrosis,  and  that  the  fibrosis  ol 
passive  congestion  may  be  included  among  them. 

Now  such  conditions  do  exist.  That  increased  nutrition  alone  can  lead 
to  hypertrophy  of  the  tissues  was  established  long  ago  by  Hunter's  classi- 
cal experiment  of  transplanting  the  cock's  spur  on  to  the  cock's  comb,  — ■ 


INFLAMMA  TION  1 2  3 


moving  it  from  a  slightly  vascular  to  a  richly  vascular  region.  In  the 
ensuing  overgrowth  there  can  here  be  no  question  of  irritation  by  any- 
thing beyond  the  normal  blood.^  And  passing  from  the  general  to  the 
particular,  we  have  evidence  that  there  is  such  a  condition  as  fibrous 
hyperplasia  due,  as  it  would  seem,  to  increased  nutrition  unassociated 
with  the  presence  of  toxins  or  other  cellular  irritants.  In  his  wonder- 
fully painstaking  series  of  observations  upon  arterial  changes,  Thomas 
has  adduced  two  cases  which  he  describes,  no  doubt,  as  examples 
of  endarteritis,  but  in  which  the  inflammation  is  not  apparent, 
nor  indeed  any  factor  other  than  altered  tension  of  the  arterial 
walls  leading  to  altered  conditions  of  nutrition.  He  shows  that 
immediately  after  birth  there  is  developed  a  thickening  of  the  intima 

—  a  connective  tissue  proliferation  immediately  below  the  endothelium 

—  of  that  portion  of  the  aorta  lying  between  the  ductus  Botalli  and 
the  passing  off  of  the  umbilical  arteries.  During  later  foetal  life  the 
umbilical  arteries  are  the  largest  branches  of  the  aorta ;  and,  when  the 
circulation  through  them  is  arrested,  the  aorta  above  is  too  large  for 
the  amount  of  blood  requisite  for  the  abdominal  viscera  and  the  lower 
extremities.  The  arterial  current  becomes  therefore  relatively  slowed, 
and  presuinably,  judging  by  the  analogy  of  what  occurs  in  the  adult 
when  large  branches  of  the  aorta  are  ligatured,  the  aortic  blood  pressure 
is  for  a  time  raised.  With  this  slowing  and  increased  pressure  there 
appears  a  compensatory  overgrowth  of  the  intima  leading  to  contrac- 
tion of  the  vessel  and  its  lumen.  Generally  speaking,  when  the  area 
of  distribution  of  an  artery  is  diminished,  as,  for  example,  when 
a  limb  is  amputated,  the  artery  shows  a  similar  proliferation  of  the 
intima.  In  both  cases  the  blood  remains  healthy,  and  the  intima 
has  undergone  no  injury;  the  only  recognisable  change  has  been  a 
slowing  of  the  blood  stream,  and  probably  increased  blood  pressure; 
and  as  the  intima  is  nourished,  not  through  the  vasa  vasorum,  but 
directly  from  the  main  arterial  fluid,  it  would  appear  that  with  the 
slowing  an  increased  nutrition  is  brought  into  action.  I  can  see  no  satis- 
factory reason  for  calling  either  of  these  cases  an  endarteritis.  It  is  quite 
possible  that  other  cases  of  thickening  of  the  intima  are  due  not  to  irrita- 
tion, but  to  increased  nutrition  brought  about  by  heightened  arterial 
tension.  The  difficulty  urged  by  Councilman  that  high  arterial  pressure 
does  not  invariably  lead  to  overgrowth  of  the  intima  is  not,  in  my 
opinion,  insuperable.  It  must  suffice  if  here  I  point  out  that  it  is  more 
than  probable  that  certain  cases  of  endarteritis  are  in  no  sense  of  inflam- 
matory origin,  or  secondary  to  degenerative  changes  ;  but  are  primarily 
associated  with  nutritional  changes.  In  this  connection  it  was  shown 
by  Prof.  Eoy  and  myself  that  when  the  aorta  of  the  dog  is  suddenly 
and   greatly  constricted,  and  as  a  consequence   the   pressure  in  the 

1 1  here  ]eave  out  of  account  a  factor  which  may  be  important,  but  about  which  we 
know  practically  nothing  —  namely,  the  effect  of  altered  innervation.  I  am  forced  to 
assume,  perhaps  wrongfully,  that,  as  this  factf>r  plays  a  like  part  in  all  the  cases  under 
consideration,  it  may  for  present  i)urposos  be  disre{jarded. 


124  SYSTEM  OF  MEDICINE 

proximal  portion  of  the  vessel  greatly  increased,  the  plasma  of  the 
blood  is  forced  into  the  cusps  of  the  aortic  valves,  and  vesicles  of  lymph 
make  their  appearance  on  the  under  surface  in  that  region  where  fibroid 
thickening  is  most  frequent  in  cases  of  chronic  high  arterial  pressure. 

Thus,  to  express  briefly  the  distinction  that  I  would  draw  between 
inflammatory  and  non-inflammatory  fibrous  hyperplasia,  I  would  say  that 
where  local  injury  leads  to  increased  nutrition  of  the  connective  tissue, 
with  increased  functional  activity  of  the  cells,  the  ensuing  fibrous  hyper- 
plasia is  to  be  regarded  as  of  inflammatory  origin ;  where,  on  the  other 
hand,  local  injury  is  not  recognisable  as  the  primary  cause  of  the  cell 
growth,  the  hyperplasia  must  be  held  to  be  non-inflammatory.  In  pas- 
sive congestion,  obstructed  lymph-flow,  and  increased  nutrition  conse- 
quent upon  arterial  change,  as  in  the  cases  cited  above,  we  can  so  far 
see  no  cause  for  the  fibrous  hyperplasia  beyond  altered  conditions  of 
nutrition  ;  there  has  been  no  primary  lesion  in  the  affected  regions  induc- 
ing the  reaction.     Such  cases  must  be  considered  as  non-inflammatory. 

But  while  I  lay  down  this  distinction,  I  must  impress  upon  the 
reader  that  the  last  word  has  by  no  means  been  said  upon  this  matter, 
and  that  further  research  may  cause  a  radical  reconstruction  of  our 
opinions. 

Forms  of  Fibrous  Hyperplasia 

A.  Of  l7ifl.ani7natory  Origin. 

f  1.  Cicatricial. 

I  2.  Perivisceral. 

Localised      -  3.  Capstilar. 

4.  Replacement  — 
I  Gross  (of  infarcts,  etc.). 

I-  Fine  (dystrophic  sclerosis,  etc.). 

[  5.   Cirrhotic,  associated  with  parenchymatous 
Generalised  -j  inflammation,  interstitial  and  lymphan- 

t  gitic. 

B.  Of  Non-Inflammatory  Origin. 

1.  Hyperplasia  of  increased  (arterial)  nutrition. 

2.  "  of  venous  congestion. 

3.  "  of  lymphatic  obstruction. 

C.  Neoplastic. 

1.  Fibromata. 


Upon  the  Increased  Temperature  of  Inflamed  Areas 

Very  little  has  of  late  been  added  to  our  knowledge  in  this  division 
of  our  subject:  what  is  to  be  said  appears  now  to  be  so  well  established 
that  I  need  do  little  more  than  state  the  main  conclusions.  The  long 
controversy  that  raged  before  these  conclusions  were  fully  accepted,  anc 


I  NFL  AM  MA  TION  125 


John  Hunter's  original  views  shown  to  be  in  the  main  correct,  scarcely 
comes  within  the  scope  of  this  article. 

1.  The  temperature  of  superficial  regions  is  raised,  it  may  be  several 
degrees  above  the  normal,  by  the  onset  of  inflammatory  hypereemia. 

2.  The  temperature  of  internal  organs  when  inflamed  may  be  raised 
above  the  normal,  but  undergoes  no  material  increase  beyond  that  of 
other  unaffected  internal  organs  tested  at  the  same  time. 

3.  The  rise  above  the  normal,  which  is  often  present,  is  an  indication 
of  the  febrile  state  accompanying  the  inflammation,  and  not  of  locally 
increased  heat  production. 

4.  The  increased  temperature  of  superficial  areas  when  inflamed  is 
due,  not  to  the  production  of  heat  in  the  part,  but  to  the  increased 
quantity  of  blood  passing  through  it.  When  the  congestion  is  so  great 
that  stasis  ensues  there  may  be  actual  decrease  in  the  temperature  of  the 
part. 

5.  The  maintenance  of  high  external  temperature  may  exert  a 
favourable  effect  upon  the  duration  and  progress  of  specific  inflammation. 
Thus  Filehne  has  recently  shown  that  the  course  of  experimental  erysip- 
elas in  rabbits  is  more  rapid  and  more  benign  when  they  are  kept  at  a 
high  temperature  than  at  a  low.  We  possess  no  clear  evidence  that  this 
is  due  to  the  unfavourable  effect  of  the  heightened  temperature  on  the 
growth  of  the  microbes.  Pasteur's  well-known  experiments  upon  the 
production  of  anthrax  in  fowls  (ordinarily  insusceptible  to  this  disease) 
by  lowering  their  temperature  can  be  explained  on  other  grounds.  We 
have  abundant  evidence  that  heightened  temperature  promotes  vascular 
dilation :  the  experiment  of  Filehne  may  therefore  supply  a  further 
demonstration  of  the  favourable  effects  of  dilation  of  the  vessels  and 
hypersemia  in  the  inflammatory  process. 

6.  Low  external  temperature,  or  the  application  of  cold  to  the  surface, 
contracts  the  vessels  :  hence,  upon  the  lines  of  what  has  already  been 
said,  it  would  appear  that 

(a)  It  is  calculated  to  diminish  the  amount  of  exudation. 

(&)  It  is  calculated  in  consequence  to  diminish  the  pain  associated 
with  inflammation. 

(c)  It  has  no  directly  good  effect  upon  inflammation  due  to  the 
presence  and  growth  of  pathogenetic  micro-organisms,  but 
may  have  the  reverse  effect  of  preventing  the  fullest  reaction 
on  the  part  of  the  organism. 

id)  Where  the  irritant  does  not  itself  grow  and  multiply,  or  present 
cumulative  action,  there  the  application  of  cold  may  not  only 
be  of  no  harm,  but  of  positive  advantage,  by  lessening  the  in- 
flammatory reaction  and  preventing  this,  where  extensive,  from 
being  itself  a  cause  of  further  injury  to  surrounding  tissues. 

The  increase  of  systemic  heat  will  be  considered  in  the  article  on 
Fever. 


126  SYSTEM   OF  MEDICINE 

PART   III.  —  Ox  THE  Vakious  Porms  of  Inflammation 
Chapter  1.  —  Classification 

The  minute  changes  Avhich  characterise  the  process  as  it  affects  one 
or  other  organ,  and  the  various  specific  forms  of  inflammation,  will  be 
fully  described  in  special  articles.  I  have  only  to  indicate  more  general 
causes  and  main  varieties.  To  give  a  complete  classification  is  impossi- 
ble unless  each  separate  tissue  be  taken  in  order,  for  each  tissue  presents 
peculiarities  either  in  liability  to  inflammation,  or  in  the  course  assumed 
by  the  process.  Even  to  attempt  a  classification  in  broad  outline  is 
beset  with  difiiculties,  for  the  inflammatory  manifestation  varies,  not 
according  to  one  or  two  series  of  causes,  but  according  to  four  at  least ; 
the  permutations  are  thus  so  numerous,  and  the  appearances  so  varied, 
that  to  give  an  adequate  scheme  of  classification  would  require  a  diagram 
in  four  dimensions.     These  four  causes  of  variation  are  — 

A.  Nature  of  tissue  affected.  B.  Position  of  tissue  affected.  C.  In- 
tensity of  irritation,  or  more  correctly  ratio  between  resistant  powers  of 
the  organism  and  intensity  of  the  irritant.     D.  Nature  of  irritant. 

A.  Nature  of  Tissue  affected.  —  As  I  have  already  shown  in  the 
first  portion  of  this  article,  there  is  in  the  earlier  stages  of  the  process 
a  difference  in  the  reaction  of  vascular  and  non-vascular  tissues,  the  one 
series  exhibiting  marked  congestion  and  vascular  disturbance,  the  other 
not.  At  a  later  stage,  or  in  more  chronic  irritation,  as  new  vessels  invade 
the  non-vascular  areas,  the  changes  in  the  two  series  do  no  doubt  approxi- 
mate ;  but  in  the  earlier  stages  we  may  distinguish  between  an  ordinary 
inflammation  and  "  inflammatio  sine  inflammatione." 

The  relative  denseness  and  compactness  of  the  tissues  also  introduce 
characteristic  alterations :  a  dense  tissue,  such  as  bone,  does  not  show 
the  signs  of  reaction  to  injury  to  nearly  the  same  extent  as  does  a  loose 
tissue  —  such  as  the  omentum,  for  example  —  thus,  in  the  former  there 
may  be  a  process  almost  as  atj^pical  as  in  non-vascular  areas.  The  rigid 
framework  of  a  tissue  like  bone  prevents  great  vascular  dilatation  and 
exiidation,  but  at  the  same  time  may  be  the  seat  of  great  pain  due  to 
pressure  of  the  confined  exiidate  upon  the  nerve  endings.  The  loose 
connective  tissue  of  a  structure  like  the  omentum,  on  the  other  hand, 
permits  great  exudation  with  little  or  no  pain. 

The  influence  of  structure  is  well  seen  in  comparing  the  course  of  in- 
flammation affecting  cutaneous,  mucous  and  serous  surfaces  respectively. 
Where  we  have  to  deal  with  cutaneous  surfaces,  or  surfaces  formed  of 
squamous  epithelium,  there  the  increased  exudation,  and  the  resistance 
offered  by  the  layers  of  flattened  cells  to  the  free  exit  of  the  exuded 
fluid,  lead  towards  the  formation  of  vesicles  or  blisters.  In  the  case  of 
serous  surfaces,  which  form  the  walls  of  a  moist  cavity,  the  irritant, 
affecting  primarily  but  one  portion  of  the  surface,  is  very  likely  to  be 
borne  into  the  cavity  with  the  exudate  and  to  set  up  an  inflammation 


INFLAMMA  TION  1 27 


extending  over  a  very  large  portion  of  the  surface.  Mucous  and  cuta- 
neous surfaces,  wliich  are  not  thus  the  boundaries  of  cavities,  exhibit  a 
more  marked  disposition  to  the  production  of  localised  inflammation  and 
of  ulcers ;  the  superficial  layers  indeed  of  a  well-formed  epithelium  or 
mucous  membrane,  by  the  protective  powers  of  their  cells,  form  a  defence 
against  irritation  from  without:  thus  the  superficial  exudate  from  a 
region  of  local  inflammation  cannot  easily  jjroduce  a  superficial  exten- 
sion of  the  process. 

Not  only  the  nature  of  the  tissues,  but  their  function  also,  profoundly 
affect  the  character  of  the  inflammatory  manifestation.  Thus,  excretory 
organs,  by  the  very  nature  of  their  function,  during  the  attempt  to 
remove  noxious  substances  from  the  system,  are  especially  liable  to 
generalised  parenchymatous  inflammations,  —  the  irritation  not  being 
local,  but  affecting  at  the  same  time  all  the  cells  whose  part  it  is  to 
take  up  and  excrete  the  irritant  bodies. 

B.  The  Position  of  Tissues.  —  It  is  difficult  to  consider  the  position 
and  relationship  of  tissues  as  they  affect  the  inflammatory  manifesta- 
tions, without  continually  touching  upon  their  structure.  Nevertheless, 
the  two,  though  very  closely  connected,  do  not  go  hand  in  hand. 

A  familiar  instance  of  modification  in  form  brought  about  by  position 
is  to  be  seen  in  the  result  of  suppurative  inflammation  —  in  the  develop- 
ment of  ulcerous  conditions  when  the  process  affects  free  surfaces,  of 
abscesses  when  it  attacks  deeper  tissues.  The  process  in  the  two  cases  is 
virtually  the  same :  there  is  the  same  abundant  determination  of  leuco- 
cytes, the  same  degeneration  of  them  into  pus.  Yet  apart  from  the 
gross  difference  in  form,  there  are  minor  differences  between  the  two. 
There  is,  for  instance,  relatively  much  more  serous  exudation  from  the 
free  surface  of  an  ulcer  than  there  is  into  and  around  an  abscess.  As 
a  general  rule,  inflamed  tissues  near  a  free  surface  are  the  seat  of  more 
abundant  exudation.  Of  this  liability  for  free  surfaces  to  be  the  seat 
of  serous  inflammation  I  have  already  spoken.  The  skin,  with  its  thiclc 
dermal  layer,  affords  a  good  example  :  when  the  full  suj)purative  stage 
is  not  reached,  inflammation  affecting  the  outermost  layers  of  the  derma 
is  most  often  of  a  vesicular  or  oedematous  character ;  when  it  affects 
the  deeper  layers  of  the  derma  the  serous  infiltration  is  less  evident. 

Yet  another  example  of  the  influence  of  position  in  modifying  form 
is  seen  in  enteric  fever.  In  this  malady,  the  lymphoid  tissue  forming 
the  Peyer's  patches  becomes  the  seat  of  excessive  cellular  infiltration 
and  proliferation,  undergoes  necrosis,  and  is  cast  off,  leaving  the  well- 
known  ulcers.  The  lymphoid  tissue  of  the  neighbouring  mesenteric 
gland  likewise  undergoes  great  infiltration  and  enlargement,  but  necrosis 
rarely  implicates  the  whole  of  a  gland :  notwithstanding  the  previous 
extensive  inflammation,  the  glands  commonly  recover  their  normal 
appearance  and  size. 

Beyond  this  there  are  few  broad  principles  to  be  laid  down  concern- 
ing tlie  relationship  between  forms  of  inflammation  and  position  that 
do  not  essentially  depend  upon  the  structure  and  functions  of  the  tissues. 


128  SYSTEM  OF  MEDICINE 

Much  can  be  said  concerning  the  intimate  connection  between  position 
and  liability  to  inflammation ;  but  this  and  the  allied  and  most  impor- 
tant subject  of  the  protective  mechanisms  of  sundry  tissues  against 
injury  are  away  from  our  present  point. 

C.  The  Relative  Intensity  of  the  Irritant  is  a  more  frequent  and 
potent  cause  of  variation.  I  have  already  in  several  places  referred  to 
the  ratio  between  the  resistant  powers  of  cells  and  the  intensity  or 
virulence  of  the  irritant  as  it  affects  the  inflammatory  process,  and  have 
shown  how  much  that  was  previously  vague  has  been  made  clear  by 
bacteriological  research;  while,  at  the  same  time,  it  has  brought  home 
the  truth  that  the  various  forms  of  inflammation  merge  insensibly  one 
into  the  other. 

Broadly  speaking,  it  may  be  stated,  as  a  result  of  these  studies, 
that,  cceteris  paribus,  increased  virulence  of  any  given  microbe  or 
diminished  power  of  resistance  on  the  part  of  the  organism  or  of  the 
tissues,  leads  to  corresponding  alterations  in  the  phenomena  of  inflam- 
mation at  the  region  of  inoculation  ;  and  vice  versa. 

Thus,  if  a  pathogenetic  microbe,  such  as  that  of  anthrax  or  erysipelas, 
be  greatly  attenuated,  the  effects  of  inoculation  into  the  subcutaneous 
tissues  may  be  scarcely  recognisable.  If  the  attenuation  be  not  so  extreme 
some  hyperaemia,  a  determination  of  leucocytes,  and,  relatively,  very 
little  exudation,  will  be  seen ;  and  .in  the  course  of  a  day  or  two  all 
traces  of  inflammation  may  have  disappeared.  With  slightly  more 
virulent  microbes  the  migration  of  leucocytes  may  be  followed  by  their 
breaking  down  and  consequent  abscess  formation  ;  with  further  increase 
of  intensity  of  action  the  migration  of  leucocytes  may  be  wanting, 
while  the  exudation  extends  and  the  inflammation  rapidly  spreads  and 
leads  to  a  septicaemia.  A  like  series  of  changes  is  observable  if  the 
strength  of  virus  be  constant  and  animals  more  and  more  susceptible 
(or  less  and  less  refractory)  be  inoculated. 

The  variation  in  tubercular  lesions,  from  isolated  dense  fibroid 
masses  to  loosely  formed  cell  accumulations  and  diffuse  tubercular  in- 
flammation, is  evidently  explicable  on  this  law.  The  law  holds  good 
also,  not  merely  for  bacterial  products,  but  for  other  irritants  also.  The 
effect  of  croton  oil  varies  with  the  strength  of  the  solution  applied;  and, 
as  shown  by  Samuel,  according  to  the  condition  of  the  animal.  The 
same  is  true  of  abrin  and  other  vegetable  extracts. 

Turning  to  physical  irritants,  while  here  the  intensity  of  the  irritant 
alone  or  almost  alone  is  called  into  play,  numerous  examples  can  be 
given  of  the  effects  of  variation  in  this  one  respect  upon  the  inflamma- 
tory manifestation —  effects  of  cold,  for  instance,  varying  from  chilblain 
through  inflammatory  oedema  to  gangrene ;  of  heat  varying  from 
hypergemia  through  vesicular  inflammation  to  complete  destruction  of 
tissue ;  and,  again,  effects  of  caustic  substances.  In  this  era  of  aseptic 
surgery  we  maj^  forget  what  was  well  known  to  the  last  generation  of 
surgeons,  that  caustic  substances  may  be  employed  either  to  originate  a 
benign  and  reparative  inflammation  (as  in  the  case  of  indolent  ulcers)  ; 


INFLAMMA  TIOM 


129 


or,  in  larger  quantities  or  greater  intensity,  to  bring  about  a  state  in 
which  the  death  of  the  tissue  elements  is  far  in  excess  of  the  subsequent 
repair.  Thus  then,  according  to  the  above-mentioned  ratio,  inflamma- 
tion in  a  tissue  may  vary  by  insensible  gradations  from  a  mere  hypercemia 
up  to  a  spreading  suppurative  or  gangrenous  process  ;  and  from  a  purely 
local  manifestation  to  the  development  of  what  may  be  termed  an  in- 
flammation of  the  whole  organism. 

D.  The  Nature  of  the  Irritant.  —  It  is  clear,  then,  that  it  is  impos- 
sible to  base  a  classification  upon  the  nature  of  the  irritant :  the 
attempt  to  mark  off:  sharply  the  inflammations  caused  by  mechanical 
and  chemical  noxae  from  those  produced  by  bacteria  and  their  products 
must  be  given  up.  Hiiter's  proposition  that  suppuration  can  only  be 
induced  by  microbes  has  been  repeatedly  shown  to  be  erroneous. 
Thanks  more  especially  to  the  researches  of  Councilman,  Leber,  Grawitz 
and  de  Bary  and  Straus  (many  more  names  might  be  mentioned  in  this 
connection),  we  now  know  that  many  chemical  substances  are  capable 
of  causing  pus  formation.^  Among  these  may  be  mentioned  turpen- 
tine, croton  oil,  mercury,  copper  and  silver  nitrate.  On  the  other 
hand,  although  this  pyogenetic  property  is  not  confined  to  microbes  and 
their  products,  yet  among  microbes  it  is  not  the  common  property  of  all. 
Some,  like  the  bacillus  of  tetanus,  never  in  themselves  induce  pus  forma- 
tion: others,  like  the  bacillus  of  tuberculosis,  lead  characteristically  to 
tissue  growth  and  the  formation  of  inflammatory  neoplasms  rather  than 
to  pus  formation.  Even  among  those  which,  like  the  micrococci,  are 
highly  pyogenetic,  the  formation  of  abscesses  only  occurs  when  there  is 
a  definite  relationship  between  the  virulence  of  the  microbe  and  the 
resistance  of  the  organism.  The  reverse  is  equally  true,  that  numerous 
microbes,  not  specially  pyogenetic,  produce  pus  under  peculiar  condi- 
tions. Thus,  the  bacillus  of  enteric  fever,  when  it  multiplies  in  the 
middle  ear,  "induces  a  suppurative  otitis,  and,  as  Dr.  C.  F.  Martin  has 
shown,  it  is  further  capable  of  originating  a  suppurative  arthritis. 

In  fact,  under  varying  conditions  the  same  microbe  can  induce  very 
various  forms  of  inflammation.  Thus,  Charrin  has  shown  that  the  B. 
pyocyaneus  and  its  products  are  capable  of  inducing  in  one  organ  —  the 
kidney  —  pathological  conditions  so  diverse  as  acute,  chronic,  parenchy- 
matous, interstitial  and  thrombotic  nephritis,  with,  in  addition,  cyst 
formation  and  amyloid  degeneration.-  This  same  microbe  can  induce 
acute  suppuration  in  the  anterior  chamber  of  the  eye  ;  and  when  inocu- 
lated into  the  blood  cause  a  heemorrhagic  inflammation  of  the  serous 
surfaces.  Hence  we  can  proceed  further  and  state  that  no  strict  classi- 
fication of  inflammation  can  be  made  according  to  the  nature    of  the 

1  While  this  is  so,  it  must  be  borne  in  mind  that  under  ordinary  conditions  these 
substances  very  rarely  act  upon  the  organism  in  a  state  of  sufficient  concentration  to  be 
pyogenic.  Thus,  while  it  is  impossible  to  make  a  sharp  line  of  demarcation  between 
bacterial  and  chemical  irritants,  it  holds  true  in  the  main  for  man  that  suppurative  dis- 
ease is  an  indication  of  the  presence  and  growth  of  micrf)bes. 

2  These  changes  are  comparal)le  with  the  diverse  conditions  of  the  kidney  in  the 
human  being  brought  about  by  the  scarlatinal  virus. 

VOT..    T  K 


I30  SYSTEM   OF  MEDICINE 

bacterial  irritants:  it  is,  however,  possible  to  make  a  general  grouping 
of  those  affecting  man,  as  follows :  — 

(i.)  Micro-organisms  characteristically  leading  to  pus  and  abscess 
formation  —  Staphylococci  and  streptococcus  pyogenes,  B.  anthracis. 

(ii.)  Those  leading  to  abundant  exudation  with  necrosis  —  B.  of 
malignant  oedema. 

(iii.)  Those  leading  to  cellular  infiltration  without  usually  causing 
abscess  formation  —  B.  typhi  abdominalis,  M.  gonorrhoeae,  B.  diphthe- 
rias, etc. 

(iv.)  Those  inducing  characteristically  the  development  of  inflam- 
matory neoplasm.s  —  B.  tuberculosis,  B.  pseudo-tuberculosis,  B.  mallei, 
Actinomyces,  Aspergillus  fumigatus. 

Similarly,  chemical  substances  may  roughly  be  grouped  into  — 

(a)  Substances  causing  so  slight  an  irritation  when  introduced  into 
the  organism  as  to  induce  cellular  overgrowth  only  in  their  immediate 
neighbourhood  —  such  as  bland  foreign  bodies,  bullets,  etc. ;  inhaled 
particles  of  coal,  stone,  iron,  and  the  like,  conveyed  into  the  pulmonary 
lymphatics. 

(6)  Substances  leading  to  vesicular  inflammation,  e.g.  blistering 
agents,  such  as  cantharides.  (This  result,  however,  depends  more  upon 
the  position  than  the  nature  of  irritant.) 

(c)  Substances  leading  to  cell  necrosis,  followed  by  the  formation 
of  granulation  tissue  —  caustic  agents. 

(d)  Substances  leading  to  cell  necrosis  and  suppuration,  such  as 
copper,  mercury,  mineral  acids,  etc.  (a  very  rare  result  in  man). 

These  lists,  from  the  considerations  given  above,  are  necessarily  un- 
satisfactory and  imperfect. 

0>-,her  Considerations.  —  Among  other  factors  varying  the  inflamma- 
tory process  may  be  mentioned  the  duration  of  the  action  of  the  irri- 
tant, which  of  necessity  must  modify  the  extent  of  the  manifestations 
of  disturbance  in  the  tissues.  A  simple  aseptic  incision,  for  example, 
leads  to  a  much  milder  and  slighter  series  of  changes  than  do  the 
prolonged  presence  and  growth  of  the  tubercle  bacillus.  Yet  while  at 
first  it  might  appear  an  easy  matter  to  name  case  after  case  where  the 
irritant  has  but  a  momentary  action,  upon  further  consideration  it  is 
found  that,  in  the  majority  of  cases  of  purely  mechanical  injury,  this 
is  not  the  case ;  or,  to  express  the  matter  more  exactly,  in  the  case  of 
physical  injuries,  it  is  not  the  act  of  wounding  that  causes  the  inflam- 
mation, but  the  damage  inflicted  upon  the  cells  of  the  tissues;  as,  to  a 
very  large  extent,  inflammation  is  set  up  by  the  products  of  the  injured 
and  destroyed  cells.  A  bone  may  be  suddenly  broken,  and  neverthe- 
less, even  under  the  most  favourable  circumstances,  pain,  swelling,  and 
congestion  may  affect  the  region  of  fracture  for  several  days.  One  or 
other  region  of  the  body  may  be  rapidly  frozen :  the  inflammation 
does  not  manifest  itself  till  after  the  physical  agent  has  ceased  to  act, 
but  it  continues  for  hours,  and  even  for  days. 

There  are,  moreover,  physical  irritants  of  another  nature  producing 


INFLAMMA  TION 


131 


definitely  chronic  inflammation ;  I  refer  to  foreign  bodies  which  have 
gained  an  entrance  into  the  system.  These  if  bland  in  themselves  may 
nevertheless  cause  irritation.  A  good  example  of  the  extensive  inflam- 
mation which  such  bodies  may  set  up  is  seen  in  the  dense  fibrous  inter- 
stitial tubercular  masses  developed  in  the  lungs  of  stone-masons  around 
fine  silicious  particles  carried  into  the  lymphatics  from  the  alveoli. 

From  such  examples  it  will  be  evident  that  no  satisfactory  distinc- 
tions between  bacterial  irritants  on  the  one  hand,  and  physical  irritants 
on  the  other,  can  be  founded  on  the  duration  of  irritation.  This  factor 
plays  no  easily  recognised  part  in  determining  the  various  forms  of  in- 
flammation, and  consequently  I  have  forborne  to  place  it  in  the  list  at 
the  beginning  of  this  chapter. 

In  thus  passing  rapidly  over  the  influence  of  each  of  the  four  main 
causes  of  variation  I  have  of  necessity  excluded  sundry  forms  of  in- 
flammation due  to  the  combined  action  of  two  or  more.  There  are,  for 
instance,  such  well-marked  forms  as  the  catarrhal  and  croupous,  due  to 
the  interaction  of  all  four  factors :  embolic  inflammation  and  lymphan- 
gitis have  also  been  passed  over ;  these,  however,  are  not  so  much  forms 
of  inflammation  as  inflammatory  processes  occurring  in  special  regions 
as  a  result  of  special  methods  of  conveyance  of  the  irritants. 

The  factors  then  are  so  many,  and  their  interaction  so  varied,  that 
anything  approaching  to  an  orderly  classification  is  hopeless.  What  I 
have  here  written  must  be  regarded,  not  as  an  attempt  to  formulate 
such  a  classification,  but  as  an  attempt  to  indicate  briefly  how  the  nature 
and  position  of  the  tissues,  and  the  nature  and  intensity  of  the  irritant 
bring  about  modifications  in  the  process  of  inflammation. 

Chapter  2.  —  On  Systemic  Changes  Consequent  upon 
Inflammation 

The  results  of  an  acute  local  inflammatory  process  are  not  confined  to 
the  immediate  locality,  but  associated  alterations  in  the  system  at  large 
have  long  been  recognised ;  yet  while  recognised  these  systemic  changes 
have  been  but  little  studied :  I  cannot  pass  the  matter  over  in  silence, 
but  my  setting  forth  of  it  must  necessarily  be  very  brief  and  imperfect. 

I  cannot  here  say  more  upon  the  effect  of  local  irritation  on  the 
nervous  system  than  that,  apart  from  direct  reflex  action  leading  to 
changes  of  nervous  origin  in  the  region  of  injury  and  the  reflexes 
affecting  associated  regions,  the  higher  centres,  and  thrcmgh  them  the 
system  at  large,  may  become  affected  by  paths  that  it  is  not  always 
easy  to  trace. 

The  disturbances  of  the  nervous  system  which  accompany  local  injury 
can  be  but  vaguely  and  indefinitely  described.  As  regards  the  secondary 
effects,  the  recent  most  suggestive  work  of  Prof.  Roy  and  Dr.  Cobbett 
upon  Shade  \^vide  art.  on  "  Shock  "  in  a  later  volume]  indicates  that  there 
is  here  a  rich  field  for  yet.f  urther  research.  Of  the  changes  in  the  general 
circulation,  and  more  especially  in  the  circulating  blood,  thanks  to  the 


132 


SYSTEM  OF  MEDICINE 


observations  of  Von  Limbeck,  Rieder,  Lowitz,  and  Sherrington,  we  are 
in  possession  of  more  exact  knowledge.  On  acute  local  inflammation 
of  some  extent  the  circulating  blood  becomes  inspissated ;  by  exudation 
it  loses  some  of  its  plasma,  while  the  more  solid  constituents  —  the  red 
corpuscles  —  do  not  escape.  The  amount  of  fluid  lost  to  the  circulation 
is  not  equalised  by  increased  entrance  of  lymph  into  the  circulation  :  in 
one  experiment  of  Prof.  Sherrington  the  blood  remained  apoplasmic  {i.e. 
its  specific  gravity  remained  heightened)  for  more  than  sixty  hours  after 
the  infliction  of  injury.  This  apoplasmia  or  diminution  in  the  relative 
amount  of  plasma  in  the  blood  appears  to  depend  in  some  measure  upon 
the  extent  of  the  vascular  area  involved  in  the  inflammation ;  for  example^ 
Sherrington  shows  that  when  both  feet  are  involved,  by  plunging  the  limbs 
in  water  of  52°  C,  the  apoplasmia  is  more  severe  than  in  experiments 
affecting  one  foot  only.  Another  well-marked  change  in  the  blood  concerns 
the  leucocytes.  As  suspected  by  Lowitz  and  proved  by  Sherrington,  there 
is,  in  some  forms  of  inflammation  at  least,  a  primary  diminution  in  the 
number  of  leucocytes  per  unit  volume  of  blood  (leucocytopenia),  followed 
by  a  marked  increase  in  the  number  of  leucocytes  in  the  blood  (leuco- 
cytosis).  The  number  of  leucocytes  was  in  some  instances  increased 
sevenfold.  In  the  leucocytopenia  of  inflammation,  the  diminution  is 
chiefly  confined  to  the  finely  granular  leucocytes  —  the  finely  granular 
oxyphile  cells  of  Kanthack  and  Hardy.  These  observations  of  Sherring- 
ton are  confirmed  by  the  observations  of  Everard,  Demoor,  and  Massart. 

Whether  the  diminution  be  due  to  disintegration,  or  to  collection  in 
some  area  of  the  circulation,  is  not  yet  determined.  The  leucocytosis 
may  become  obvious  within  an  hour  after  the  establishment  of  a  local 
lesion ;  and  it  may  be  prolonged  for  several  days,  even  in  cases  where 
the  injury  has  been  of  a  mechanical  nature.  Here,  again,  according  to 
most  observers,  it  is  chiefly  the  polynuclear  or  finely  granular  oxyphile 
cells  which  increase  in  numbers.  It  is  interesting  to  note  that  coinci- 
dently  the  coarsely  granular  eosinophile  cells  appear  to  undergo  great 
diminution.  I  can  do  no  more  than  point  out  the  existence  of  those 
blood  changes,  and  further  that  changes  in  the  number  of  leucocytes  in 
the  blood  are  certainly  not  accounted  for  by  the  number  passing  from 
the  blood  into  the  inflamed  area.  It  would  seem  that  local  inflammar 
tion  in  some  way  brings  about  an  over-stimulation  of  lymph  glands, 
whereby  an  increased  number  of  leucocytes  are  poured  into  the  blood ; 
or  it  may  initiate  increased  proliferation  of  the  leucocytes  already  in 
the  circulation ;  but  how  one  or  other  of  these  effects  is  produced  is 
at  present  unknown.  Certainly  the  direct  introduction  of  the  products 
of  bacterial  growth  into  the  circulating  blood  may  lead  to  a  more  or  less 
pronounced  and  rapid  diminution  of  the  number  of  leucocytes  in  the 
blood,  and  this  diminution,  as  shown  by  Lowitz,  may  be  preliminary 
to  a  subsequent  increase. 

The  further  important  general  disturbance  associated  with  local 
injury,  more  especially  when  of  bacterial  origin,  namely,  the  occurrence 
of  fever,  will  be  described  in  another  article.     Bacteriological  studies 


INFLAMMATION  133 


lead  to  the  conclusion  that  traumatic  fever,  at  any  rate,  is  largely  due  to 
the  diffusion  in  the  blood  stream  of  soluble  bacterial  products,  and  of  the 
products  of  tissue  destruction  derived  from  the  inflammatory  focus. 

Chapter  3.  —  Conclusion 

In  studying  thus  the  reactions  of  the  organism  to  injury,  we 
are  impressed  by  the  multifariousness  of  natural  processes ;  the  end 
may  be  attained  not  in  one  way  only  but  in  many.  "It  is  not  by 
cells  of  one  order  alone  —  by  phagocytes  —  or  by  leucocytes  in  general 
and  only  leucocytes,  or  merely  by  the  reaction  on  the  part  of  the  fixed 
cells  of  the  tissue,  or  by  vascular  changes  alone,  or  by  altered  tempera- 
ture, or  solely  by  the  chemical  and  mechanical  action  of  the  exudate  that 
repair  is  effected.  All  means  are  employed  to  antagonise  the  irritant  and 
to  effect  healing.  The  cells  of  the  body,  fixed  and  free,  play  their  part ; 
the  nervous  system  aids  the  process ;  the  bodily  humours  render  efficient 
help ;  modifications  in  the  vessel  walls  and  blood  stream  are  valuable 
auxiliaries.  Diverse  processes  are  employed,  now  one  more  particularly, 
now  another,  according  to  the  needs  of  the  moment,  but  none  exclusively." 

The  time  has  come  when,  example  after  example  having  clearly  indi- 
cated the  meaning  and  the  tendency  of  that  response,  we  may  securely 
acknowledge  the  tendency,  and  see  in  inflammation  not  merely  the  re- 
sponse to  injury,  but  the  attempt  to  repair  injury.  To  object  that  a 
definition  containing  this  statement  is  teleological  is  absurd  in  the  face  of 
fact  after  fact  that  can  be  interpreted  on  this  assumption  only.  What  is 
the  development  of  cicatricial  tissue  but  an  attempt  at  repair  ?  What 
other  meaning  can  be  ascribed  to  the  increased  bactericidal  power  of  the 
inflammatory  exudate  as  compared  with  that  of  ordinary  lymph  and 
blood  serum  ?  Why  do  leucocytes  accumulate  in  a  region  of  injury  ? 
Why  do  some  of  them  incorporate  bacteria  and  irritant  particles,  and 
others  bring  about  the  destruction  of  these  without  necessarily  ingest- 
ing them  ?  All  these  are  means  whereby  irritants  are  antagonised  or 
removed,  aud  reparation  and  return  to  the  normal  sought  after. 

It  must  be  kept  in  mind  that  attempt  to  repair  may  be  far  from 
repair.  Indeed,  we  frequently  find  that  the  reaction  to  injury  is  dispro- 
portionate to  the  strength  of  the  irritant,  being  either  insufficient  or  ex- 
cessive. The  exudation  may  possess  but  slight  bactericidal  powers,  or 
may  be  poured  out  in  such  quantities  that  the  microbic  irritant,  instead 
of  being  retained  in  the  region  of  injury,  is  conveyed  outside  that  region ; 
the  wandering  cells  instead  of  destroying,  may  undergo  destruction ;  they 
may  incorporate  bacteria,  but  not  be  able  to  annihilate  them ;  the  fixed 
cells  may  either  form  an  incomplete  cicatrix,  or  continue  to  proliferate  in 
excess.  The  means  of  defence  on  the  part  of  the  organism  are  not  so 
much  a  preparation  in  advance  as  an  inheritance  or  an  acquirement  — 
either  a  transmission  from  those  forms  which,  being  possessed  of  the  most 
highly  developed  means  of  defence,  have  survived  while  forms  with  fewer 
resources  have  been  destroyed;  or,  on  the  other  hand,  an  accession  derived 


134  SYSTEM  OF  MEDICINE 

from  previous  successful  resistance :  not  being  a  preparation  in  advance,  the 
reaction  to  injury  is  not  exactly  proportionate  to  any  and  every  irritant. 

But  the  mere  statement  that  inflammation  is  an  attempt  to  repair 
injury,  or  that  it  is  the  response  thereto,  is  insufl&cient  as  a  defini- 
tion, for  thereby  the  general  disturbances  which  may  accompany  the 
changes  occurring  at  the  seat  of  lesion  are  included ;  these,  however,  may 
be  excluded  without  seriously  affecting  our  conception  of  the  process,  in 
fact  with  positive  advantage  to  a  clear  comprehension  of  the  distinction 
between  inflammation  and  fever.  And,  further,  if  what  I  have  urged  in 
the  chapter  upon  the  part  played  by  the  nervous  system  be  correct, 
account  must  be  taken  of  the  fact  that  the  leading  phenomena  associated 
with  the  inflammatory  process  may  occasionally  present  themselves  solely 
under  the  direction  of  perverted  nerve  action,  and  apart  from  actual  local 
injury. 

Hence  I  am  inclined  to  consider  that  we  can  now  pass  beyond  the 
conception  of  the  process  with  which  I  began  this  article,  and  cannot 
merely  regard  it  as  a  succession  of  changes  in  a  part  constituting  the  re- 
action to  injury,  but  can  with  propriety  acknowledge  the  purpose  of  that 
succession.  From  these  considerations  I  am  led  to  define  inflammation 
as  the  series  of  changes  constituting  the  local  manifestation  of  the  attempt  at 
repair  of  actual  or  referred  injury  to  a  part,  or,  briefly,  as  the  local  attempt 
at  repair  of  actual  or  referred  injury. 

So  diverse  are  the  opinions  of  pathologists  upon  many  branches  of 
this  subject  of  inflammation,  and  so  great  is  the  amount  of  recent  research 
that  I  can  neither  hope  that  all  the  conclusions  here  set  down  will  gain 
acceptance,  nor  that  in  these  pages,  inevitably  condensed  as  they  are,  I 
have  succeeded  in  recognising  and  duly  acknowledging  all  work  of  primary 
importance.  It  is  possible  also  that,  having  been  unavoidably  prevented 
of  late  from  seeing  and  discussing  with  others  the  results  they  have  ob- 
tained, I  may  in  some  cases  have  viewed  facts  in  a  wrong  perspective. 
In  the  rapid  progress  of  our  science,  much,  it  may  be,  that  is  here  set 
forth  will  be  modified.  Nevertheless  I  hold  that  the  conception  of  the 
inflammatory  process  indicated  in  this  article  is  that  which  embraces  the 
largest  number  of  like  phenomena,  and  excludes  most  satisfactorily  those 
which  if'associated  are  imessential ;  and  that  it  is  by  the  study  of  cellular 
pathology  in  its  strictest  sense  that  the  surest  advance  has  been  and  is 
to  be  made  in  our  knowledge  of  this  the  dominating  process  in  disease. 

John  George  Adami. 


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I'Inst.  P.  iii.  1889,  and  No.  14,  gives  main  literature. — 33.  Pfeffer.  Unters.  a.  d. 
botan.  hist,  in  Tubingen,  vols.  i.  and  ii.  —  34.  Reinke.  Unters.  a.  d.  bot.  Inst,  in 
Gottingen,  1881.  —  35.  Stahl.     Botan.  Zeitung,  1884,  Nos.  10-12. 

III.   The  Steps  of  the  Inflammatory  Process  in  the  Higher  Animals 

In  addition  to  Nos.  6,  7,  8,  12,  19  and  23,  consult  — 36.  Flemming.  Virch.  Arch. 
Ivi.  1872,  p.  146,  on  "Development  of  Fibrin  in  Inflamed  Tissues."  —  37.  Hess. 
Vivch.  Arch.  cix.  1887,  p.  365.  —  38.  Hohnfeldt.  Ziegler's  Beitr.  iii.  1888,  p.  343. 
—  39.  Jacobs.  B^itr.  z.  Histol.  d.  acut.  Entziindung  d.  Cornea,  Inaug.  Diss.  Bonn, 
1887.  _40.  Ranvier.  Ctes.  rend.  d.  I'Acad.  d.  Sc.  1891,  April  20th,  p.  845.-41. 
Senftleben.  Virch.  Arch.  Ixxii.  p.  542.  —  A  satisfactory  bibliography  of  this  sub- 
ject is  given  by  Burdon-Sanderson,  Nos.  4  and  5.  For  full  references  to  recent  work 
upon  mycotic  inflammation  consult  Baumgarten's  Jahresbericht. 

IV.   On  the  Forms  and  Varieties  of  Leucocytes 

42.  Ehrlich.  "  Farbenanalytische  Unters.  z.  Histrl.  n.  Klinik  des  Blutes," 
Gesamm.  Mitthl.  Berlin,  Hirschwald,  1891.— 43.  Everard,  Demoor,  and  Massart. 
A.  de  ri  P.  vii.  1893.-44.  Gluge.  Observat.  nonn.  microscop.  in  Inflamm.  1835.— 
45.  GuLLAND.  Lah.  Rep.  R.  C.  P.  Edin.  iii.  1891,  p.  106.-46.  Gulland.  J.  of 
Pathol,  ii.  1894,  p.  447.-47.  Wharton  Jones.  Phil.  Trans.  1846,  p.  64.-48. 
Kanthack.  Med.  Chron.  New  series,  i.  1894,  pp.  246,  332.-49.  Kanthack  and 
Hardy.  J.  of  Pathol,  xvii.  1894,  p.  81:  and  Phil.  Trans.  1894.  — TO.  Mesnil. 
A.  de  I'l.  P.  ix.  189"),  May. -51.  Metschnikoff.  B.  M.  J.  31st  Jan.  1891,  and 
No.  14.-52.  Ranvier.  "Des  Clasmatocytes,"  Ctes.  rend.  d.  I'Acad.  des  Sc.  ex. 
1889,  p.  lC-5.  —  53.  RiEDER.  Beitr.  z.  Kenntniss  d.  Leucocytose,  Leipzig,  1892;  and 
Atlas  d.  klin.  Microsconi".  d''S  Blutes.  Leipzis.  1892.-54.  Rindfleifch.  Pathol, 
tl'stnlnqie.  1861;  und  Exptelle.  Studien  ii.  d.  Hi-tologie  des  lUutes.  Leipzig,  1863.— 
55.  Max  Schultze.  Arch.  f.  m.ikr.  Anat.  i.  1863,  p.  1.-56.  Sherrington.  Proc. 
R'jf.  Son.  Iv.  1893,  p.  161.— .57.  Siawcillo.  A.  de  I'L  P.  ix.  May  1895.— For  fuller 
bibliograjjhy  consult  Nos.  46,  48,  and  53. 


136  SYSTEM   OF  MEDICINE 


V.  On  the  Nature  of  Giant  Cells 

58.  BoRREL.  A.  de  I'Inst.  Pasteur,  vii.  1893,  p.  593.  —  59.  Duenschmann.  J.  of 
Pathol,  iii.  1894,  p.  118. —60.  Faber,  Knud.  J.  of  Pathol,  i.  1893,  p.  349.-61. 
Koch.  Mittheil.  a.  d.  kaiserl.  Gesandheitsamt,  ii.  1884.  —  62.  Langhans.  Virch. 
Arch.  xlii.  1868,  p.  382,  and  xlix.  1870,  p.  66. — 63.  Marchand,  P.  Virch.  Arch. 
xciii.  1883. — 64.  Johannes  Muller.  Ueber  den  feineren  Bau  und  die  For  men  der 
Krankhaften-Geschiv'dlste.  Berlin,  1838. — 65.  Ribbert.  Der  imtergang.  pathogen. 
Schiminelpilze  im  Korper.  Bonn,  1887.-66.  Ruffer.  A.  de  I'Inst.  P.  v.  1891.— 
67.  Soudakewitch.  Virch.  Arc'i.  cxv.  1889.  —  68.  Stchastny.  A.  de  I'Inst.  P. 
V.  1891,  p.  225.-69.  Virchow.  Virch.  Arch.  xiv.  1858,  p.  47. — 70.  Weigert.  IJ. 
vied.  Wochenschr.  1885,  and  Virch.  Arch,  cxiii.  1889.  —  71.  Ziegler.  Expt.  Unter- 
such.  ii.  d.  Ilerkvrift  d.  T uherkelelemente.  "Wurzburg,  1875.  —  Earlier  literature  given 
by  Marchand  (No.  63),  later  by  Faber  (No.  60). 

VI.   On  Chemiotaxis 

72.  Councilman.  Virch.  Arch.  xcii.  1883.  —  73.  Gabritchewski.  A.  de  I'l.  P. 
iv.  1890,  p.  346.-74.  Kanthack.  See  No.  48,  and  B.  M.  J.,  June  18th,  1892.-75. 
Leber.  See  No.  12.-76.  Massart,  J.  A.  de  I'l.  P.  vi.  1892,  p.  321.— 77.  Massart 
and  BoRDET.  J.  d.  I.  Soc.  Roy.  d.  Sc.  Med.  et  Nat.  de  Bruxelles,  1890.  —  78.  Massart 
and  Bordet.  A.  de  I'l.  P.  v.  1891,  p.  417.  — 79.  Pekelharing.  La  Semaine  nied.  1889, 
No.  22,  p.  184.-80.  Pfeiffer.  See  No.  33.— 81.  Stahl.  See  No.  35.  — For  fuller 
bibliography  consult  INLassart  and  Bordet,  No.  77. 

VII.   On  Phagocytosis  —  General  Articles 

82.  Adami.  Med.  Chron.  Nov.  and  Dec.  1891. — 83.  Baumgarten.  Ctbl.  f.  klin. 
Med.  1888,  No.  26;  Zeigler's  Beitr.  vii.  1889;  Berl.  klin.  Woch.  1884,  Nos.  50  and 
51. — 84.  Bitter.  Zeitschr.  f.  Hygiene,  iv.  1888,  p.  405.  —  85.  Discussion  on  Immunity 
(Roux,  Metsehnikoff,  Hankin,  Behring,  Buchner,  etc.).  Trans.  Internat.  (Jongr.  of 
Ihjgiene,  London,  1891,  vol.  ii.  —  86.  Discussion  on  Immunity.  Internat.  (Jongr. 
of  Ihjgiene  Buda-Pesth,  1894  (Metsehnikoff,  Ronx,  Buchner,  Denys,  etc.),  Cthl.  f. 
Bakt.  1894.  —  87.  Discussion  on  Immunity.  Path.  Soc.  London,  1892  (Woodhead, 
Klein,  Hankin,  Martin,  etc.) ;  Path.  Trans.  1892,  v.;  also  B.  M.  J.  of  Feb.  20  and  27, 
1892. — 88.  Lubarsch.  Fortschr.  d.  Med.  viii.  1890,  No.  17.  —  89.  Lubarsch.  Zeitschr. 
f.  klin.  Med.  xviii.  1891,  p.  421. — 90.  Metschnikoff.  See  Nos.  14  and  51. — 91. 
Nieczajeff.  Verhandl.  das  X.  Internat.  Med.  Congress,  Berlin,  1890,  ii.  pt.  3,  p. 
54.  —  92.  Sanarelli.  Ctbl.  f.  Bakt.  x.  1891,  p.  514. — 93.  Sternberg.  Am.  J.  of 
Med.  Sc.  April  1881.  —  For  the  abundant  literature  on  this  subject  consult  Bitter 
(No.  84)  and  Lubarsch  (No.  88),  as  also  the  full  bibliography  (up  to  1892)  given  by 
Sternberg  in  his  Manual  of  Bacteriology.  New  York,  1892,  and  (to  1895)  in  his  Immu- 
nity, Protective  Inoculation,  etc.    New  York,  1895. 

VIII.    Phagocytosis    in    Connection    -with    Pathogenic    Microbes  of  Various 
Diseases   (for  Shortness  Names  of  Diseases  alone  given) 

Actinomycosis: — 94.  Marchand.  Eulenhurg's  Realencyclopddie,  article  "Actino- 
mycosis."—  95.  BosTROM.  Zeigler's  Beitr.  ix.  1890.  —  96.  Pawlowsky  and 
Maksukoff.  a.  de  I'Inst.  Pasteur,  vii.  1893,  p.  544.  Anthrax: — 97.  Hess.  Virch. 
Arch.  cix.  p.  365.  —  98.  Koch.  Cohn's  Beitr.  z.  Biol,  der  Pflanzen,  ii.  1876.  —  99. 
Lubarsch.  Fortschr.  d.  Med.  1888,  p.  4.  — 100.  Metschnikoff.  Virch.  Arch,  xcvii. 
p.  502.  and  A.  de  I'Inst.  Pasteur,  i.  1887,  p.  7.  — 101.  Nutall.  Zeitschr.  f.  Hygiene, 
iv.  1888.  — 102.  Petruschky.  Zeigler's  Beitr.  iii.  1888,  p.  357,  and  Fortschr.  d. 
Med.  viii.  1890,  No.  15.  Cholera:  — 103.  Metschnikoff.  A.  de  VI.  P.  viii.  1894, 
p.  529.  —  104.  Pfeiffer  and  Wasserman.  Zeitschr.  f.  Hygiene,  xiv.  1893,  p.  59.  — 
105.  Cantacuzene.  Recherch-'s  stir  le  mode  de  destruction  du  Vibrinn  Cholerique. 
Paris,  1894.  Diphtheria :  — 106.  Gabritchewski.  A.  de  I'l.  P.  viii.  1894.-107. 
Massart.  See  No.  76.  Erysipelas:  — 108.  Metschnikoff.  Virch.  Arch.  cvii.  1887, 
p.  209,  and  numerous  other  observers.      Gonorrhoea:  — 109.  Neisser  and  all  subse- 


I  NFL  A  MM  A  TION 


137 


quent  observers  (for  bibliography  see  Sternberg).  Hog  Cholera :  — 110.  Metschnikoff. 
A.  de  VI.  P.  vi.  1892,  p.  289.  Leprosy :  — 111.  "Metschnikoff  and  Soudakkwitch. 
Virch.  Arch.  cvii.  1887,  p.  228  (and  all  recent  observers).  Malaria:  — 112.  Golgi. 
Gaz.  degli  Ospituli,  188G,  No.  53  (parasites  in  leucocytes,  as  distinguished  from  red 
corpuscles).  Mouse  Septicaemia:  —  llo.  Metschnikoff.  A.  de  I' Inst.  P.  v.  1891. 
Pathogenetic  Torulse  in  Daphnia:  — 114.  Metschnikoff.  Virch.  Arch.  xcvi.  Patho- 
genic Moulds  (Aspergillus,  etc.):  — 115.  Ribbert.  See  No.  65.  Pneumonia  (Diplo- 
coccus)  :  —  IK).  Gamaleia.  A.  de  VI.  P.  ii.  1888,  p.  445.  —  117.  Isaeff.  Ibid. 
vii.  1893,  p.  260.  — 118.  Tchistovitch.  Ibid.  iii.  1889,  p.  337.  Relapsing  Fever: 
—  119,  Metschnikoff.  Ihid.  i.  1887,  p.  329.  — 120.  Soudakewitch.  Ibid.  v. 
1891,  p.  545.  Suppuration  (Staphylococcus  pyogenes)  :  — 121.  Fleck.  Die  acute 
Entziiiidung  der  Lunge.  Dissert.,  Bonn,  1886.  — 122.  Hess.  See  No.  37.  — 123.  Hohn- 
feldt.  See  No.  38.  — 124.  Lahr.  Ueber  d.  Untergang  d.  Staph,  in  der  Lunge. 
Dissert.,  Bonn,  1887  (and  numerous  other  observers).  Swine  Erysipelas  ("  Rouget " 
or  "  Rothlauf  ") :  — 125.  Metschnikoff.  A.  de  VI.  P.  iii.  1889,  p.  289.  — 126.  ScHiJTZ. 
Arb.  a.  d.  Kaiserl.  Gesundheitsamt,  i.  1885,  p.  61.  — 127.  Tchistovitch.  See  No.  118. 
Symptomatic  Anthrax  (Quarter-evil)  :  — 128.  Ruffer.  B.  M.  J.  May  24th,  1890.  —  129. 
RuFFER.  A.  de  VI.  P.  V.  1891,  p.  673.  Tuberculosis  :  — 130.  Borrel.  See  No.  58.— 
131.  Metschnikoff.  See  No.  51.  —  1.32.  Stschastny.  Virch.  Arch.  cxv.  1889,  and  No. 
68.  Vibrio  Gamaleia  vel  Metschnikovi :  — 133.  Metschnikoff.  A.  de  VI.  Pasteur,  v. 
1891,  p.  465.  — 134.  Sanarelli.     16 Jd.  vii.  p.  225. 


IX.    On  the  Bactericidal  Action  of  the  Bodily  Humours 

135.  Behring  and  Nissen.  Zeitschr.f.  Hygiene,  viii.  1890,  p.  424.  — 136.  Buchner. 
Arch./.  Hygiene,  x.  1890,  pts.  1  and  2 ;  Centrlbl.'f.  Bakt.  v.  1889,  p.  817,  and  vi.  p.  1.  — 137. 
Emmerich  and  di  Mattel  Fortschr.  de  Med.  vi.  p.  729. — 138.  Von  Fodor.  D.  Med. 
Woch.  1887,  p.  745;  and  Ctbl.f.  Bakt.  vii.  1890,  p.  753.-139.  Hankin.  See  No.  150.— 
140.  Lubarsch.  Ctbl.f.  Bakt.  vi.  1889,  p.  841.-141.  Nissen.  Zeitschr.f.  Hygiene,  vi. 
1889,  p.  487.  — 142.  Nuttall.  Ibid.  iv.  1888,  p.  353.-143.  Pekelharing.  La  Sem.  med. 
1892,  p.  503.  — 144.  Traube  and  Gschleiden.  Jahresbr.  d.  Schlesischen  Gesell.  Iii.  1874, 
p.  179.  — 145.  Weigert.  Fortschr.  d.  3Ied.  v.  1887,  p.  733. — For  other  articles  consult 
the  works  of  Sternberg  previously  mentioned. 


X.   Upon  Extra-Cellular  Activity  and  the  Production  of  Bactericidal  and 
ToxiciDAL  Substances  from  Wandering  Cells,  etc. 

146.  Adami.  See  No.  82.  — 147.  Buchner.  Fortschr.  d.  Med.:s..  1892,  Nos.  9  and 
10;  Miinch.  Med.  Woch.  1894;  Ctbl.f.  Bakt.  xvi.  1894,  p.  738,  and  No.  86.-148. 
Denys.  La  Cellule,  1894.  — 149.  Denys  and  Havel.  Arch,  de  med.  exptlle.  vi.  1894. — 
1.50.  Hankin.  Proc.  Roy.  Soc.  xlviii.  1890,  p.  93 ;  Ctbl.  f.  Bakt.  ix.  1892,  p.  722 ;  Ibid. 
vols.  xi.  and  xii. ;  see  also  No.  85.  — 151.  Kanthack  and  Hardy.  Proc.  Rov.  Soc. 
Nov.  1,  1892.-152.  Kanthack  and  Hardy.  J.  of  Physiol.  1893.-153.  Kanthack 
and  Hardy.  Phil.  Trans.  1894.  — 1.54.  Kossel.  Ze.itschr.f.  Hygiene,  xvi.  1894.  — 155. 
Metschnikoff.  A.  de  VI.  P.  viii.  1894,  p.  706.  — 156.  Pfeiffer.  Zeitschr.f.  Hygiene, 
xvi.  1894,  p.  268,  and  xviii.  p.  1.  —  157.  Ribbert.  See  No.  65.  — 158.  TizzoNi  and  Cat- 
TANi.  Bcrl.  klin.  Wochenschr.  3.  1894. —  159.  Vaughan  and  M'Clintock.  Med.  News 
(N.Y.),Dec.  23rd,  1893. 


XI.   On  the  Part  played  by  the  Blood  Vessels  in  Inflammation 

In  addition  to  Cohnheim  (No.  6),  Hamilton  (No.  9),  Leber  (No.  12),  Reckling- 
hausen (No.  16),  Samuel  (No.  18),  Weigert  (No.  23),  and  Ziegler  (No.  24),  consult 
— 160.  Arnold.  Virch.  Arch.  liv.  1871,  on  "Development  of  Capillaries." — 161. 
Charrin  and  Gley.  Arch,  de  Physiol.  Oct.  1890.  — 162.  Israel.  Lehrbuch  d.  Path. 
Anat.~VV.'..  Samuel.  Virch.  Arch,  xliii.  1868,  p.  .552,  and  li.  1870,  p.  178  ("Change 
in  Vessel  Wall,  indiicitig  slowing  of  Current  ").  —  164.  Thiersch.  Pitha  and  Billroth' s 
Chirurgie,  1867,  i.  fit.  2,  p.  529  (on  "Now  Formation  of  Vessels").  —  Fuller  references 
given  in  Ziegleb,  (No.  24)  and  Hamilton  (No.  9). 


138  SYSTEM  OF  MEDICINE 


XII.   On  the  Diapedesis  of  Leucocytes 

165.  Addison.  Exptl.  and  Pract.  Researches  upon  Infl.  London,  1813.  — 166. 
Arnold.  Virch.  Arch.  Iviii.  1872,  Ixvi.  1874,  and  Ixviii.  1875. —1()7.  Bixz.  Virch. 
Arch,  lix.,  Ixxiii.,  and  Ixxxix. ;  Arch./,  expt.  Path.  vii.  and  xiii.  —  KiS.  Cohnheim. 
See  No.  6.-169.  Disselhorst.  Virch.  Arch,  cxiii.  18S8,  p.  108.  — 170.  LIering.  Wien. 
Acad.  Bericht.  Ivii.  1868,  p.  170  (on  the  "Adhesion  of  Corpuscles").  — 171.  Kalten- 
BRUNNER.  Exp.  circa  stttt.  sanguinis  ei  vasoruni  ininfl.  182().  — 172.  Kerner.  Pfliiger's 
Archiv,  vii.  — 173.  Lavdowsky.  Virch.  Arch,  xcvii.  — 174.  Metsohnikofp.  See  No. 
14. — 175.  Pekelharing.  Kn-c/i.  J7-c/i.  ci.  1885.  —  176.  Recklinghausen.  Strieker's 
Uandb.  Article,  "Das  Lymphgefiisssystem."- 177.  Schklarewsky.  Pfiiger's  Arch. 
i.  18(18,  pp.  603  and  657.  — 178.  Thoma.  Berl.  klin.  IFoc/i.  1886.  — 179.  Waller.  Phil. 
Mag.  xxix.  1846,  pp.  217,  298,  397. 

(a)  On  the  Effect  cf  Intra  and  Extra-Vascular  "Toxins"  upon  Dla.pedesis 

180.  Bouchard.  Essai  d'une  theoric  de  I'infection.  Verhandl.  d.  X.  Internal. 
Med.  Congr.  Berlin,  1890.-181.  Charrin.  Ibid.  ii.  pt.  3,  p.  29.  — 182.  Roger. 
Contrib.  a  I'etude  de  Vinunun.  acquire,  p.  1.— 18.3.  Ruffer.  A.  de  I'l.  P.  v.  1891, 
p.  (i7.s.  —  The  earlier  literature  of  diapedesis  is  given  in  detail  by  Wagner  (No.  22) 
and  Hamilton  (No.  9).  The  last  (German)  edition  of  Ziegler  (No.  24)  is  also  very- 
full. 

XIII.  On  the  Part  played  by  the  Nervous  System  in  Inflammation 

184.  Berkley.  A7int.  Anz.  viii.  1893,  Nos.  23  and  24,  and  ix.  1893,  Nos.  1  and 
2;  Journ.  of  C'untp.  Neurol,  iii.  1893,  p.  107;  Pathol.  Studies,  Johns  Hopkins  Univ., 
Neurology ,\\.  1894  ("Upon  Nerve  Endings  in  Vessel  Walls,  etc.").  — 185.  Charcot. 
Le(;ons  sur  les  maladies  du  syst.  nerveux.  Paris,  1873,  p.  lOl!.  — 186.  Cohnheim.  See 
No.  6.  — 187.  Dache  and  Malvoz.  A.  de  VI.  P.  vi.  1892,  p.  538  (on  "Influence  of 
Nervous  System  iu  Mycotic  Inflammations").  — 188.  De  Paolis.  Rifoi-ma  Medica, 
1889,  No.  2C0.  —  189.  Frenkel.  Arch.d.  med.  expt.  iv.  1892,  p.  638.  —  lliO.  Gergens. 
Pfliiger's  Arch.  xiii.  p.  591.  — 191.  Klebs.  Allg.  Pathol,  ii.  1889,  p.  384.-192.  Len- 
HossEK.  Arch.  f.  mikr.  Anat.  xxxix.  1892  (on  "  Nerve  Endings").  — 193.  Mitchell, 
S.  Weir.  Irjur'ies  of  Nerves.  Phila.  1872,  p.  168. — 191.  Ochotine.  Arch,  de  m^d. 
expt.  iv.  1892,  p.  245.  — 195.  Retzius.  Bi'>L  Untersuchungen,  Neue  Folge,  iii.  1891, 
p.  49,  and  iv.  — 196.  Roger.  C'oniptes  Rend.  Soc.  de  Biol.  3rd  May  1890,  and  22nd 
Nov.  1890.  — 197.  RuTiMEYER.  Arch.  f.  expt.  Pathol,  xiv.  p.  384.  — 198.  Samuel. 
Virch.  Arch,  cxxi.  — 199.  Saviotti.  Virch.  Arch.  1.  1870,  p.  592  (on  "Dilation  and 
Contraction  of  Arteries  according  to  Nature  of  Irritant"). — 200.  Severini.  La  con- 
trattilita  dei  capillari,  1881. — 201.  Wagner,  A.  Arch.  f.  klin.  Chirurg.  xi.  1869, 
p.l. 

XIV.  On  the  Part  played  by  the  Connective  Tissue  Cells  in  Inflammation 

202.  Arnold.  Arch.  f.  Mikr.  Anat.  xxx.  1887. — 203.  Baumgarten.  Virch. 
Arch.  Ixxviii.  1879;  Ueber  Tuberkel  unci  Tuberkulose,  i.  Die  Ili.stogenese  des  Tuber- 
ku'o.ienprocesses.  Berlin,  1885.-204.  Bobrel.  See  No.  58. — 205.  Coen.  Ziegler's 
Beifr.  ii.  1887. — 206.  Cornil  and  Ranvier.  See  No.  7. — 207.  Discussion  at  the 
Tenth  Internal.  Med.  Cong.  Berlin,  1890.  (Ziegler,  Marchand,  Grawitz.)  Verhandl. 
ii.  pt.  3,  p.  1.  —  208.  Fischer.  Untersuch.  ii.  die  Ileilung  von  Schnittu-vuden  der  Ilaut. 
Inaug.  Diss.  Tubingen,  1888. — 209.  Flemming.  Virch.  Arch.  Ivi.  1872,  p.  146. 
—  210.  Grawttz.  D.  Med.  Wochenschr.  1889.  No.  23,  on  "Slumbering  Cells."— 211. 
Graw-tz.  Vii-ch.  Ar'-h.  cxviii.  1889.- 212.  GrfFiTH,  J.  J.  of  Pathol,  ii.  1894 
(on  "Development  of  Wandering  from  Fixed  Cells").  —  213.  Gull  and  Sutton.  Med.- 
C'lir.  Trans.  Iv.  1872,  p.  273. — 214.  Huchard.  Traite  d"s  maladies  du  cu!U-\  Paris, 
1889  (on  "Dystrophic  Sclerosis "). —  215.  Krafft.  Ziegl.  Beitr.  i.  1884.- 216.  . 
Marchand.  Ibid.  iv.  188^.  —  217.  Metschnikoff.  Biol.  Centrbl.  1883,  p.  561; 
A.  de  VI.  P.  vi.  1892,  p.  1  (on  "Development  of  Wandering  from  Fixed  Cells  ").— 218. 
NiKiFOROFF.     Ziegl.  Beitr.    viii.    1890,    p.  419. — 219.    Podwyssozki.    Ibid.  i.   1884. 


THE  DOCTRINE    OF  FEVER  139 

aud  ii.  1886.-220.  Ranvier.  Comptes  rend,  de  I' Acad.  d.  Sc.  1891,  p.  84.3. —  221. 
Reinke.     Ziegl.  Beltr.  v.  1889.-222.  Roy  and  Adami.    B.  M.  J.  15th  Dec.   1888. 

—  223.  ScHELTEMA.  D.Med.  W^oc/j.  1887,  p.  463.  —  224.  Sherrington  and  Ballance. 
J.  of  Physiol.  1889,  p.  856.-225.  Soudakewitch.  A.  de  I'l.  P.  vi.  ]8!i2,  p.  13.— 
226.  Stricker.  Studipn  a.  d.  Inst.  f.  exp.  Pathol.  Vienna,  i.  1870.  —  227.  Toupet. 
Des  modifications  cellul.  dans  Vinjl.  simple  du  peritoine.  Thesis,  Paris,  1887. — 228. 
Ziegler.     Sxp.  Untersttch.  ii.  die  Herkimft  der   Tuberkelelement.     Wurzburg,  1875. 

—  229.  Ziegler.  Untersuch.  ii.  pathol.  Bindgewehs-  und  Gefdssneubildunr/.  Wurz- 
burg, 187(). — 230.  Grawitz,  No.  211,  gives  a  very  full  bibliography  up  to  1889  of  the 
part  played  by  the  connective  tissue  cells.  Consult  also  Virchow  (No.  21),  Cohnheim 
(6),  Metschnikoff  (14),  and  Ziegler  (24).  The  later  German  editions  of  Zi'^.f/ler's 
Handbook  contain  a  very  judicial  discussion  of  the  relationship  of  fibrous  hyperplasia 
to  inflammation. 

XV.   On  the  Temperature  Changes  in  Inflamed  Areas 

231.   Billroth  and  Hufschmidt.    Arch.  f.  klin.  Chirurg.  vi.  1864,  p.  373.  —  232. 
Hunter,  John.     On  the  Blood,  Inflammation,  and  Gunshot   Wounds.    London,  1793. 

—  233.  HuppERT.  Arch.  d.  Ileilktinde,  xiv.  1873,  p.  73.  —  234.  Jacobson  and  Bern- 
hardt. Med.  Centlbl.  1869,  No.  19.  —  235.  Laudien.  Ibid.  1869,  No.  19.  —  236. 
Schneider.  Ibid.  1870,  No.  34.-237.  Simon.  Holmes's  System  of  Surgery,  1860, 
article  "  Inflammation." — 238.  Weber,  O.    DeiiZsc/i.  £"/««.  1864,  Nos.  43  and  44. 

J.  G.  A. 


THE   DOCTEINE   OF  FEVER 

This  essay  is  divided  into  two  parts.  In  the  first,  which  is  intro- 
ductory, the  subject  is  treated  in  the  order  of  time.  Beginning  with 
Virchow  an  account  is  given  of  his  doctrine  of  Fever ;  then  follow  the 
doctrines  of  his  most  distinguished  contemporaries  and  successors  in  the 
field  of  Pathology  —  Traube,  Liebermeister,  Senator,  Leyden,  Cohnheim. 
The  second  part,  entitled  "  Recent  Researches,"  relates  to  the  years 
which  have  elapsed  since  Cohnheim's  death  in  1874.  The  aspects  of 
each  branch  of  the  subject  of  Fever  are  dealt  with  under  the  following 
heads  :  —  Disorder  of  Nutrition,  Thermogenesis,  Pyrexia,  Cerebral  Heat- 
Centres,  Antipyretics,  J^tiology. 

In  a  concluding  section  I  have  endeavoured  to  set  forth  that  view  of 
the  nature  of  Fever  which,  in  my  judgment,  harmonises  best  with  our 
present  knowledge  of  the  subject. 


Part  I.  —  Historical  Retrospect,  1850-1883 

Of  the  scientific  conceptions  relating  to  the  origin  and  nature  of 
diseases,  out  of  which  the  science  of  pathology,  as  we  now  understand  it, 
was  built  about  fifty  years  ago  by  Virchow  and  his  immediate  prede- 
cessors, none  were  more  fundamental  than  those  relating  to  fever  and 
inflammation.  These  conceptions  were  so  entirely  unconnected  with 
the  theories  which  had  previously  been  taught   under  the  name  of 


I40  SYSTEM  OF  MEDICINE 

General  Pathology  that,  in  tracing  the  development  of  our  present 
knowledge,  no  advantage  would  be  gained  in  going  farther  back  in 
our  retrospect  than  the  middle  of  the  present  century. 

Johannes  Mtlller  —  whose  teaching  was  the  spring  of  the  great  move- 
ment in  all  matters  relating  to  the  nature  of  disease,  of  which  Virchow 
was  the  exponent —  had  compared  fever  to  a  reflex  process  of  which  the 
phenomena  were  the  response  to  stimulation  of  the  spiaal  cord  by  means 
of  "organic  nerves."  About  the  same  time  the  discovery  by  E.  H. 
Weber  of  the  inhibitory  nerve  of  the  heart  had  suggested  new  ideas 
as  to  the  way  in  which  the  central  nervous  system  governs  the  cir- 
culation. He  had  shown  that  this  influence  is  exercised,  so  far  as  the 
heart  is  concerned,  by  two  channels  of  which  the  actions  are  antagonistic, 
that  of  the  one  exciting,  that  of  the  other  quelling.  As  regards  the  blood- 
vessels, constricting  or  tonic  nerves  had  been  discovered,  but  it  remained 
for  Schiff  to  find  out  that  there  are  also  nerves  which  control  vascular 
tone. 

Out  of  the  principle  of  antagonism  which  the  discovery  of  Weber 
involves,  there  developed  in  the  fertile  mind  of  Virchow  the  notion  (he 
declined  to  call  it  a  theory)^  oi  fever  as  a  neurosis,  which  was  expressed 
in  his  treatise  on  Pathology  published  in  1853.  Students  of  pathology 
were  taught  by  him  for  the  first  time  that  fever  was  not  an  over-activity, 
but  a  paralytic  state ;  that  its  excesses  —  the  over-action  of  the  heart,  the 
"  tension  of  the  whole  vascular  system,"  "  the  abnormal  production  of 
heat "  —  were  the  expression  oi  failure  of  control,  of  weakness  rather  than 
strength.  But  of  the  way  in  which  this  control  was  exercised,  or  how  it 
failed,  he  could  at  that  time  give  no  explanation ;  he  contented  himself 
with  suggesting  that  the  "  moderating  centres "  could  influence  not 
merely  the  heart  and  blood-vessels,  but  also  the  "  /Stofftvechsel,"  what  we 
now  call  metabolism.  According  to  Virchow,  the  nervous  system  in 
fever  loses  its  control  over  all  the  organic  processes,  and  in  this  the 
essence  of  the  febrile  state  consists. 

In  1855  Traube  (1)  made  the  discovery  that  in  fever  the  elimination 
of  nitroyen  is  increased.^  The  fact  seemed  to  indicate  that  if  fever  be  a 
neurosis,  there  must  either  be  "  trophic  nerves  "  by  which  the  chemical 
processes  of  the  organism  can  be  controlled  —  for  how  else  could  an 
affection  of  the  nervous  system  bring  about  tissue  disintegration  ?  —  or  we 
must  suppose,  as  did  Dr.  Parkes,  that  the  cause  of  fever,  the  catalytic 
agent  of  which  Virchow  wrote,  directly  attacks  the  tissues.  Traube's 
explanation,  however,  differed  from  both  of  these,  for  he  thought  that 
the  admitted  increase  of  disintegration  of  albuminous  compounds  was 
secondary  to  the  disturbance  of  the  circulation.  Of  the  nature  of  this 
disturbance  he  framed  a  theory  which,  whether  true  or  not,  exercised  a 
greater  influence  than  any  other  on  the  progress  of  investigation.    It  may 

1  "  Das  Alles  ist  gewiss  sehr  wenig  und  geniigt  auch  nicht  annahernd  um  eine  Theorie 
daratif  zn  bauen."  —  Virchow,  Handb.  der  Pathnl.,  p.  80. 

2  It  is  noteworthy  that  the  paper  in  which  this  discovery  was  made  known  is  one  of 
three  pages. 


THE  DOCTRINE    OF  FEVER  141 

be  shortly  stated  as  follows  :  — Traube,  like  Virchow,  assumes  the  exist- 
ence of  a  fever-producing  agent,  but  holds  that  its  action  is  exercised, 
not  on  inhibitoiy,  but  on  tonic  vaso-motor  nerves  ;  that  the  first  physio- 
logical result  of  this  influence  is  contraction  of  the  peripheral  arterioles, 
and  consequently  a  rapidly  diminished  flow  of  blood  to  the  surface ;  the 
temperature  of  the  skin  declines,  and  a  rapid  rise  of  internal  temperature 
follows.  To  the  increase  of  the  difference  between  the  external  and 
internal  temperatures  he  attributes  the  rigor  of  accession.  The  decline 
of  tem.j)erature  is  due  to  nothing  more  than  the  cessation  of  the  vascular 
spasm.  So  hard  and  fast  a  statement  of  what  happens  in  fever  was 
found  difficult  to  accept ;  and  it  soon  appeared  that  it  was  not  in  accord- 
ance with  observation.  In  the  initial  stage  its  utility  as  a  "  working 
hypothesis  "  consisted  in  this,  that  it  gave  prominence  to  the  influence 
of  the  nervous  system  on  the  liberation  of  heat  at  the  surface,  and  to  the 
adjustments  by  which  this  liberation  is  adapted  to  the  requirements  of 
the  organism ;  thus  investigation  was  guided  in  a  direction  which  the 
event  has  proved  to  be  the  right  one. 

Liebermeister  was  the  first  pathologist  who  attempted  to  investi- 
gate fever  calorimetrically,  the  outcome  of  his  work  being  firstly  to 
demonstrate  that  even  when  the  surface  loss  is  entirely  annulled  by 
raising  the  temperature  of  the  environment  to  such  a  point  that  no  heat 
is  parted  with,  the  increase  of  bodily  temperature  is  not  so  rapid  as  in 
the  initial  stage  of  many  fevers ;  and  that,  consequently,  the  latter  could 
not  be  explained  on  Traube's  principle ;  secondly,  to  give  prominence  to 
two  doctrines  of  "his  own,  which  for  a  long  time  were  very  generally 
accepted.  Liebermeister's  doctrines  were  —  (1 )  that  in  fever,  as  in  health, 
constancy  of  temperature  is  ensured  by  the  adaptation  of  production  to 
discharge,  not  of  discharge  to  production,  as  Traube  taught;  and  (2) 
that  in  fever  bodily  temperature  is  regulated  in  the  same  way  as  in 
health,  with  this  difference  that  the  norma  has  become  several  degrees 
higher.  In  fever  the  organism,  according  to  Liebermeister,  strives  not 
towards  the  temperature  98-6°  F.,  but  towards  104°  or  106°,  as  the  case 
may  be.  Liebermeister's  inference  from  his  experiments,  that  arrest  of 
surface  loss  is  inadequate  to  produce  pyrexia,  will  not,  as  we  shall  see, 
bear  experimental  criticism.  To  the  theory  stated  above  much  greater 
interest  attaches,  because  if  illogical  in  form,  it  conceals  an  important 
truth.  An  abnormal  norma  may  be  a  contradiction  in  terms,  but  the 
fact  that  the  bodily  temperature  in  continued  fever  approaches  a  certain 
limit  which  it  does  not  tend  to  exceed,  is  one  which  will  not  be  dis- 
puted.^ Its  meaning,  however,  will  be  more  advantageously  discussed  in 
a  subsequent  jjaragraph. 

1  There  are  many  distinguished  pathologists  who  still  hold  to  Liebermeister's  doctrine 
that  in  fever  the  temperature  is  adjusted  to  a  new  norma.  The  facts  which  seem  to  sup- 
port it  may  be  exemplified  in  the  following  experiment:  — 

It  is  possible  either  to  raise  or  to  depress  the  temperature  of  a  healthy  person  by 
gradually  cooling  or  warming  the  water  of  a  warm  bath  in  which  he  is  placed.  If  by  this 
means  you  depress  the  temperature  of  his  body  as  much  as  \  degree  F.  he  shivers,  if  you 
raise  it  to  the  same  amount  he  perspires.    Repeating  the  experiment  on  a  fever  patient 


142  SYSTEM  OF  MEDICINE 

At  this  point  the  subject  was  taken  up  by  Senator,  the  most 
successful,  if  not  the  ablest,  of  all  the  investigators  of  fever.  We  have 
seen  that  although  Traube  and  Liebermeister  differed  very  widely  in 
their  views,  they  agreed  with.  Virchow  in  regarding  fever  as  a  disorder  of 
that  function  of  the  nervous  system  by  which  constancy  of  temperature 
is  maintained  —  the  function  of  thermotaxis.  Traube,  being  both  a 
physiologist  and  a  physician,  was  guided  by  the  application  of  physio- 
logical inferences  to  clinical  facts,  Liebermeister  very  largely  by  obser- 
vations relating  to  the  treatment  of  fever  by  the  tepid  bath.  Both 
recognised  regulating  centres,  but  as  regards  the  way  in  which  they 
act  their  views  were  antagonistic ;  the  one  relied  on  vaso-motor  nerves, 
the  other  on  the  control  of  heat-producing  chemical  processes  by  the 
nervous  system.  To  Senator  it  appeared  that  the  time  had  come  for 
investigating  the  subject  from  all  sides,  experimental  and  clinical.  Fever 
comprehends  vascular,  thermal,  and  metabolic  phenomena,  and  no  in- 
vestigation seemed  likely  to  be  of  value  unless  all  three  were  dealt 
with. 

In  the  laboratory,  Senator  compares  for  the  first  time  the  discharge 
of  heat  of  animals  in  which  fever  had  been  produced  artificially,  with  the 
previous  heat  loss  of  the  same  animal  atid  with  the  heat  loss  after  re- 
covery, employing,  at  the  same  time,  the  best  methods  then  available 
for  measuring  the  respiratory  exchange  and  the  elimination  of  nitrogen. 
One  of  the  most  noteworthy  results  was  that,  while  the  nitrogenous 
waste  was  considerably  increased,  there  was  no  increase  whatever  of  the 
consumption  of  fat,  and  no  evidence  of  any  greater*  increase  of  the 
respiratory  exchange  than  could  fairly  be  attributed  to  the  existence 
in  fever  of  conditions  more  favourable  to  the  discharge  of  carbonic 
acid  gas. 

As  regards  the  discharge  of  heat,  measured  calorimetrically  by  a 
method  far  more  accurate  than  that  of  Liebermeister,  the  results  were 
negative.  In  the  initial  stage  the  surface  heat  loss  appeared  to  be 
diminished,  but  it  could  be  ascertained  that  this  diminution  was  compen- 
sated later.  In  respect  of  the  discharge  of  nitrogen.  Senator's  clinical 
observations  confirmed  and  extended  what  had  previously  been  observed, 
and  showed  in  this  respect  a  complete  correspondence  between  natural 
and  artificial  fever.  He  estimated  the  rate  of  elimination  of  nitrogen  in 
many  instances  to  be  more  than  double,  i.e.  to  be  increased  in  a  degree 
out  of  all  proportion  to  any  increase  which  could  be  supposed  to  take 
place  in  the  rate  of  heat  production. 

At  the  time  that  Senator  published  his  Researches  on  the  Process  of 
Fever  (1873),  Leyden  was  engaged  in  clinical  investigations  of  the  same 
subject  (4),  with  results  which  differed  from  Senator's  in  some  points  of 
importance.     The  absence  in  animals  of  any  marked  increase  of  the 

you  obtain  a  similar  result,  with  this  difference,  that  if  the  temperature  is  say  104''  F.,  he 
shivers  at  103-7°  and  perspires  at  104'3' ;  whereas  the  healthy  person,  whose  normal  tem- 
perature is  98'8^,  shivers  at  98-'S°  and  sweats  at  9!)'2°.  The  explanation  is  that  it  is  the 
change  of  temperature  that  produces  the  reaction,  and  the  direction  which  determines  its 
cliaracter  —  shivering  if  it  is  descending,  sweating  if  it  is  ascending. 


THE   DOCTRTNR    OF  FEVER  143 

respiratory  discharge  of  water  and  carbon  dioxide  had  led  Senator  to 
conclude  that  in  fever  the  only  essential  change  in  metabolism  relates  to 
the  increased  disintegration  of  proteid.  On  this  point,  however,  Senator 
was  for  the  most  part  guided  by  experiments  on  animals.  Leyden, 
therefore,  directed  his  efforts  to  ascertain  the  condition  of  the  respiratory 
exchange  and  thermogenesis  in  man.  Considering  that  in  continued 
fever  there  is  no  obvious  indication  of  increased  thermolysis,  it  was 
desirable  to  test  this  by  more  exact  observation.  For  this  purpose  he 
employed  a  method  of  calorimetry  which  can  be  used  clinically  without 
inconvenience  to  the  patient.  Enclosing  a  limb  in  a  cylindrical  calori- 
metrical  chamber,  he  estimated  the  loss  of  heat  by  escape  of  water, 
evaporation  and  radiation  of  the  limb  in  relation  to  the  surface,  and 
calculated  therefrom  the  whole  surface-loss  of  the  body,  with  the  result 
that  in  fever,  even  when  there  is  no  visible  perspiration,  the  thermolysis 
may  be  40  per  cent  greater  than  in  health.  Having  arrived  at  this 
result  by  clinical  observation  he  had  recourse  to  experiment  (5),  in  the 
hope  of  confirming  it  by  investigating  the  respiratory  exchange  in 
animals.  The  result  was  that  in  all  cases  the  rise  of  temperature  was 
accompanied  by  a  corresponding  increase  of  the  discharge  of  carbon 
dioxide,  the  amount  and  duration  of  which  was  such  as  to  preclude  the 
possibility  of  attributing  it  to  the  greater  activity  of  the  respiratory 
movements.  Shortly  after  the  completion  of  these  observations  a  series 
of  experiments  were  made  under  Pfltlger's  direction  (6),  in  which  both 
the  oxygen  intake  and  the  output  of  carbon  dioxide  in  normal  and 
fevered  animals  were  compared.  These  led  the  great  physiologist  to 
incline  to  Liebermeister's  view,  that  normal  regulation  consists  in  the 
adaptation  of  production  to  discharge,  and  that  increased  production  is 
an  essential  element  of  fever. 

By  way  of  conclusion  to  this  retrospect  I  propose  to  state  summarily 
how  the  question  of  fever  presented  itself  to  the  two  pathologists  most 
competent  to  discuss  it,  —  Senator  and  Cohnheim. 

Cohnheim,  like  Pfltlger,  in  the  Lecture  on  Fever  which  concludes  the 
second  volume  of  his  General  Pathology,  sums  up  in  favoiir  of  the  doc- 
trine that  the  nervous  system  presides  over  thermogenesis  no  less  directly 
than  over  thermolysis.  He  accordingly  seeks  for  evidence  of  increased 
production  of  heat  throughout  the  whole  febrile  process. 

In  the  initial  stage,  particularly  when  the  rise  of  temperature  is  rapid, 
he  admits  that  the  cutaneous  circulation  is  restricted,  but  not  that  this 
restriction  is  the  cause  of  the  rise.  The  sensation  of  chill  is  due  to  the 
suddenness  of  the  diminution  of  temperature  at  the  surface :  when  the 
change  occurs  gradually,  it  is  absent.  It  is  succeeded,  in  the  fastigiura, 
by  a  feeling  of  Avarmth  which  means  that  the  constricted  vessels  relax. 
He  leaves  undecided  whether  this  is  due  to  the  intervention  of  inhibitory 
nerves  or  not,  but  emphasises  the  fact,  as  evidence  of  vaso-motor  disturb- 
ance, that  the  more  favourable  state  of  the  ciitaneous  circulation  which 
characterises  the  beginning  of  the  fastigium  is  liable  to  interruption  by 


144  SYSTEM   OF  MEDICINE 


the  recurrence  of  chills,  in  which  the  skin  becomes  dry  and  the  tempera- 
ture tends  to  rise.  The  critical  sweating  is  of  course  regarded  by  Cohn-, 
heim  as  a  sign  of  increased  flow  of  blood  to  the  surface,  which  he  does  not 
hesitate  to  attribute  to  the  influence  of  dilating  nerves.  Of  cutaneous 
nerves  of  secretion  little  was  known  at  the  time  when  he  wrote. 

The  remarkable  fact  that  in  fever  the  diurnal  range  of  variation  is 
much  greater  than  in  health,  Cohnheim  attributes  rather  to  fluctuations 
in  thermogenesis  than  to  changes  in  the  circulation.  This  view  seems 
to  him  supported  by  the  consideration  that  in  relapsing  fever  the  efiicient 
cause  of  pyrexia  is  plainly  the  presence  of  spirilla  in  the  blood,  and  that 
these  would  influence  thermogenesis  rather  than  surface  loss.  Had  he 
known  how  close  is  the  relation  between  the  successive  stages  of  ague 
and  the  life  history  of  the  organism  which  causes  it,  he  would  have  been 
confirmed  in  his  conclusion  that  in  periodical  fevers  the  periodicity  is 
a  function  of  the  cause,  not  of  the  disease. 

In  common  with  Virchow  and  all  modern  pathologists.  Senator 
regards  fever  as  a  disorder  of  temperature  regulation,  but  for  him  the 
term  regulation  connotes  "  regulation  by  the  cutaneous  circulation."  It  is 
thermolysis,  not  thermogenesis,  that  is  in  the  first  instance  disordered. 
This  disorder  is  most  marked  in  the  initial  stage,  but  exists  in  the  fasti- 
gium,  declining  towards  its  close.  Its  presence  manifests  itself  in  dry- 
ness of  the  skin  and  maintenance  of  the  high  temperature,  but  of  these 
two  neither  is  caused  by  the  other ;  both  are  directly  dependent  on  the 
nervous  system. 

Finally,  Senator  regards  the  relation  between  the  constituents  of 
fever  as  a  loose  one :  he  believes  there  is  no  absolute  inter-dependence 
of  the  disorder  of  nutrition  and  the  pyrexia.  The  only  invariable 
causal  relation  is  that  which  subsists  between  pyrexia  and  disorder 
of  the  cutaneous  circulation. 


Part  II. — Recent  Researches 

I.  The  Disorder  of  Nutrition  in  Fever.  —  (a)  The  Respiratory  Ex- 
change. —  When,  after  a  pause  of  several  years,  the  investigation  of  the 
febrile  exchange  of  material  was  resumed  both  from  the  clinical  and  the 
experimental  side,  the  new  methods  for  measuring  the  normal  exchange 
which  had  in  the  meantime  been  devised,  and  the  discoveries  they  had 
rendered  possible,  afforded  to  the  pathologist  advantages  which  he  did  not 
before  possess.  With  reference  to  the  gaseous  exchange  particularly,  the 
apparatus  devised  by  Professor  Zuntz  had  rendered  it  possible  to  measure 
the  oxygen  intake  and  the  discharge  of  carbon  dioxide  in  man  for  very 
short  as  well  as  for  longer  periods,  with  an  accuracy  which  had  before 
been  attainable  only  in  investigations  on  small  animals ;  and  by  this 
means  very  important  new  information  had  been  obtained  as  to  the 
respiratory  exchange  in  man,  particularly  by  Lehmann  and  Zuntz's  ex- 
periments on  the  fasting  men  Cetti  and  Breithaupt.     It  was  under  these 


THE  DOCTRINE    OF  FEVER  145 

conditions  that  Dr.  F.  Kraus,  using  the  same  apparatus  and  method, 
entered  on  his  investigation  of  the  respiratory  process  in  human  fever, 
his  aim  was  to  obtain  data  relating  to  the  febrile  exchange  of  gases  in 
such  form  that  the  rate  of  discharge  of  carbon  dioxide  and  that  of  the 
oxygen  intake  should  be  determined  at  short  intervals,  and  that,  in  order 
to  secure  constancy  and  uniformity  as  regards  the  state  of  nutrition  of 
the  patient,  each  period  of  observation  in  fever  should  begin  at  a  sufficient 
interval  of  time  (sixteen  hours)  after  the  last  meal,  and  be  repeated  in 
convalescence.  The  general  result  of  this  inquiry  was  that  in  all  cases  of 
acute  fever  there  is  increase  of  respiratory  activity  {i.e.  greater  frequency 
and  depth  of  respirations),  and  that,  whenever  this  is  the  case,  the  actual 
intake  of  oxygen  is  increased,  but  that  when  the  febrile  state  is  pro- 
longed this  effect  soon  subsides,  notwithstanding  the  continued  abnormal 
elimination  of  nitrogen.    It  v^as  further  found  that  in  man,  as  in  animals, 

the  respiration  quotient  [——■]  remained  unaltered.     As  regards  the 

degree  of  augmentation  of  both  factors  the  results  were  in  satisfactory 
accordance  with  those  yielded  by  observations  on  artificial  fever.  They 
were  further  confirmed  by  a  subsequent  series  of  observations  on  the 
febrile  state  induced  in  tuberculous  patients  by  the  use  of  tuberculin. 
The  observations  of  Dr.  Loewy  in  the  Charite  and  Moabit  hospitals 
at  Berlin  were  made  in  the  same  way,  with  perhaps  even  greater  exacti- 
tude, and  particularly  with  more  careful  attention  to  the  state  of  the 
patient  and  the  stage  of  the  disease.  The  results  differed  in  some  respects 
from  those  of  Kraus,  but  the  differences  were  of  little  moment.  Thus  it 
was  found  that  although  there  was  usually  augmentation  of  the  oxygen 
intake  with  or  without  increase,  depth,  or  frequency  of  respiration,  this 
was  only  observed  when  the  temperature  was  actually  rising;  so  that  Dr. 
Loewy  was  led  to  regard  this  effect  as  a  character  of  the  initial  stage,  and 
to  associate  it  with  the  shivering  of  the  skeletal  muscles  and  the  increased 
tone  of  the  vascular  muscles  which  are  the  concomitants  of  this  stage. 

In  many  cases  the  respiratory  quotient  remained  the  same ;  but  in 
others  there  was  a  diminution,  which  might  have  been  regarded  as  a  con- 
sequence of  the  febrile  state  had  not  the  general  principle  which  serves  as 
the  pathologist's  guide  in  all  investigations  relating  to  febrile  metabolism 
been  attended  to,  namely,  that  the  comparison  of  the  pathological  state 
with  the  normal,  as  a  guide  to  the  correct  interpretation  of  the  results, 
can  only  be  relied  upon  when  care  is  taken  to  compare  data  relating 
to  the  same  individual  at  different  times ;  or,  if  this  cannot  be  done,  to 
make  the  comparison  between  normal  and  fevered  individuals  in  the 
same  physiological  conditions  as  regards  nutrition.  The  exact  observa- 
tions already  mentioned  by  Lehmann  and  Zuntz  (9)  as  to  the  two  fasting 
men  afforded  the  information.  By  comparing  Loewy's  results  with  theirs, 
it  is  seen  that  the  diminution  of  the  respiratory  quotient  which  he  observed 
in  his  fever  cases  was  normal  for  a  person  on  fever  diet. 

The  general  result  is  that  in  man  the  respiratory  exchange  is  not 
materially  altered  in  fever  either  in  quantity  or  quality,  and  that  when  it 

VOIi.    I  r 


146  SYSTEM  OF  MEDICINE 

is  increased  the  increase  is  not  to  be  regarded  as -an  essential  character  of 
the  febrile  state,  but  rather  as  an  effect  of  some  abnormal  form  of  muscular 
activity.  Comparing  this  statement  with  the  experimental  results  ob- 
tained by  Liebermeister,  which  led  him  to  believe  that  in  the  initial  stage 
the  respiratory  exchange  was  often  doubled  or  trebled,  the  reader  will  at 
once  see  that  the  key  to  the  apparent  discrepancy  is  to  be  found  in 
oxidation  processes  which  are  associated  with  muscular  contraction,  but 
have  only  a  secondary  connection  with  fever. 

(6)  The  Discharge  of  Nitrogen.  —  The  fact  that  the  rate  of  discharge  of 
nitrogen  by  the  kidneys  in  fever  is  equal  to  or  even  greater  than  that 
which  prevails  in  health,  notwithstanding  that  the  intake  of  nitrogen  is 
reduced  to  a  minimum,  has  been  long  familiar  to  pathological  students. 
First  discovered  and  made  known  by  Traube  (10)  in  1855,  it  was  in- 
vestigated clinically  by  Ringer  in  1859,  experimentally  by  Naunyn 
(1870),  Senator,  and  many  others.  It  has  also  been  long  known  that 
on  the  whole  the  elimination  of  nitrogen  r^uns  with  the  temperature 
(Huppert,  1866)  (12) ;  that  the  daily  discharge  is  often  more  than  double 
what  it  would  be  in  a  healthy  person  on  fever  diet ;  that  although  the 
increase  of  nitrogen  elimination  l>egins,  as  was  observed  by  Einger, 
before  the  temperature  rises,  the  rate  of  elimination  is  greatest,  not 
during  the  initial  stage,  but  at  an  early  period  in  the  fastigium,  and 
linally  that  defervescence  is  often  followed  by  an  epicritical  increase. 

The  discharge  of  nitrogen  affords  much  plainer  indications  in  fever 
than  the  respiratory  exchange ;  it  unquestionably  denotes  that  proteid 
material  is  being  disintegrated ;  and  the  rate  at  which  this  takes  place 
can  be  easily  estimated  from  that  of  the  discharge  of  nitrogen.  The 
fevered,  like  the  starved  organism  maintains  itself  on  its  own  proteid 
and  fat.  It  discharges  nitrogen  by  the  kidneys,  carbon  chiefly  by 
respiration.  Modern  methods  of  research  enable  us  to  determine  the 
rate  of  both  discharges  with  exactitude,  and  thereby  to  ascertain  how 
much  proteid  and  how  much  fat  the  organism  uses  per  hour  or  day 
for  its  maintenance.  Such  investigations  are  required,  not  for  the  pur- 
pose of  confirming  the  well-established  observation  that  in  fever  disin- 
tegration of  proteid  is  increased,  but  with  a  view  to  the  much  more 
difficult  question  whether  the  febrile  disorder  of  metabolism  is  of  the 
same  nature  as  that  which  occurs  in  inanition,  and  is  dependent  on  the 
inability  of  the  individual  to  take  nourishment,  or  is  partly  or  wholly  the 
result  of  some  change  in  the  living  substance  of  such  a  nature  as  to  render 
it  more  prone  to  disintegration.  As  already  indicated,  the  only  way  to 
answer  this  question  is  by  comparing  the  exchange  of  the  fevered  indi- 
vidual with  that  of  the  normal  man  who  abstains  from  food,  or  of  the 
animal  which  is  deprived  of  it.  In  animals  the  comparison  can  be  made 
with  a  degree  of  exactitude  which  cannot  be  approached  in  man.  The 
method  to  be  followed,  therefore,  consists  in  first  ascertaining  with  pre- 
cision v/hat  happens  in  artificial  fever,  and  then  using  the  data  so  obtained 
as  a  basis  for  our  observations  on  man.  And  it  is  important  to  notice 
that  in  relation  to  a  question  like  the  present,  the  common  objection  that 


THE  DOCTRINE    OF  FEVER  147 

the  processes  of  nutrition  in  a  small  rodent  cannot  be  applied  to  man  does 
not  hold.     If  our  object  were  to  obtain  data  for  a  general  view  of  the 
whole  process  of  nutrition  in  man,  those  furnished  by  observations  on  the 
rabbit,  for  example,  would  be  inadequate.     But  the  question  now  before 
us  is  much  more  elementary.     If  it  can  be  shown  that  fever  can  be  pro- 
duced in  the  rabbit,  and  that  it  is  accompanied  by  a  disintegration  of 
proteid  which  is  obviously  of  the  same  nature  as  that  which  we  observe 
in  man,  we  are  justified  in  using  the  precise  knowledge  which  the  experi- 
mental method  affords  us,  as  a  key  to  the  interpretation  of  clinical  obser- 
vations made  under  circumstances  less  favourable  to  perfect  accuracy. 
As  regards  the  rabbit  it  has  been  further,  and  Avith  much  more  reason, 
objected  that  its  nutritive  process  is  subject  to  irregularities  which  it  is 
difficult  to  account  for,  and  which  unfit  it  for  observations  the  value  of 
which  depends  on  the  constancy  of  the  observed  phenomena.    But  even 
this  objection  admits  of  an  answer ;  for  it  has  been  found  that,  in  animals 
deprived  of  food,  a  condition  is  very  soon  reached  in  which  the  discharge 
of  nitrogen  becomes  constant.    This  constancy  obviously  denotes  that  the 
nitrogenous  material  derived  froin  the  food  last  taken  has  been  used  up. 
In  inanition  where,  as  has  been  said,  the  organism  feeds  upon  itself, 
the  ordinary  process  of  life  is  so  modified  that  tissue  no  longer  maintains 
its  integrity.     It  wastes,  and  by  wasting  supplies  the  material  for  the 
maintenance  of  systemic  life.     In  the  rabbit  this  waste  is  sufficiently 
constant  for  the  purposes  of  investigation.    Thus  Dr.  May  in  his  recent 
research  on  the  exchange  of  material  in  fever,  found  that  in  eight  rabbits 
on  the  third  and  fourth  day  of  inanition,  the  daily  discharge  of  nitrogen 
was  (with  little  variation)  O'OoS  per  cent  of  the  body  weight :  it  could 
be  assumed,  therefore,  with  certainty  that  when,  by  inducing  fever,  this 
amount  was  increased  —  e.g.  to  0-066  per  cent  —  this  increase  was  due  to 
exaggeration  of  the  normal  elimination  of  nitrogen.     That  in  fever,  as  in 
inanition  without  fever,  the  increased  discharge  of  nitrogen  represents 
disintegration  of  tissue  can  scarcely  be  doubted ;  but  the  immediate  cause 
of  this  disintegration  admits  of  discussion.     In  the  absence  of  disease,  if 
I  may  so  express  myself,  the  tissues  of  the  starved  body  yield  to  necessity. 
Sugar,  derived  from  the  digestion  of  amylaceous  food,  being  no  longer 
available  for  the  maintenance  of  respiration,  proteid  goes  to  meet  the  in- 
exorable requirements  of  the  organism.     In  fever  there  is  no  prima  facie 
reason  for  supposing  that  a  new  process  is  brought  into  existence,  or  that 
the  state  of  things  is  not  the  same  as  in  inanition.    But  the  question  can- 
not fail  to  suggest  itself  whether  in  fever  the  organised  inaterial  is  more 
labile  than  it  is  in  health,  i.e.  that  the  direct  injury  which  it  receives 
from  the  fever-producing  cause  (the  nature  of  which  will  be  discussed 
later)  renders  it  less  able  to  resist  the  demand  of  the  organism.     The 
j^rounds  for  this  very  generally  accepted  assumption  are  as  regards  the 
initial  stage  of  fever  not  very  substantial.     Eventually  the  living  mate- 
rial of  the  body  no  doubt  suffers  from  the  continuance  of  high  temperature 
and  defective  nutrition;  but  there  is  no  reason  for  supposing  that  this 
damage  is  the  precursor  of  the  general  disorder.   In  favour  of  the  opposite 


148  SYSTEM  OF  MEDICINE 

view  —  namely,  that  the  disintegration  is  essentially  dystrophic  —  there 
are  several  arguments.  If  the  proteid  disintegration  of  fever  were  of  a 
different  nature  from  that  of  inanition,  we  should  expect  that  the  prod- 
ucts would  be  different.  It  has  indeed  been  suggested  that  the  presence 
of  acetone  in  the  urine  in  febrile  diseases  indicates  that  is  so ;  but  the 
investigation  of  the  cases  of  voluntary  starvation  (Cetti  and  Breithaupt) 
by  Lehmann  and  Zuntz  have  shown  that  acetonuria  belongs  as  much  to 
inanition  as  to  fever.  We  know  also  that  this  condition  is  an  accom- 
paniment of  many  wasting  diseases  (particularly  cancer)  in  which  fever 
is  absent.  Another  reason  for  the  same  view  is  that  in  fever  the  nitro- 
genous waste  can  be  diminished  by  a  suitable  diet.  In  fever  glycogen 
disappears  from  the  liver,  and  cannot  be  replaced  by  the  administration 
of  amylaceous  food :  this  obviously  means  that  the  supply  of  carbohy- 
drate in  the  organism  is  exhausted  early,  and  that  in  consequence  the 
organism  begins  almost  at  once  to  feed  on  itself.  This  consideration 
led  Dr.  May  to  make  experiments  for  the  purpose  of  ascertaining  whether 
in  his  fasting  rabbits  the  extra  consumption  of  proteid  could  be  pre- 
vented by  the  administration  of  grape  sugar,  i.e.  of  a  carbohydrate  ready 
for  immediate  metabolism.  '  In  an  inanition  without  fever  the  diminu- 
tion of  nitrogenous  waste  was  immediate,  and  amounted  to  25  per  cent. 
In  fever  it  was  about  the  same,  showing  that  the  febrile  waste  may,  in 
the  first  instance,  be  entirely  dystrophic.  It  is  a  question  for  clinical 
observation  whether  in  the  human  subject  good  might  not  be  done  by 
following  out  the  same  principle. 

2.  Production  of  Heat  (Thermogenosis).  —  To  some  readers  it  may 
appear  superfluous  to  inquire  whether  thermogenesis  is  increased  in 
fever;  for  it  might  seem  to  follow  from  the  increased  temperature  of 
the  body  that  more  heat  is  produced.  A  moment's  consideration  will, 
however,  convince  any  one  Avho  is  willing  to  take  the  trouble  to  reflect, 
that  constancy  of  temperature  depends  not  on  the  quantity  of  heat  gen- 
erated by  the  consumption  of  food,  or  on  the  quantity  lost  at  the  sur- 
face, but  on  the  power  which  the  organism  possesses  of  so  controlling 
either  production,  or  loss,  or  both,  that  the  normal  temperature  shall  not 
fluctuate  in  either  direction.  In  fever  it  cannot  be  questioned  that  this 
power  of  control  is  so  impaired  or  weakened  as  to  make  it  inadequate 
for  its  purpose ;  the  way  in  which  this  is  brought  about  will  be  consid- 
ered in  the  next  paragraph.  What  we  have  now  before  us  is  the  fact 
that  in  fever  the  production  of  heat  is  on  the  whole  somewhat  increased 
and  the  reason  why  it  is  so. 

It  is  now  nearly  thirty  years  since  Frankland  determined,  by  a  series 
of  calorimetrical  experiments  made  at  the  Royal  Institution,  the  "  heat 
values  "  of  the  chief  constituents  of  food.  These  data,  combined  with 
what  was  known  or  could  be  ascertained  as  to  the  quantities  of  each 
constituent  consumed  daily  in  maintaining  the  animal  machine,  enabled 
physiologists  to  estimate  approximately  the  total  quantity  of  heat  con- 
sumed therein  in  a  day  or  an  hour.  The  endeavour  was  made  at  the 
same  time,  by  the  employment  of  calorimetrical  methods,  to  measure  the 


THE  DOCTRINE    OF  FEVER  149 

same  quantity  directly.  The  results  of  these  early  efforts  have  given 
place  to  more  precise  ones,  for  we  are  now  not  only  able  to  state  the  heat 
values  of  the  various  nutritive  substances  with  much  greater  correctness 
than  before,  but  are  able  to  measure  with  like  precision  the  quantity  of 
heat  which  each  substance  actually  produces  physiologically,  i.e.  when  it 
is  consumed  by  the  organism  as  food,  and  to  show  that  the  two  values 
agree.  It  is  also  found  that  the  total  heat  production  of  the  body  in  a 
given  time,  as  measured  directly,  equals  the  sum  of  the  heat  values  of  the 
various  substances  consumed  during  the  same  period.  We  have  therefore 
in  our  hands  the  experimental  proof  of  what  Mayer  told  us  half  a  century 
ago,  namely,  that  food  is  the  sole  source  of  animal  heat.  The  production 
of  heat  in  fever  must  be  estimated  in  the  same  ways  as  the  production  in 
health,  i.e.  either  by  determining  the  quantity  of  each  nutritive  material 
used,  and  adding  the  corresponding  heat  values,  or  by  direct  calori- 
metrical  measurement.  In  fever  the  organism  consumes,  as  we  have 
seen,  its  own  proteid  and  fat.  The  data  and  methods  which  we  now 
possess  render  it  possible,  as  is  well  exemplified  in  Dr.  May's  research,  to 
estimate  the  rate  of  each  of  these  processes  of  consumption  in  fever,  and 
to  compare  the  results  obtained  under  the  same  nutritive  conditions  in 
health.  By  such  comparison  it  was  found,  in  the  rabbit,  that  the  fevered 
animal  produces  and  discharges  something  like  ten  per  cent  more  heat 
than  the  healthy  under  the  same  conditions  of  nutrition,  and  that  this 
is  due,  not  to  the  disappearance  of  fat,  but  to  the  consumption  by  the 
fevered  organism  of  its  own  proteid;  for,  while  the  consumption  of  fat  is 
approximately  the  same  in  both  cases,  the  nitrogenous  waste  in  fever  is 
about  25  per  cent  greater.^  In  another  recent  research,  in  which 
the  excellent  calorimetrical  method  of  Professor  Eubner  was  used,  the 
maximum  increase  of  heat  production  in  fever  was  determined  under  the 
same  conditions  and  on  the  same  animal  by  direct  measurement.  The 
result  thus  obtained  closely  accorded  with  the  estimate  founded  on  the 
quantities  of  proteid  and  fat  consumed.  The  increase  never  exceeded  10 
per  cent,  but  was  often  less,  and  in  some  experiments  was  so  inconsiderable, 
that  the  author  was  unable  to  say  more  than  that  while  in  the  rabbit 
there  may  be  an  increased  production  and  discharge  of  heat  in  fever,  the 
possibility  of  fever  without  such  increase  cannot  be  excluded  (14). 

3.  Pyrexia. — We  now  come  to  the  most  important  part  of  our 
inquiry.  Why  does  the  bodily  temperature  rise  above  the  normal  ?  I 
have  already  explained  why  the  dictum  of  Liebermeister,  that  in  fever 
the  organism  is  adjusted  to  a  higher  normal,  cannot  be  accepted  as  it 
stands.  The  truth  which  it  encloses  may  be  expressed  by  saying  that,  in 
consequence  of  the  injurious  action  of  the  fever-producing  cause,  the 
organism  loses  its  power  of  keeping  itself  at  the  normal  temperature.  In 
this  very  modified  form  Liebermeister's  principle  is  now  accepted  by  all 
pathologists.  All  that  is  asserted  is  that  the  organism  possesses  and 
exercises  the  power  of  adapting  its  temperature  to  a  norma,  that  norma 

i  See  J).  57  of  Dr.  May's  paper.  I  much  regret  that  space  will  not  allow  me  to  give 
details. 


I50  SYSTEM  OF  MEDICINE 

being  the  temperature  which  is  most  conducive  to  its  own  interests,  and 
that  this  power  is  impaired  in  fever.  It  leaves  untouched  two  other 
inquiries,  viz.,  (1)  in  wliat  part  of  the  organism  the  power  is  vested,  and 
(2)  why  the  departure  from  the  normal  moves  upwards  and  not  down- 
wards.    Let  us  consider  these  two  questions  separately. 

It  is  conceivable  that  in  an  organism  consisting  of  cells,  all  of  which  are 
similar  to  one  another  in  physiological  endowment,  i.e.  without  a  nervous 
system,  each  cell  might  be  able  to  govern  its  own  chemical,  i.e.  heat-pro- 
ducing processes,  in  such  a  way  as  to  maintain  a  constant  temperature ; 
but  this  could  only  happen  if  all  of  the  cells  were  under  the  same  con- 
ditions, i.e.  inhabited  the  same  environment.  Identity  of  endowment 
without  identity  of  environment  would  not  bring  about  the  required 
result,  viz.,  identity  of  temperature.  It  need  scarcely  be  said  that  though 
conceivable,  no  such  organism  is  possible.  Constancy  of  temperature  is 
met  with  only  in  animals  of  advanced  organization  and  highly-developed 
nervous  system ;  and  in  them  constancy  of  temperature  presents  itself 
exclusively  in  internal  parts.  Of  external  parts  the  temperature  is 
variable.  The  circulation  affords  an  efficient  mechanism  by  which  out- 
side variability  is  used  for  the  maintenance  of  inside  constancy.  In  other 
words,  such  a  relation  is  kept  up  by  the  circulation  between  surface  and 
interior  as  to  ensure  equability  of  the  latter.  The  existence  of  such  a 
relation  implies  the  agency  of  a  nervous  system  to  maintain  it.  It  there- 
fore needs  no  experimental  evidence  to  prove  that  to  this  system  must 
be  assigned  the  "thermotactic"  function.  This  being  admitted,  we  may 
go  a  step  farthe]'.  From  what  we  know  of  the  mode  in  which  the 
nervous  system  co-ordinates  functions,  it  may  be  assumed  thatthermotaxis 
is  conducted  by  a  "  centre  "  or  "  centres  " ;  that  it  or  they  receive  im- 
pressions of  "too  warm"  or  "too  cold"  by  afferent  channels  in  those 
parts  in  which  it  is  their  business  to  maintain  constancy,  i.e.  normality  ; 
and  that  they  (the  centres)  are  able  to  influence  "  thermolytic  "  or  ther- 
mogenetic  processes  accordingly.  The  organism,  represented  by  the 
"centres,"  recognises  as  normal  the  temperature  which  in  the  phylo- 
genetic  development  of  the  species  has  established  itself  as  most  advan- 
tageous. If,  therefore,  we  speak  of  impairment  of  thermotaxis,  we  mean 
that  the  centre  loses  its  power  more  or  less  of  responding  to  impressions 
of  abnormality  in  the  parts  with  which  it  is  in  relation  by  afferent 
channels.  If  so,  why  does  the  defect  show  itself  in  one  direction  only  ? 
If  fever  implies  paresis  of  the  regulating  centre,  why  does  the  tempera- 
ture rise,  never  fall  ?  To  this  there  is  but  one  answer,  and  that  a  very 
simple  one.  A  good  horse  needs  the  bridle  only,  not  the  whip.  The 
heat-producing  activities  of  the  organism  tend  to  exceed,  not  to  fall  short 
of  its  requirements.  So  long  as  this  tendency  is  operative,  pyrexia  must 
result  from  mere  impairment  of  the  regulating  function.  It  is  not  until 
it  ceases,  as  happens  in  many  instances  as  death  approaches,  that  fever 
becomes  collapse  (26). 

So  far  we  may  proceed  independently  of  experimental  evidence.  In 
approaching  the  question  which  next  presents  itself — the  question  where 


THE  DOCTRINE    OF  FEVER 


151 


the  thermotactie  centre  or  centres  are  to  be  found,  and  how  they  act  in 
fever  —  we  may,  I  think,  take  as  our  guide  the  principle  that,  whatever 
the  agency  which  in  health  prevents  the  temperature  of  the  body  from  ris- 
ing above  the  normal,  it  must  be  that  agency  which  in  fever  is  disordered. 
If  so,  the  question  how  this  control  is  normally  exercised  —  how  tlie 
organism  deals  with  its  surplus  production,  is  one  of  great  pathological 
interest.  The  best  way  of  answering  it  is  by  another  inquiry.  How 
does  the  organism  deal  with  increase  of  surplus,  when  the  increase  is 
dependent  on  conditions  which  are  not  those  of  disease  ?  There  are  two 
such  conditions  —  food  and  exercise  —  both  which  are  under  the  control 
of  the  will.  In  the  fasting  animal  the  effect  of  feeding  is  to  double  or 
treble  thermogenesis.  By  muscular  exertion  it  may  be  increased  in 
somewhat  similar  proportion.  The  storage  of  heat  and  consequent 
increase  of  temperature  in  either  of  these  two  cases  would  be  disastrous, 
were  the  latter  not  promptly  got  rid  of  by  some  arrangement  of  unfailing 
efficiency.  In  the  case  of  food  it  is  conceivable  that  the  organism  might 
be  able  to  protect  itself  by  putting  a  stop  to  the  thermogenetic  chemical 
processes  to  which  the  taking  in  of  food  gives  rise ;  but  there  is  no  way 
in  which  the  heat  produced  by  muscular  exertion  could  be  so  dealt  Avith 
as  not  to  increase  the  temperature  of  the  body  other  than  increased 
liberation  of  heat  at  the  surface.  The  physiological  processes  which  are 
connected  with  the  discharge  of  heat  at  the  surface  are  presided  over  by 
two  systems  of  nerves  (secreting  and  vascular)  which  are  closely  associated 
with  each  other  functionally  and  anatomically.  The  secreting  nerves 
which  are  distributed  to  the  sweat  glands,  and  the  inhibitory  vascular 
nerves  by  the  stimulation  of  which  the  minute  arterioles  of  the  skin  dilate 
so  as  to  increase  the  vascularity  and  heighten  the  colour  of  the  skin,  come 
from  centres  which  are  situated  in  the  bulb  and  spinal  cord.  The  two 
systems  of  nerves  follow  the  same  lines  and  are  very  similarly  distributed. 
That  the  dilating  nerves  and  hidrotic  nerves  are  very  prompt  and  efficient 
agents  in  guarding  against  increase  of  temperature  can  hardly  be  doubted, 
for  in  all  known  instances  in  which  the  temperature  tends  to  rise  they 
at  once  manifest  their  activity.  In  fever  this  activity  fails  ;  considera- 
tions which  we  have  already  had  before  us  suggest  that  this  power  of 
responding  is  still  present,  l3ut  is  impaired.  We  have  now,  with  a  view 
to  this  hypothesis,  to  inquire  how  far  it  is  supported  by  clinical  observa- 
tion and  experiment  as  to  the  phases  of  the  cutaneous  circulation  and  of 
the  secreting  function  of  the  skin.  In  this  inquiry  we  shall  have  to  do, 
not  with  production  and  discharge,  but  with  the  behaviour  of  the  vessels 
and  glands,  and  with  the  centre  or  centres  by  which  they  are  regulated. 
When  the  accession  of  pyrexia  is  marked  by  rigor  the  skin  exhibits 
the  conditions  which  were  regarded  by  Traube  as  belonging  to  the  whole 
process.  It  is  obvious  that  in  many  fevers,  particularly  ague,  there  is 
in  this  stage  of  accession  "  spasm  of  the  extreme  vessels" — anaemia  of 
the  skin.  This  is  followed  by  an  opposite  condition  which,  although 
neither  so  marked  nor  so  constant  as  the  previous  pallor,  is  by  contrast 
sufficiently  obvious.     If,  at  the  beginning  of  the  fastigium  the  surface 


152  SYSTEM  OF  MEDICINE 

be  exposed,  rigor  is  apt  to  return,  as  if  the  shuddering  contraction  of 
the  muscles  were  a  reiiex  evoked  by  the  cooling  of  the  skin. 

Whenever  pyrexia  ends  in  a  distinct  crisis,  i.e.  a  sudden  return  of  the 
bodily  temperature  to  the  normal,  that  return  has  associated  with  it 
changes  in  the  skin  still  more  favourable  to  the  discharge  of  heat; 
eventually  it  resumes  its  normal  condition,  but  before  doing  so  the  circu- 
lation becomes  more  active  and  sweat  breaks  out  abundantly.  Thus  in 
typical  fevers  we  have  two  states  which  are  easy  to  appreciate  —  the 
anaemic  dryness  of  rigor  and  the  warm,  hyperaemic  moisture  of  deferves- 
cence. Between  the  two  comes  the  fastigium,  during  which  the  vascular 
condition,  even  if  not  markedly  hyperaemic,  is  abnormal  and  variable. 
Of  this  we  have  plain  indications  in  the  observation  that  even  rough 
measurements  of  the  surface  temperature  show  such  differences  between 
corresponding  parts  on  opposite  sides  of  the  body,  and  between  the  tem- 
peratures of  the  same  part  at  different  times,  as  are  never  observed  in 
health.  This  is  further  shoAvn  by  the  abnormal  way  in  which  the  skin 
responds  to  stimulation.  In  prolonged  fevers,  particularly  typhoid,  it  is 
observed  that  if  a  pencil  is  drawn  firmly  over  the  skin  the  path  it  has 
followed  becomes  after  a  few  seconds  traceable  by  its  relative  paleness. 
This  blanching  lasts  for  several  minutes,  spreading  slightly  as  it  fades. 
In  animals  the  evidence  that  the  cutaneous  vascular  system  reacts  ab- 
normally in  fever  is  much  more  precise.  It  is  a  quarter  of  a  century 
since  Heidenhain  (15)  showed  that  whereas  in  health  the  effect  of  reflex 
stimulation  of  the  vaso-motor  centre  is  to  increase  the  cutaneous  circula- 
tion, and  thereby  bring  down  the  temperature  of  the  blood,  this  is  not 
the  case  in  fever,  but  rather  the  contrary.  There  is  no  dilatation  of  the 
cutaneous  vessels,  no  increase  of  the  temperature  of  the  extremities  —  a 
result  which  we  can  best  explain  by  saying  that  the  normal  vascular  re- 
sponse to  stimulation  takes  place  less  readily  than  before;  or,  in  other 
words,  that  the  nerves  and  centres  which  preside  over  that  response  are 
no  longer  capable  of  discharging  their  function  efficiently. 

The  subject  is  one  in  respect  of  which  results  as  valuable  can  be  ob- 
tained by  clinical  investigation  as  by  experiments  on  animals ;  for  of  the 
three  criteria  by  which  the  physiologist  judges  of  the  quantity  of  blood 
contained  in  apart — its  volume,  its  temperature,  and  its  colour — the  first 
two  can  be  as  well  observed  in  man  as  in  animals,  and  the  third  better. 

The  changes  of  volume  of  the  limbs  in  fever  have  been  very  successfully 
examined  by  Dr.  Maragliano  of  Genoa,  with  the  aid  of  Mosso's  plethysmo- 
graph.  By  a  preliminary  series  of  experiments  it  was  first  ascertained 
that  in  healthy  persons,  after  a  meal,  the  volume  of  the  arm,  as  thus 
measured  for  a  number  of  hours,  slowly  declines  as  the  time  which  has 
elapsed  since  taking  food  increases,  and  that  the  rate  of  this  decline  is 
uniform.  The  same  method  of  observation  was  then  applied  to  a  variety  of 
typical  fevers.  In  ague  it  was  found  that  the  accession  of  an  attack  is 
marked  by  a  very  obvious  diminution  of  volume,  which  is  antecedentto  the 
rigor  ;  and  that  in  the  crisis  likewise  an  increase  of  volume  is  always  the 
harbinger  of  the  critical  thermolysis.    The  measurements  given,  however, 


THE  DOCTRINE    OF  FEVER  153 

seem  to  show  that,  in  intermittent  fever  at  all  events,  the  interval 
between  the  expansion  of  the  arm  and  the  fall  of  the  temperature  is 
much  longer  than  that  between  the  contraction  and  the  rise.  In  some 
cases  in  which  the  f astigium  lasted  for  some  time  with  a  temperature  of 
over  104°,  the  critical  expansion  was  preceded  by  a  gradual  enlargement 
of  the  arm  which  could  be  observed  for  hours  before  there  was  any 
change  in  the  readings  of  the  thermometer. 

As  regards  the  temperature  of  the  surface  we  possessed  until  lately 
very  little  reliable  information.  The  best  clinical  observations,  so  far  as  I 
know,  are  those  recently  made  by  Dr.  Geigel  at  Wtirzburg,  by  a  thermo- 
electrical  method,  of  which  it  is  sufficient  to  say  that  the  apparatus  con- 
sists of  a  single  pair  of  junctions,  one  of  which  can  be  apjjlied  to  the  skin, 
the  other  being  in  a  vessel  containing  oil  at  known  and  constant  tem- 
perature. Simultaneous  measurements  were  made  of  the  temperature 
at  four  different  spots  —  some  covered,  others  exposed  —  and  compared 
with  readings  of  the  temperature  in  the  rectum  taken  during  the  same 
period.  The  results,  which  are  of  special  interest  in  connection  with  the 
Genoa  observations,  may  be  best  stated  according  to  the  stage  in  the 
febrile  process  to  which  they  relate.  In  rigor  it  was  found  that  the  sur- 
face temperature  sinks  very  considerably,  and  consequently  that  the 
difference  between  the  surface  and  internal  temperature — the  latter  ris- 
ing while  the  former  falls  —  rapidly  augments.  On  this  subject  the  data 
given  are  so  unequivocal  that  the  often-repeated  statement,  that  while 
the  patient  shivers  the  skin  becomes  hotter,  can  no  longer  be  made.  As 
regards  the  period  of  defervescence,  it  is  as  clearly  shown  that  the  fall  of 
the  blood  temperature  is  preceded  by  rise  of  surface  temperature  —  that 
while  the  internal  parts  are  still  at  fever  heat  the  temperature  of  the 
skin  rises — in  consequence  of  the  more  ample  afflux  of  blood  to  the  sur- 
face, the  relation  between  this  afflux  and  the  critical  sweating  being 
most  strikingly  shown  by  the  temperature  curves.  Another  interesting 
point  is  that  in  the  f astigium,  notwithstanding  that  to  the  hand  the 
skin  feels  hot  and  dry,  its  temperature  is  only  a  little  greater  than  in 
health  —  less  than  that  which  it  attains  as  defervescence  approaches. 

We  have  thus  perfect  harmony  between  what  has  been  learnt  from 
the  observation  of  surface  temperature  and  the  results  of  plethysmo- 
graphic  measurement.  Increase  of  volume  of  the  extremity  and  increase 
of  the  temperature  of  the  surface  mean  the  same  thing,  viz.,  that  the 
flow  of  warm  blood  as  supplied  through  the  skin  is  augmented.  It  is 
thus  that  the  organism  reacts  promptly  and  effectually  against  any 
increase  of  the  temperature  of  the  blood. 

4.  Cerebral  Heat  Centres.  —  Although  it  may  be  doubted  whether 
the  pyrexia,  which  is  produced  by  stimulation  or  injury  of  the  brain, 
comes  under  the  designation  of  "fever,"  the  facts  relating  to  this  subject 
cannot  be  passed  over  in  the  present  discussion.  For  in  some  instances 
the  pathological  state  observed,  if  not  fever,  so  much  resembles  it  that  it 
cannot  fail  to  be  of  interest  to  compare  the  one  with  the  other.  Space 
wiil  not  allow  me  to  refer  in  any  detail  to  the  older  observations  relating 


154 


SYSTEM  OF  MEDICINE 


to  the  effects  of  severance  of  tlie  spinal  cord  in  the  cervical  region  and 
of  injury  of  the  bulb.  It  is  sufticient  to  say  that  the  observed  effects  of 
section  of  the  spinal  cord  were  such  as  to  show  that  the  animals  experi- 
mented on  were  incapable  of  maintaining  constancy  of  temperature,  while 
on  other  grounds  it  seemed  probable  that  the  antagonistic  functions  of 
production  and  discharge  of  heat  ^s^ere  presided  over  or  regulated  by 
different  parts  of  the  intracranial'  nervous  system.  Since  1880  the 
question  of  the  localisation  of  these  functions  has  assumed  a  different 
aspect.  In  that  year  Dr.  Wood  of  Philadelphia  discovered  that  injury 
of  a  certain  part  of  the  cortical  motor  area  which  surrounds  the  crucial 
sulcus  in  the  dog  produced  pyrexia.  Soon  afterwards  it  was  discovered 
independently  in  Paris  and  in  Berlin  that  a  thermogenetic  region  exists 
on  the  medial  side  of  the  corpus  striatum,  the  excitation  of  which, 
whether  by  puncture  or  electrical  currents,  gives  rise  to  a  similar  increase 
of  temperature.  The  conditions  and  results  of  the  experiment  were 
most  carefully  investigated,  under  the  guidance  of  Professor  Zuntz,  by 
Aronsohn  and  Sachs  (20),  who  found  that  the  thermogenetic  region  corre- 
sponded in  position  to  the  nodus  curson'us  of  Nothnagel,  and  was  strictly 
limited.  It  was  also  found  that  the  pyrexia,  which  did  not  come  on  until 
some  time  after  the  injury,  was  accompanied  by  an  increased  elimination 
of  nitrogen,  so  that  at  first  sight  it  might  appear  as  if  a  genuine  fever 
had  been  produced.  There  are,  however,  points  of  difference  by  which 
the  one  pathological  state  may  be  distinguished  from  the  other.  The 
"hyperthermic"  state  produced  by  puncture  is  found  to  differ  from  true 
febrile  pyrexia  above  all  in  the  absence  of  those  vascular  conditions  of 
the  skin  which  we  have  seen  to  be  so  characteristic.  The  bodily  tempera^ 
ture  rises  gradually  to  a  febrile  height  (105°  P.  to  106°  P.),  and  then  as 
gradually  subsides  ;  but  there  is  no  rigor,  nor  is  the  subsidence  preceded 
by  any  vascular  dilatation.  The  vessels,  indeed,  are  so  incapable  of 
responding  in  the  normal  way  to  their  environment,  that  if  the  animal 
be  placed  in  a  warm  chamber  at  37°  C.  it  becomes  hyperpyrexic,  yet  the 
ears  remain  pale  as  before.  These  facts  seem  clearly  to  indicate  that  the 
disorder  of  vascular  innervation  due  to  puncture  is  of  a  different  kind 
from  that  of  fever,  the  regulation  of  temperature  being  almost,  but  as  we 
shall  see  farther  on,  not  completely  in  abeyance ;  whereas  in  fever  the 
power  of  guarding  against  excessive  thermogenesis  is  weakened  in  much 
less  degree.  There  being  this  essential  difference  between  brain  pyrexia 
and  that  of  fever,  how  are  we  to  account  for  the  fact  that  in  Aronsohn 
and  Sachs'  very  elaborate  investigation  there  was  found  to  be  increase 
not  only  of  the  respiratory  exchange,  but  of  the  elimination  of  nitrogen 
(20).  The  answer  is  that  although  Dr.  Ringer's  observation  (1859), 
confirmed  as  it  has  been,  both  clinically  and  experimently  —  that  in  the 
accession  of  fever  increased  metabolism  precedes  rise  of  temperature  — 
clearly  proves  that  in  fever  the  high  temperature  is  not,  as  some  have 
thought,  the  sole  cause  of  the  nitrogenous  waste,  yet  the  evidence  that  the 
latter  may  have  this  origin  is  quite  as  conclusive.  A  temperature  of  over 
104°,  if  it  continue,  produces  tissue  waste,  however  it  is  itself  brought 


THE  DOCTRFNE    OF  FEVER  155 

about.  The  simplest  mode  of  raising  the  bodily  temperature  of  an  animal 
without  inducing  any  other  disorder  consists  in  subjecting  it  to  a  tem- 
perature just  sufficient  to  prevent  a  discharge  of  heat  from  its  surface. 
Thus,  by  placing  a  dog  in  a  chamber  at  37°  C.  its  body  temperature  may 
be  easily  maintained  at  a  point  approaching  that  of  fever.  The  result 
is  to  produce  both  of  the  effects  which  follow  brain  puncture.  The 
increase  of  the  nitrogen  elimination  lasts  for  two  or  three  days,  and  is 
quite  as  great  as  that  observed  (20)  in  Aronsohn  and  Sachs'  experiment. 

5.  Antipyretics.  —  The  discovery  about  fourteen  years  ago  of  several 
bodies  which  possess  the  power  of  reducing  temperature  in  fever,  and 
the  investigations  of  their  action  by  various  observers,  have  contributed 
very  materially  to  the  elucidation  of  the  phenomena  of  febrile  pyrexia. 
Of  these  bodies  kairin,  of  which  the  properties  were  first  made  known 
in  1882  by  Professor  Filehne  (21),  acts  more  promptly  than  any  other. 
Next  to  it  comes  antipyrin,  which  was  discovered  two  years  later,  and 
was  also  first  examined  by  Filehne  (22),  and  has  since  held  its  ground 
as  an  antifebrile  remedy.  I  allude  to  them,  not  with  any  reference 
to  their  therapeutic  value,  but  because  the  phenomena  of  their  physio- 
logical action  are  well  known,  and  throw  light  on  the  process  which 
they  counteract. 

In  man  the  effect  of  kairin,  as  Filehne  expresses  it,  is  to  ''open  all 
the  sluices  for  the  escape  of  heat  from  the  surface."  In  animals  it  is 
equally  prompt.  The  rate  of  surface  loss,  as  measured  calorimetrically 
by  Dr.  Richter  (23),  exceeds  by  25  per  cent  the  previous  fever  rate,  and 
the  normal  rate  by  75  per  cent.  As  the  effect,  which  is  of  short  duration, 
passes  off  the  discharge  of  heat  diminishes  to  a  point  below  the  normal. 

The  same  year  that  these  observations  were  recorded.  Dr.  R.  Gottlieb 
(24)  applied  the  more  exact  calorimetrical  method  of  Rubner  in  obser- 
vations on  antipyrin  —  with  this  difference,  however,  that  his  investiga- 
tion related  not  to  artificial  fever  produced  by  the  introduction  of  pyro- 
genetic  substances,  but  to  the  brain-puncture  pyrexia  referred  to  above. 
The  results  distinctly  prove  that  in  the  normal  animal  the  diminution  of 
temperature  produced  by  antipyrin  is  due  entirely  to  increase  of  surface 
loss.  Notwithstanding  that  it  has  been  clearly  proved  that  antipyrin  in 
repeated  doses  in  man  is  known  to  diminish  the  discharge  of  nitrogen 
(25),  it  is  clear  that  the  increased  metabolism  which  this  implies  has 
nothing  to  do  with  the  antipyretic  action,  for  the  increase  of  surface  loss 
more  than  covers  the  diminution  of  temperature.  In  brain  pyrexia  the 
increase  of  surface  loss  after  antipyrin  is  much  greater  than  in  health, 
and  probably  greater  than  in  fever,  for  the  previous  constriction  of  the 
cutaneous  vessels  is  greater.  The  fall  of  temperature  to  which  this  gives 
rise  is  also  much  greater,  but  still  is  not  so  great  as  it  would  be  if  the 
whole  excess  of  heat  loss  were  at  the  expense  of  the  organism.  It  there- 
fore ap])ears  that  even  in  brain  pyrexia  the  power  which  the  organism  pos- 
sesses of  compensating  loss  by  increased  production  is  not  entirely  absent. 

That  the  two  antipyretics  act  primarily  by  augmenting  the  surface  loss 
we  have  even  more  direct  evidence  from  their  effect  on  the  temperature 


1^6  SYSTEM  OF  MEDICINE 

of  the  skin  and  of  the  volume  of  the  extremities ;  and  we  have  here 
the  additional  advantage  that  in  both  of  these  points  we  can  base  our 
conclusions  on  observations  at  the  bedside.  Maragliano  (loc.  cit.)  found 
that  the  action  of  kairin  and  antipyfin  in  continued  fever  as  well  as  in 
ague  can  be  readily  observed  by  the  arm-plethysmograph.  It  manifests 
itself  by  an  expansion  of  the  limb  which  accompanies  the  diminution 
of  temperature ;  and  in  typhoid  it  can  be  observed  that  the  passing  off  of 
the  effect  and  the  return  of  the  pyrexia  is  attended  by  a  corresponding 
diminution  of  the  volume  of  the  arm.  As  regards  the  temperature  of 
the  skiu,  equally  satisfactory  results  are  supplied  by  Geigel,  to  whose 
thermo-electric  measurements  reference  has  already  been  made.  It  is 
shown  that  in  all  cases  in  which  antipyrin  produces  its  characteristic 
effect  the  diminution  of  central  temperature  is  preceded  by  increase  of 
surface  temperature,  clearly  indicating  that  the  mode  of  action  of  the 
drug  is  to  diminish  the  temperature  of  the  blood  by  increasing  the  rate 
at  which  it  flows  towards  the  superficial  parts  of  the  body. 

It  thus  appears  that  increased  volume  of  the  extremities,  increased 
temperature  of  the  skin,  and  increased  discharge  of  heat  from  the  surface 
(as  measured  calorimetrically)  are  the  characteristic  phenomena  of  anti- 
pyretic action  in  man  and  in  animals.  It  need  not  be  pointed  out  that 
these  phenomena  are  physiologically  correlated.  They  plainly  indicate 
that  antipyretics  act  on  that  part  of  the  nervous  system  which  presides 
over  the  inhibitory  or  dilating  vascular  nerves.  The  bearing  of  this  fact 
on  the  question  of  the  nature  of  fever  lies  in  this,  that  they  afford  clearer 
evidence  than  can  be  obtained  otherwise,  that  the  power  which  the  ner- 
vous system  possesses  of  regulating  the  loss  of  heat  at  the  surface  is  ad- 
equate to  bring  about  changes  of  bodily  temperature  as  great  as  those 
which  take  place  in  febrile  pyrexia.  What  they  do  not  prove  is  that 
fever  is  nothing  more  than  a  disorder  of  thermotaxis. 

6.  iEtiolog^  of  Fever.  —  It  is  now  thirty  years  since  Otto  Weber  and 
Billroth  investigated  the  fever  which  is  produced  by  the  introduction  of 
septic  material  into  the  circulating  blood  or  into  the  cellular  tissue,  and 
showed  in  what  respect  the  artificial  fever  resembled  or  differed  from 
surgical  fever.  It  was  soon  after*wards  found  that  the  products  of  acute 
inflammation  give  rise  to  fever  under  similar  conditions.  And  when,  at 
a  later  period,  it  was  recognised  that  these  products  owe  their  infective 
properties  to  the  presence  of  microphytes  (as  we  then  called  them),  the 
inference  naturally  followed  that  the  power  of  producing  fever  was  also 
dependent  on  the  presence  of  those  organisms. 

At  that  early  period  (1872)  the  methods  now  familiar  to  the  patholo- 
gist of  discriminating  between  different  kinds  of  bacteria  were  unknown. 
When  some  eight  years  later  Dr.  Koch  taught  us  how  to  do  this,  and  thus 
founded  the  science  or  rather  technique  of  bacteriology,  it  seemed  likely 
that  the  fever-producing  property  would  turn  out  to  be  an  endowment  of 
particular  species,  and  that  by  using  pure  cultivations  it  would  be  possible 
to  induce  fever  experimentally  with  much  greater  certainty  than  had 
before  been  possible.     This  expectation,  whether  rightly  or  wrongly 


THE  DOCTRINE    OF  FEVER  157 


entertained,  has  not  been  realised.  There  are  several  species  which  are 
phlogogenetic,  but  none  which  can  be  relied  upon  to  produce  fever. 
The  one  which  has  lately  appeared  to  answer  the  purpose  best  is  the 
bacillus  of  Rouget  (the  erysipelas  of  swine),  but  others,  as  for  example 
the  bacterium  coli  communis,  and  the  ordinary  chaplet-coccus  of  acute 
abscesses,  are  also  available. 

The  question  whether  the  micro-organisms  themselves  or  their  prod- 
ucts produce  fever  is  an  old  one.  In  1875  I  prepared  a  substance,  which 
I  ventured  to  call  pyrogen,  from  putrid  extract  of  flesh,  by  first  destroy- 
ing all  bacterial  life  by  the  addition  of  alcohol  in  sufficient  quantities  to 
precipitate  most  of  the  proteids  it  contained,  separating  the  precipitate 
by  filtration,  evaporating  the  clear  filtrate,  and  redissolving  in  water. 
This  sterile  product  produced  fever,  but  was  deprived  of  that  property 
by  filtration  through  porcelain,  whence  I  conjectured  that  the  pyrogenic 
substance  was  perhaps  a  body  analogous  to  the  unformed  ferments  or 
enzymes  (26).  About  the  same  time,  experiments  made  at  Dorpat  by 
pupils  of  A.  Schmidt  proved  that  the  obscure  constituent  of  the  blood  to 
which  he  attributes  the  property  of  exciting  coagulation  has  also  that  of 
prodiicing  fever,  so  that  the  introduction  of  any  material  which  either 
contains  fibrin-ferment,  or  gives  rise  to  its  formation  in  the  circulating 
blood,  has  the  same  effect  (27).  It  thus  became  possible  to  explain  why, 
when  transfusion  with  lamb's  blood  was  in  vogue,  the  operation,  notwith- 
standing antiseptic  precautions,  was  always  followed  by  fever.  I  think 
we  may  associate  with  these  old  observations  the  discussions  which  have 
recently  taken  place  on  the  production  of  fever  by  the  injection  of  extracts 
of  fresh  tissues  (muscle,  liver,  thyroid,  etc.)  (28),  which  have  this  in  com- 
mon with  transfusion  of  blood  derived  from  animals  into  the  circulation 
of  man,  that  in  both  instances  there  is  disintegration  of  cells. 

As  regards  ferments,  it  has  been  shown  that  all  the  commercial 
enzymes  are  apt  to  cause  fever  when  introduced  into  the  circulation  or 
into  the  cellular  tissue,  but  inasmuch  as  in  certain  recent  experiments 
pure  enzymes  prepared  at  Heidelberg  under  Prof.  Ktihne's  direction  were 
found  to  have  no  such  property,  it  may  probably  be  assumed  that  in  the 
others  the  effect  is  to  be  attributed  to  the  albuminous  products  of  diges- 
tion of  which  they  largely  consist.  This  seems  the  more  probable  when 
we  remember  that  albumoses  derived  from  very  different  sources  have  been 
found  to  be  actively  pyrogenetic,  the  most  striking  instance  being  that  of 
the  "  deutero-albumose "  found  by  Prof.  Klihne  to  be  a  constituent  of 
tuberculin.  A  fever-producing  albumose  has  also  been  obtained  by 
Prof.  Krehl  from  cultivations  of  bacterium  coli  commune  (29). 

The  discovery  by  Koch  of  the  remarkable  way  in  which  the  sub- 
stance just  mentioned  influences  the  organism  of  tuberculous  individuals, 
whether  fiuman  or  animal,  stirring  up  in  the  neighbourhood  of  the  dis- 
eased parts  inflammation  attended  by  pyrexia,  seems  to  be  calculated  to 
thi'ow  considerable  light  on  the  genesis  of  fever  —  and  all  the  more  since 
it  has  been  discovered,  not  only  that  extracts  similarly  prepared  from  other 
micro-organisms  have  the  same  action,  but  that  proteids  of  non-bacterial 


158  SYSTEM   OF  MEDICINE 

origin  act  in  a  similar  way.  For  a  recent  publication  of  Dr.  Mattlies 
(30)  seems  to  show  that,  in  common  with  the  deutero-albumose  prepared 
from  tuberculin,  the  similar  product  obtained  by  peptic  digestion  pro- 
duces both  in  man  and  animals  the  well-known  local  and  constitutional 
effects  of  tuberculin,  if  tuberculous  disease  exist,  but  no  reaction  what- 
ever in  healthy  individuals.  It  has  indeed  been  found  possible  to 
obtain  a  proteid  body  from  the  same  source,  which  produces  tuberculin 
effects  in  smaller  dose  than  those  of  tuberculin  itself. 

Several  questions  present  themselves  in  connection  with  this  subject 
of  which  it  would  be  premature  to  speak  at  present  —  such  as  the  rela- 
tion between  the  group  of  proteids  and  the  toxins  Avhich  appear  to  play 
so  important  a  part  in  the  specific  infective  processes,  and  the  relation 
between  the  extraordinary  physiological  activity  of  these  bodies  and 
their  chemical  properties. 

The  fact  that  severe  injuries,  such  as  simple  fractures,  which  are  nec- 
essarily attended  with  a  certain  amount  of  disintegration  of  tissue,  are 
known  to  be  followed  by  febrile  reaction  (31),  sometimes  of  great  inten- 
sity, notwithstanding  that  the  reparative  process  is  not  in  the  slightest 
degree  interfered  with,  and  that  the  integrity  of  the  skin  affords  a  certain 
guarantee  for  the  exclusion  of  bacterial  contamination  (29),  seems  to  con- 
firm the  inference  of  Charrin,  from  the  experiments  already  referred  to 
on  extracts  of  fresh  tissues,  that  in  the  bodies  of  all  cells  "  thermogenic 
substances"  —  or  i-ather  materials  from  which  they  can  be  generated  — 
are  contained.  However  this  may  be,  it  is  clear  that  the  property  of 
inducing  febrile  reaction  is  by  no  means  confined  to  substances  which 
depend  for  their  existence  on  bacteria.  Susceptibility  to  the  action  of 
fever-producing  substances  is  not  only  very  different  in  animals  of  dif- 
ferent species,  but  depends  largely  on  individual  peculiarities,  Avhether 
natural  or  acquired.  We  have  already  seen  how  it  is  increased  by  the 
previous  existence  of  certain  organic  diseases,  and  it  may  be  added  that 
in  experiments  on  artificial  fever  a  "fresh"  S,nimal  ip  usually  found  to  be 
less  susceptible  than  one  which  has  been  previously  "  fevered." 

Conclusion 

Although  I  have  endeavoured  in  the  preceding  paragraphs  to  state 
the  leading  facts  and  considerations  relating  to  the  origin  and  character- 
istic phenomena  of  fever  in  such  a  way  as  to  enable  the  reader  to  draw 
his  own  inferences,  it  may,  perhaps,  be  convenient  that  I  should  state 
the  views  which  I  am  inclined  to  adopt. 

In  the  concluding  paragraph  of  the  essay  on  fever  which  I  published 
in  1875,  I  set  against  each  other  two  possible  alternatives  (26).  Either 
fever  originates  in  disorder  of  the  nervous  centres,  producing  pyrexia  and 
as  a  secondary  result  disorder  of  nutrition,  or  it  originates  in  a  disorder 
of  protoplasm  to  which  the  nervous  phenomena  are  secondary.  Although 
the  second  of  these  hypotheses  seemed  at  that  time  preferable  to  the  first, 
I  did  not  think  that  either  afforded  a  sufficient  explanation  of  fever  so 


THE  DOCTRINE    OF  FEVER  159 

long  as  the  problem  of  the  normal  relation  between  temperature  and  ther- 
mogenesis  remained  unsolved.  Since  that  time  considerable  progress 
towards  this  elucidation  has  been  made.  By  the  labours  of  Rubner  the 
relations  between  the  heat  values  of  the  constituents  of  food  and  the  pro- 
duction of  heat,  in  animals,  has  been  ascertained  with  such  exactitude  as 
to  afford  a  safe  basis  for  investigating  the  relations  between  production 
and  loss  in  various  conditions,  while  from  Professor  Zuntz  and  those  who 
have  worked  with  him  we  have  received  very  compleie  iii formation  as 
to  the  way  in  which  the  organism  reacts  to  variations  in  the  tempera- 
ture of  its  environment  in  either  direction.  The  researches  of  Zuntz 
show  conclusively  that  the  only  reflex  apparatus  for  regulating  tempera- 
ture wMcli  is  always  at  work  is  that  which  governs  the  loss  of  heat  at  the 
surface.  At  the  same  time,  it  is  obvious  that,  when  required,  the  organ- 
ism can  bring  the  other  kind  of  regulation  into  play.  No  one  doubts 
that  shivering  and  the  other  almost  involuntary  muscular  movements 
which  are  occasioned  by  exposure  to  cold  are  in  a  sense  reflex.  Even  in 
a  vigorous  person  the  effect  of  the  cold  bath  is  to  induce  a  tendency  to 
the  performance  of  such  movements,  the  obvious  purpose  of  which  is 
to  augment  the  production  of  heat  (as  can  be  readily  shown  if  the 
respiratory  exchange  be  measured),  and  so  to  compensate  the  increase  of 
surface  loss.  But  the  reflex  of  shivering  has  in  it  a  psychical  element; 
it  is  associated  with  the  sensation  of  chill,  and  may  be  resisted  by  a 
strong  effort.  When  this  tendency  to  shudder  is  resisted,  the  excessive 
intake  of  oxygen  and  output  of  carbon  dioxide  was  no  longer  observable 
(as  Professor  Zuntz  found  when  he  made  himself  the  subject  of  experi- 
ment). Yet,  notwithstanding  the  absence  of  any  evidence  of  increased 
thermogenesis,  the  temperature  was  maintained,  so  that  the  augmenta- 
tion of  respiratory  exchange  was  evidently  accessory,  not  essential. 

Whether  in  small  animals  such  as  mice,  in  which  the  surface  loss  of 
heat  per  unit  of  body  weight  must  be  more  than  ten  times  as  great  as 
in  man,  there  is  anything  like  a  reflex  regulation  of  thermogenesis  in- 
dependent of  muscular  activity,  is  a  question  not  yet  decided.  Dr. 
Pembrey's  researches  on  the  subject  do  not  seem  to  make  it  probable ;  for 
he  finds  that  the  power  of  regulating  the  respiratory  exchange  depends 
on  the  development  and  activity  of  the  neuro-muscular  system. 

In  Dr.  Macalister's  admirable  Goulstonian  Lectures  on  Fever  it  is 
suggested  that  thermogenesis,  thermolysis,  and  therm otaxis  miist  be 
regarded  as  three  separate  functions  of  the  nervous  system.  It  seems  at 
first  sight  difficult  to  see  how,  under  conditions  tending  to  bring  down 
the  bodily  temperature,  the  cooling  of  the  body  can  be  prevented  in  any 
other  way  than  by  the  direct  influence  of  the  nervous  system  on  the  pro- 
duction of  heat.  We  have  learned  from  Zuntz's  experiments  that  the 
exercise  of  this  influence  is  not  essential.  The  key  to  the  apparent 
difficulty  is  to  be  sought  for  in  the  consideration,  that  in  a  warm 
blooded  animal  of  constant  temperature  the  supply  of  heat  is  always 
poteniially  in  excess.  It  is  obvious  that  in  a  warm  room  more  heat  is 
produced  than  is  wanted,  but  not  so  obvious,  though  equally  true,  that 


l6o  SYSTEM   OF  MEDICINE 

in  tlie  cold  of  winter  the  body  temperature  would  rise  at  any  moment 
if  surface  loss  were  suspended  or  annulled.  In  the  two  cases  the 
"  mechanism  "  is  the  same.  It,  therefore,  does  not  seem  necessary  to 
imagine  more  than  one  regulating  centre  in  constant  operation  —  that 
which  presides  over  surface  loss. 

The  last  question  to  be  discussed  is  that  of  the  relation  between 
pyrexia  from  cerebral  puncture,  and  febrile  pyrexia. 

The  question  is  one  of  words.  If  the  word  fever  be  understood  to 
mean  the  reaction  of  the  organism  to  a  fever-producing  substance 
introduced  into  the  circulating  blood  and  conveyed  thereby  to  the  parts 
on  which  it  acts,  then  the  pyrexia  of  cerebral  puncture  is  not  fever. 
In  the  present  paper  the  term  has  been  used  in  this  sense  only.  The 
study  of  puncture  pyrexia  is  of  great  interest  in  enabling  us  to 
determine  which  of  the  phenomena  of  fever  are  or  may  be  secondary  to 
the  rise  of  temperature,  and  in  what  degree  they  may  be  attributed  to  it, 
but  it  cannot  be  admitted  that  the  two  processes  are  identical  or  even 
kindred.  In  nosology  difference  of  cause  is  a  distinction  which  over- 
rides all  others. 

J.  Burdon-Sandeeson. 


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THE    GENERAL  PATHOLOGY  OF  NUTRITLON  i6i 


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J.  B.-S. 


THE  GENERAL  PATHOLOGY  OF  NUTRITION 

The  life  of  the  individual  is  dependent  upon  the  life  of  the  cells  or 
derivatives  of  the  cells,  which  together  make  up  the  organs  and  tissues  of 
the  body.  Every  cell  possesses  the  property  of  taking  up  from  the  fluid 
medium  by  which  it  is  surrounded  the  substances  which  are  necessary 
for  its  vital  activity,  and  of  casting  out  the  waste  products. 

It  was  John  Hunter  who  said :  "  Every  individual  particle  of  the 
animal  matter  is  possessed  of  life,  and  the  least  imaginable  part  which 
we  can  separate  is  as  much  alive  as  the  whole." 

Owing  to  differentiation  of  structure  and  specialisation  of  function, 
certain  master  tissues  {e.g.  glandular,  nervous,  and  muscular)  possess,  in 
addition  to  their  general  functions  of  repair  and  waste,  a  special  function 
peculiar  to  each  tissue  involving  storage  of  material.  The  mammary  gland 
before  lactation  occurs  is  in  a  quiescent  state  ;  its  cells  are  living  and 
awaiting  the  natural  physiological  stimulus  which  will  arouse  their 
special  function  of  elaboration  and  secretion  of  milk  ;  but,  prior  to  this, 
the  cells  are  still  the  seat  of  that  perpetual  circulation  of  matter  termed 
metabolism,  constructive  and  destructive  —  activities  common  to  all 
living  protoplasm. 

Physiologically,  the  cells  of  the  body  are  dependent  upon  one 
another  and  upon  the  circulating  blood  which,  as  it  streams  slowly 
through  the  capillaries,  brings  into  harmonious  relation  the  effects  of 
each  and  all  of  their  vital  activities.  This  functional  harmony  between 
the  different  tissues  is  brought  about  by  the  blood,  and  serves  to  maintain 
a  constant  in  the  chemical  composition  and  temperature  of  that  fluid ; 
the  maintenance  of  this  constant  is  essential  to  the  well-being  of  all  the 
cells  of  the  body.  There  is  thus  an  interdependence  of  all  the  tissues;; 
if  one  suffers,  all  suffer. 

The  dictum  of  Virchow,  Omnis  cellula  e  celluld,  is  a  fundamental 
principle  underlying  all  physiological  and  pathological  problems.  The 
fertilised  ovum  may  be  looked  upon  as  the  fusion  of  the  essential  portion 

VOL.    I  M 


1 62  SYSTEM   OF  MEDICINE 

of  the  male  sperm  cell  with  the  female  germ  cell,  and  with  this  process 
there  is  a  fusion  of  the  properties  and  attributes  of  the  germinal  plasm 
of  the  parents.  This  cell  possesses,  then,  specific  properties  which  dis- 
tinguish it  from  every  other  cell  in  existence  ;  likewise  all  the  cells  which 
are  derived  from  it  by  segmentation  possess  specific  vital  properties  which 
make  them  differ  from  the  cells  which  constitute  the  tissues  and  organs  of 
another  animal.  We  may  not  be  able  to  show  by  chemical  antdyses  and 
microscopical  examination  any  differences  in  the  tissues  of  two  individ- 
uals ;  they  may  seem  identical ;  the  distinction,  however,  appears  in  the 
differences  of  adaptation  in  the  cells  of  the  organism  to  their  environ- 
ment, individually  and  collectively.  The  instability  and  mobility  of  the 
material  substance  of  the  cell  constitutes  its  life :  no  portion  of  the 
living  body  is  stable,  but  new  formation  and  regeneration  are  continually 
taking  place  during  life,  even  after  completion  of  the  growing  period. 
Many  examples  of  these  processes  could  be  cited,  viz.,  the  epithelium 
lining  the  alimentary  and  respiratory  tracts  which  is  continually  being 
destroyed  and  replaced ;  likewise  the  epithelium  covering  the  surface  of 
the  body,  and  the  never  ceasing  disintegration  and  new  formation  of  the 
blood  corpuscles.  The  mechanism  by  which  cells  are  enabled  to  take  up 
nutrient  material  from  the  surrounding  lymph  ?nd  to  cast  out  their  waste 
products  is  unknown  to  us.  It  is  a  specific  property  of  the  protoplasm 
of  the  cell,  controlled  in  the  higher  differentiated  tissues  by  nervous 
impressions  which  not  only  (as  may  be  proved  in  the  submaxillary  gland) 
directly  control  the  functional  activity  of  the  epithelial  cell  elements,  but 
also  the  amount  of  blood  flowing  through  the  gland.  In  health  there  is 
a  constant  adaptation  of  repair  to  waste  ;  and,  although  the  organic  form  of 
the  cell  or  fibre  is  generally  preserved,  the  contents  are  continually  under- 
going molecular  and  chemical  changes,  with  conversion  of  potential  into 
kinetic  energy,  consumption  of  oxygen  and  organic  substances,  and  the 
liberation  of  carbonic  acid,  water,  and  other  waste  products.  The  energy 
is  replaced  and  the  tissue  waste  repaired  by  the  circulating  blood.  This, 
however,  necessitates  a  constant  in  the  quantity,  quality  and  temperature 
of  the  blood,  which  can  only  be  affected  by  the  assimilation  of  oxygen, 
food  and  water  in  such  proportion  as  to  make  up  that  which  is  lost  to  the 
body  by  disassimilation  in  the  tissues,  and  elimination  by  the  lungs,  skin 
and  kidneys.  "  A  man  can  live  a  few  minutes  without  oxygen,  a  few  days 
without  water,  and  a  few  weeks  without  food  "  (Waller). 

The  balance  of  nutrition  Taajhe  maintained  when  the  export  is  repaired 
by  a  corresponding  import;  and  physiologists  have  shown  that  the  mini- 
mum daily  income  required  by  a  healthy  man  performing  his  average 
daily  work,  and  maintaining  his  usual  body  Aveight,  is  o  per  cent  of  that 
body  weight  —  1  per  cent  being  solid  food,  1  per  cent  oxygen,  and  3 
per  cent  water.  These  amounts  may  be  modified  by  various  circum- 
stances, such  as  climate,  work,  age,  convalescence  from  illness,  lactation, 
and  the  like. 

An  infant  or  growing  child  requires  not  only  food  for  repair  but  also 
for  new  growth.    A  mother  during  lactation,  over  and  above  the  normal 


THE   GENERAL  PATHOLOGY  OF  NUTRITLON  163 


amount  of  nourishment,  requires  a  suitable  excess  to  provide  the  milk 
necessary  for  the  suckling  infant. 

If  digestion  and  assimilation  are  normal  the  blood  will  be  maintained 
at  a  constant  in  its  chemical  composition ;  should  there  be,  however,  an 
insufficiency  of  the  intake,  inanition  will  follow.  Inasmuch  as  the  in- 
take of  food  is  always  intermittent,  and  owing  to  exigencies  in  obtaining 
it  is  at  times  very  much  so,  certain  tissues  and  organs  of  the  body  pos- 
sess storage  functions  which  provide  reserve  material  upon  which  the 
blood  can  draw  as  required.  The  storage  of  fat  in  the  connective  tissue 
and  liver  cells  of  the  body  represents  so  much  potential  energy.  The 
glycogen  in  the  liver  is  a  store  of  carbohydrate  which  is  continually  being 
utilised  in  maintaining  an  average  constant  of  sugar  in  the  blood.  The 
sugar  is  used  up  continually  by  the  muscles  in  the  production  of  energy, 
but  if  more  than  a  certain  quantity  exist  in  the  blood,  it  would  be 
injurious ;  consequently  the  liver  intercepts  the  intermittent  supply  of 
carbohydrate  material  in  the  form  of  glucose  absorbed  by  the  portal 
blood,  converts  it  into  glycogen,  and  stores  it  in  its  cells  to  be  used  as 
required  (Bernard).  Probably  all  the  cells  of  the  body  possess  the 
power  of  oxygen  storage  ;  we  have  definite  proof  of  its  existence  in  the 
muscles.  T,he  muscles  of  the  frog  can  contract  and  produce  heat  and 
work  in  an  atmosphere  of  IST  with  liberation  of  CO  2  and  other  waste 
products  ;  and  the  muscles  of  warm-blooded  animals  will  display  similar 
functional  activity  (when  stimulated)  for  some  time  after  the  circulation 
has  ceased.  During  sleep  and  rest  the  tissues  are  storing  up  materials 
for  their  functional  activity,  and  this  has  been  most  clearly  shown  by  the 
histological  appearances  of  the  cells  of  secreting  glands  during  rest  and 
during  activity.  Another  very  important  factor  complementary  to  de- 
structive metabolism,  in  connection  with  the  maintenance  of  the  normal 
composition  of  the  blood,  is  what  is  termed  the  internal  secretion  of  glands. 

Blood  —  the  Nutrient  Fluid  and  Medium  of  Exchange.  —  The  quantity 
of  blood  in  the  body  is  about  yV^^^  ^^  ^■'^®  body  weight,  and  its  mode 
of  distribution  is  varied  in  accordance  with  the  functional  needs  of  the 
tissues.  Certain  organs  and  tissues,  requiring  large  quantities  of  blood 
to  perform  their  functions,  are  highly  vascular  in  proportion  ;  the  supply 
to  a  part  is  regulated  automatically  by  the  vaso-motor  nervous  system, 
and  the  physiological  stimulus  wldch  excites  the  activity  of  an  organ 
may  also  determine  an  increase  of  blood  to  the  part.  Thus,  experimen- 
tally, an  increase  of  urea  in  the  blood  causes  an  expansion  of  the  kidney 
due  to  vaso-dilation,  which  signifies  an  increased  flow  of  blood  associated 
with  the  secretory  activity  of  the  organ. 

There  is  an  essential  similarity  between  the  composition  of  protoplasm 
and  that  of  the  normal  human  body  —  between  the  normal  human  body 
and  the  circulating  blood  which  provides  it  with  nutrition  ;  for,  during 
gestation  in  utero,  a  new  body  is  entirely  built  up  from  the  maternal 
blood ;  and  there  is  also  an  essential  similarity  between  milk,  the  natural 
food  of  the  suckling  animal,  and  the  composition  of  the  body  —  with  one 
important  exception  to  be  mentioned  hereafter.     The  cells  of  the  body 


i64  SYSTEM  OF  MEDICINE 

assimilate  from  the  blood  organic  proximate  principles  representing  so 
much  potential  energy,  which  they  convert  into  kinetic  energy  in  the 
form  of  mental  and  bodily  work. 

Cell  activity,  then,  depends  upon  chemical  action,  and  the  products 
of  cell  activity  are  carbonic  acid,  water,  and  nitrogenous  waste  products, 
of  which  urea  is  by  far  the  most  important. 

To  restore  to  the  blood  that  which  it  has  given  up  to  the  tissues 
requires  daily  ingestion  of  a  certain  amount  of  food  in  the  form  of  organic 
proximate  principles :  proteids,  carbohydrates,  fats,  water,  salts  and 
oxygen.  The  proximate  principles  which  enter  into  the  composition  of 
the  human  body  are  composed  of  fourteen  elements,  united  in  various 
combinations  to  form  complex  energy-producing  organic  substances  and 
simpler  inorganic  substances  —  the  latter  incapable  of  producing  energy, 
but  still  essential  for  nutrition,  water  making  up  at  least  two-thirds  of 
the  body  weight.  The  elements  contained  in  the  body,  and  therefore  in 
the  blood,  are  C .  H .  0 .  N .  S .  P .  Fe .  Na .  K .  Mg .  Ca .  CI .  F .  Si .  Although 
many  of  these  exist  in  very  small  quantities,  yet  in  all  probability  they 
are  essential  to  the  blood  for  the  proper  nutrition  of  the  cells  of  the 
body.  Even  fluorine,  which  exists  only  in  minutest  traces,  is  essential 
to  the  formation  of  the  teeth  and  bones. 

''  The  law  of  the  minimum  "  holds  as  good  for  the  nutrition  of  the 
human  body  as  it  does  for  agriculture  ;  that  is  to  say,  the  food  must 
contain  not  less  than  certain  quantities  of  the  above  elements,  and  in 
such  forms  as  can  be  assimilated.  Iron  is  the  element  of  great  impor- 
tance in  connection  with  the  function  of  oxygenation  of  the  tissues, 
by  means  of  the  iron-containing  haemoglobin.  The  iron  in  the  body  of 
an  average-sized  man  is  3  to  5  grammes,  the  greater  part  of  which  is 
contained  in  the  blood  in  the  form  of  haemoglobin ;  the  rest  is  combined 
with  nucleo-albumins  of  the  tissues.  Bunge  points  out  that  the  ash  of  • 
a  bitch's  milk  corresponded  with  the  ash  of  the  body  of  the  puppy  in 
every  respect  save  one  —  there  was  six  times  less  iron.  The  explanation 
of  this  doubtless  lies  in  the  fact  that  the  young  animal  acquires  its  store 
of  iron  during  its  development  in  utero.  The  proportional  amount  of 
iron  to  the  weight  of  the  body  is  highest  at  birth,  and  gradually  dimin- . 
ishes  with  the  development  of  the  animal  during  lactation.  These  facts 
may  explain  the  wonderful  effect  of  small  doses  of  iron  and  cod  liver 
oil  on  the  nutrition  of  ill-nourished,  rickety  infants,  and  the  advisability 
of  not  deferring  weaning  or  not  adhering  too  long  to  a  purely  milk  diet, 
but  of  using  food  which  supplies  more  iron. 

We  obtain  in  our  food  enough  of  all  the  inorganic  salts  save  one  — 
sodium  chloride  ;  but  our  diet  is  by  no  means  deficient  even  in  this.  No 
animal  can  live  if  its  food  be  deprived  of  salts.  It  has  been  suggested 
that  as  the  blood  loses  a  large  amount  of  its  inorganic  salts,  and  these 
are  not  replenished  by  the  food,  there  are  no  bases  to  unite  with  the 
S.O3  formed  by  the  oxidation  of  the  sulphur  of  the  disintegrated  pro- 
teids. It  is  probable  that  the  salts  favour  osmotic  changes  by  their 
power  of  diffusion ;  and  certain  salts,  especially  sodium  chloride,  play 


THE    GENERAL  PATHOLOGY  OF  NUTRITION  165 

an  important  part  in  nutritive  exchange  by  holding  in  solution  in  the 
blood  and  muscle  plasma  certain  proteids  of  the  globulin  class.  The 
important  part  played  by  lime  salts  in  the  formation  of  bone  and  by 
potash  salts  in  the  tissues  is  well  known.  [Vide  articles  Rickets  and 
Scurvy.] 

Proteids  are  essential  to  restore  to  the  blood  those  proteid  substances 
which  have  been  used  by  the  tissues  for  repairing  waste.  Muscular 
energy  can  be  obtained  from  proteid,  but  normally  it  is  obtained  from 
carbohydrates  and  fat,  a  more  economical  method.  It  has  been 
found,  however,  that  proteids  alone  can  repair  tissue-waste,  and  that  if 
proteids  are  not  contained  in  the  food  in  proper  proportion  the  tissues 
feed  on  themselves.  In  inanition  or  starvation,  on  the  other  hand,  a 
selective  process  seems  to  take  place,  and  the  tissues  which  are  of  the 
least  consequence  suffer  the  most.  Fat  rapidly  disappears,  muscle  wastes ; 
so  also  do  many  of  the  glands,  the  spleen,  and  liver,  and  even  the  blood 
itself;  but  the  circulating  medium  nourishes  the  nervous  system  and 
heart,  so  that  the  master  organs  essential  to  the  life  of  the  individual 
may  be  supported  at  the  expense  of  the  less  important  tissues.  This 
vicarious  nutrition  may  be  considered  as  a  defensive  power  of  the  organ- 
ism to  resist  dissolution  of  the  nervous  system  and  heart. 

Dr.  Barlow  (in  the  Bradshaw  Lecture,  1894)  has  shown  that  condensed 
milk  or  even  sterilised  milk  is  not  an  eflRcient  substitute  for  the  natural 
food  of  the  suckling  infant,  and  that  infantile  scurvy  may  be  occasioned 
by  their  sole  use.  It  is  a  noteworthy  fact  that  although  animals  can  live 
on  milk  alone,  yet  if  a  mixture  be  made  of  all  the  supposed  constituents 
of  milk  which,  according  to  the  present  teaching  of  physiology,  are 
necessary  for  the  maintenance  of  the  organism,  the  animals  fed  on  it 
rapidly  die.  Does  milk  then,  besides  carbohydrates,  fat,  proteids,  salts 
and  water,  contain  other  substances  indispensable  to  the  maintenance  of 
life? 

Of  like  importance  in  nutrition  are  certain  phosphorus-containing 
substances  in  the  body,  viz.,  a  phosphuretted  fat  termed  lecithin,  indis- 
pensable for  the  constructive  metabolism  of  the  central  nervous  system 
and  red  blood  corpuscles ;  and  nudein,  which  consists  of  an  organic 
phosphorus-containing  acid,  termed  nucleic  acid,  in  combination  with 
proteid.  The  amount  of  P  varies  in  different  forms  of  nuclein,  as 
the  sulphur  varies  in  amount  in  different  forms  of  proteid.  Nucleic  acid 
contains  C .  H .  0 .  IST .  P  but  no  S.  The  nucleus  of  a  cell  serves  two  functions 
—  the  nutritive  and  the  formative  ;  it  exercises  a  controlling  influence  on 
the  nutrition  of  the  cell,  and  it  is  in  the  nucleus  that  the  first  evidences 
of  cell-proliferation  are  manifested.  The  essential  portion  of  the  male 
sperm  cell,  namely,  the  head  of  the  spermatozoon,  chemically  consists 
entirely  of  nucleic  acid. 

The  composition  of  cells  is  mainly  spongioplasm  and  hyaloplasm ;  the 
former  is  the  mesh  work  in  which  the  latter  more  fluid  protoplasm  is  . 
contained.     The  spongioplasm  stains   readily,  and  is  therefore  called 
chromatin,  a  body  which  contains  both  P  and  Fe.     Experiments  seem 


i66  SYSTEM  OF  MEDICINE 

to  show  that  the  daily  output  of  uric  acid  is  derived  from  destructive 
metabolism  of  nucleo-albumin.  If  this  represent  the  total  N  derived  from 
the  waste  of  nucleo-albumin,  it  shows  how  very  small  is  the  destruction 
of  the  fixed  framework  of  the  cell  elements,  and  how  carefully  are  these 
highly  complex  organic  bodies  preserved  from  waste.  The  fluid  which 
surrounds  and  bathes  every  cell  of  the  body  is  a  transudation  from  the 
blood ;  and  it  is  the  property  of  every  anatomical  element  to  take  from 
the  fluid  the  materials  which  it  requires,  to  incorporate  them  for  a  time, 
to  utilise  them  in  various  ways  according  to  its  special  function,  and  to 
give  back  to  the  fluid  various  waste  products  or  bye-products,  the  out- 
come of  its  functional  activity.  There  is  thus  going  on  in  the  cells  a 
continual  and  associated  process  of  recom'position  and  decomj'tosition  —  of 
constructive  and  destructive  metabolism  —  a  nutritive  exchange  essential  to 
all  forms  of  physiological  function,  whether  it  be  of  body  or  mind. 

TJie  deficient  supply  of  blood  or  deficient  quality  of  the  blood  is,  then,  one 
of  the  causes  of  nutritive  derangement,  and  of  cell-degradation  and  death. 
Another  cause  may  be,  tJie  failure  on  the  piart  of  the  organism  to  eliminate 
the  waste  products  ichich  accumulate  in  the  blood,  causing  injury  to  the  cell 
elements,  as  in  uraemia. 

There  is  yet  another  cause  of  defect  of  nutrition  due  to  alteration  of 
the  blood,  which  lies  in  the  interdependence  of  each  and  all  of  the  tissues 
of  the  body  upon  one  another.  No  part  can  be  removed  without  some 
effect  upon  the  rest  of  the  body.  We  may  note,  for  example,  the  pro- 
found effect  on  nutrition  and  on  the  male  character  produced  by  early 
castration;  and  recently  various  other  organs  have  been  shown  to 
exercise  a  very  considerable  influence  upon  the  blood  and  tissues  by 
acts  complementary  to  their  special  functional  activity.  I  refer  to  those 
glands  believed  to  have  an  internal  secretion  passing  into  the  blood 
and  playing  an  important  part  in  metabolism  ;  and  I  shall  now  consider 
certain  of  these  functions. 

I.  TJie  Liver.^  —  Minkowski  has  shown  that,  after  extirpation  of  the 
liver  in  birds,  uric  acid  is  in  great  part  replaced  by  ammonia  and  lactic 
acid.  It  is  impossible  to  extirpate  the  liver  in  warm-blooded  animals  ; 
but  Murchison  always  taught  that  nitrogenous  waste  products  of 
tissue-metabolism  were  converted  by  the  liver  into  urea.  It  is  known 
that  in  acute  yellow  atrophy  leucin  and  tirosin  appear  in  the  urine. 
There  is  not  the  slightest  doubt  that  urea  is  far  less  poisonous  than  its 
antecedents ;  moreover,  urea  favours  urinary  secretion,  and  may  be  con- 
sidered a  physiological  diuretic.  The  experiments  of  Hahn,  Masson, 
Pawlow,  and  Nencki  have  shown  that  in  dogs  carbamate  of  ammonia 
may  be  made  to  accumulate  in  the  urine,  that  it  is  highly  poisonous,  and 
that  it  arises  from  tissue  metabolism  and  disintegration.  They  also 
found  that  the  injection  of  sodic  carbamate  into  the  circulation  of  dogs 
was  poisonous  only  to  those  animals  in  which  the  portal  current  had 
been  diverted  into  the  vena  cava,  the  portal  vein  ligatured,  and  the  liver 
thus  thrown  out  of  action  (fistula  of  Eck).  This  suggests  that  the  car- 
1  As  this  is  mostly  new  work  the  names  of  the  observers  will  be  mentioned  in  the  text, 


THE    GENERAL  PATHOLOGY  OF  NUTRLTLON  167 

bamate  of  ammonia  is  converted  into  urea  by  the  liver.  When  the  hepatic 
artery  is  simultaneously  ligatured  there  is  a  great  increase  of  carbamate 
of  ammonia.  It  has  been  shown  that  small  quantities  of  this  salt  exist 
in  the  blood,  and  animals  in  which  the  liver  is  normal  suffer  no  ill  effects 
from  its  injection;  whereas  those  in  which  the  liver  has  been  put  out  of 
action  die  of  peculiar  nervous  phenomena.  These  observers  think  the 
intoxication  of  the  organism  by  the  products  of  cellular  activity  is  a 
complex  process,  and  that  their  experiments  show  that  one  function  of 
the  liver  is  to  destroy  and  transform  poisons  arising  in  the  organism 
from  cellular  activity.  Their  long  series  of  experiraents  indicate  that 
the  liver  protects  the  organism  from  poisoning  by  the  products  of  its 
own  cellular  activity;  and  they  make  it  probable  that  certain  compli- 
cations arising  in  hepatic  insufficiency  of  various  kinds  are  due  to  car- 
bamate of  ammonia.  It  is  probable,  however,  that  this  is  one  only  of 
many  nitrogenous  antecedents  of  urea. 

The  liver,  again,  standing  as  a  safeguard  between  the  portal  and 
general  circulations,  protects  the  body  from  the  influence  of  toxic  sub- 
stances produced  by  the  alimentary  canal  or  taken  into  it.  The  re- 
searches of  M.  Bouchard  have  proved  that,  for  the  same  quantity  of 
nitrogen,  urea  is  forty  times  less  poisonous  than  ammoniacal  salts ;  and 
in  his  recent  work  on  Auto-intoxication  he  has  demonstrated  that  this 
function  of  the  liver  diminishes  in  an  enormous  proportion  the  toxicity 
of  the  waste  products. 

II.  T]ie  Pancreas.  —  Recent  researches  and  clinical  observations  have 
shown  that  this  organ,  besides  its  digestive  functions,  discharges  into 
the  blood  certain  ■  products  without  which  the  organism  is  incapable  of 
utilising  the  glucose  normally  contained  in  the  blood ;  hence  this  accu- 
mulates and  gives  rise  to  glycosuria  or  pancreatic  diabetes.  Von  Mer- 
ing  and  Minkowski  have  proved  that  animals  from  which  the  pancreas 
has  been  completely  extirpated  become  glycosuric.  Lancereaux  and 
other  clinicians  had  previously  called  attention  to  lesions  of  the  pan- 
creas in  association  with  diabetes.  But  the  trouble  does  not  seem  to 
come  from  the  accumulation  in  the  organism  of  a  poisonous  substance, 
for  no  effect  is  produced  on  a  healthy  dog  by  injecting  into  its  system 
the  blood  of  an  animal  which  has  become  diabetic  by  extirpation  of  the 
pancreas.  Gi-ley  succeeded  in  tying  all  the  veins  of  the  pancreas  and 
produced  glycosuria ;  and  other  experiments  seem  to  show  that  the  pan- 
creas has  normally  a  function  of  elaborating  and  tiirning  into  the  blood 
a  glycolytic  ferment,  necessary  to  enable  the  tissues  to  utilise  tlie  sugar 
contained  in  it.  Complete  extirpation  of  the  pancreas  (like  complete 
extirpation  of  the  thyroid)  must  be  attained  in  order  that  the  sugar 
may  thus  accumulate  in  the  blood. 

III.  Tlie  Tliyroid  Body.  —  As  early  as  1856  Schiff  proved  that  dogs 
in  which  he  had  completely  extirpated  the  thyroid  gland,  presented 
numerous  troubles  and  alterations  of  nutrition  analogous  to  those 
observed  in  man  after  thyroidectomy.  He  put  forward  the  hypothesis 
that  the  thyroid  elaborated  a  substance  which  passed  into  the  circulation. 


i68  SYSTEM  OF  MEDICINE 

and  which,  played  an  important  role  in  the  nutrition  of  the  nervous 
system.  Tnis  has  since  been  verified  experimentally  and  clinically. 
[  Vide  art.  Myxoedema.] 

IV.  The  Pituitary  Body.  —  Experiments  by  Gley  have  shown  that  in 
a  rabbit  which  had  survived  thyroidectomy,  destruction  of  the  hypo- 
physis cerebri  would  lead  to  trophic  troubles  similar  to  those  produced 
in  the  dog  by  total  extirpation  of  the  thyroid.  [Vide  article  Acrome- 
galy, a  peculiar  hypertrophy  associated  with  disease  of  pituitary  body.] 

V.  TJie  Suprarenal  Capsules.  —  Addison  pointed  out  a  peculiar  pig- 
mentation of  the  skin  associated  with  caseous  degeneration  of  these 
glands.  Brown-Sequard  has  shown  that  extirpation  caused  great  dis- 
turbances of  nutrition,  often  followed  by  death.  In  all  cases  of  ablation 
of  these  organs  there  is  accumulation  of  pigment  in  the  blood,  and  also, 
according  to  the  researches  of  Abelous  and  Langlois,  of  poisonous  prod- 
ucts of  unknown  nature.  Schafer  and  Oliver  have  lately  shown  that 
injection  of  suprarenal  extract  into  the  circulation  of  animals  is  followed 
by  an  enormous  rise  of  blood  pressure.  They  have  come  to  the  conclu- 
sion that  the  medullary  portion  of  the  gland  secretes  a  material  which 
increases  the  tone  of  all  muscle  tissue  especially  of  the  heart  and 
arteries. 

Bradford's  experiments  also  show  that  the  kidneys,  besides  the  func- 
tions of  elimination  of  waste  products,  possess  another  concerned  with 
the  metabolism  of  the  tissues.  [  Vide  art.  Gen.  Path.  Dis.  of  Kidneys.] 
The  spleen,  in  contradistinction  to  the  above-mentioned  organs,  can  be 
removed  without  producing  any  notable  physiological  effect  beyond 
compensatory  hypertrophy  of  the  lympathic  glands. 

Influence  of  the  Nervous  System  upon  Nutrition. — The  influence  of 
the  mind  upon  the  nutrition  of  the  body  is  well  known  :  anxiety,  mental 
strain,  with  associated  insomnia,  are  followed  by  lowered  nutrition  and 
general  wasting  of  the  body.  Many  neuroses  —  such  as  hysteria,  epi- 
lepsy and  insanity  —  are  associated  Avith  failure  of  nutrition  and  general 
wasting  of  the  body ;  and  this  condition  also  obtains  in  certain  cases  of 
nervous  exhaustion  in  highly  intellectual  persons.  Improvement  of  the 
nutrition  of  the  body  is  often  followed  by  improvement  of  the  mental 
state,  as  in  mania,  melancholia,  hysteria  and  neurasthenia. 

The  question  before  us,  however,  is  not  whether  derangement  of  the 
nervous  system  may  prevent  assimilation,  but  whether  the  nervous 
system  exercises  a  direct  trophic  influence  upon  the  tissues  ?  We  have 
undoubted  proof  within  the  nervous  system  that  nerve-cells  exercise 
a  trophic  influence  upon  nerve-fibres ;  but  are  there  nerve-fibres  which 
can  modify  the  "nutritive  exchanges  "  of  the  cells  independently  of  the 
vascular  or  other  known  changes  ?  In  reply  I  shall  treat  of  the  experi- 
mental data,  reserving  clinical  incidents  for  the  articles  Hypertrophy, 
Atrophy  and  Necrosis. 

Intracranial  section  of  the  fifth  nerve  produces  inflammation  of  the 
eye,  ulceration  of  the  cornea,  and  suppuration  and  destruction  of  the 
eyeball  of  the  same  side  ;  but  it  is  asserted  that  these  accidents  do  not 


THE    GENERAL  PATHOLOGY  OF  NUTRITLON  169 

occur  if  the  eyelids  are  sewn  together,  and  the  delicate  surfaces  of  the 
conjunctiva  and  cornea  thus  protected  from  the  injury  of  foreign  bodies, 
especially  microbes.^ 

Section  of  the  cervical  sympathetic  is  said  to  produce  in  a  young 
rabbit  an  increased  growth  of  the  ear ;  section  of  the  facial  nerve  to 
produce  an  increase  in  size  of  the  maxillary  bones :  doubtless  in  both 
cases  the  results  are  due  to  increased  vascularity,  and  consequent 
increased  nutrition  of  those  parts. 

Section  of  the  anterior  roots  or  motor  nerves  offers  perhaps  the  best 
evidence  of  trophic  influence,  for  the  wasting  of  the  muscles  is  then 
much  more  rapid  and  extensive  than  disuse  of  the  muscles  would 
produce ;  and  it  is  attended  by  electrical  changes  with  "  reaction  of 
degeneration."  Some  physiologists  object  that  the  effects  may  be  due 
to  disuse,  irritation,  or  vascular  changes ;  but  in  my  opinion  they  are  a 
proof  of  direct  trophic  influence,  for  Professor  Sherrington  and  I  have 
produced  complete  disuse  of  the  muscles  of  the  limb  by  section  of  all 
the  posterior  afferent  roots  of  a  limb  —  the  anterior  motor  roots  being 
left  intact.  Animals  kept  alive  three  months  had  never  been  seen  since 
the  operation  to  use  the  hand  or  foot  of  the  limb  thus  deprived  of  sen- 
sation, yet  on  stimulation  of  the  cortical  centre  or  of  the  nerve  presiding 
over  these  muscles,  a  contraction  was  obtained  even  more  readily  than 
on  the  sound  side.  Certainly  the  assumption  of  a  direct  trophic  influ- 
ence of  the  nervous  system  upon  the  cells  and  tissues  of  the  body  helps 
us  to  explain  many  important  clinical  phenomena;  but  it  cannot  be 
asserted  that  the  clinical  facts  afford  indisputable  proof  of  the  existence 
of  independent  trophic  nerve  fibres. 

The  Acquired  or  Inherited  Specific  Properties  of  the  Blood  and 
Tissues.  —  On  the  failure  of  nutrition  in  wasting  diseases  such  as  phthisis, 
cancer,  infectious  diseases,  the  reader  is  referred  to  special  articles ;  so 
also  on  the  efi^ects  of  poisons  such  as  lead,  alcohol  and  phosphorus. 

The  "  durability  of  life  "  of  the  cells  of  each  and  all  the  tissues  of  the 
body  depends  largely  upon  specific  inherited  properties  of  longevity.  It 
may  happen  that  all  the  organs  of  the  body  possess  an  inherited 
longevity,  that  if  environment  be  favourable  all  the  tissues  will  pass 
through  all  the  stages  of  growth  and  natural  decay,  terminating  in 
gradual  dissolution  ;  and  the  organism  pass  out  of  the  world  as  un- 
conscious of  death  as  of  birth.  On  the  other  hand,  there  may  be 
an  inherited  defect  in  the  "make-up  "  of  one  particular  tissue,  rendering 
it  susceptible  to  disease  and  degeneration.  Should  such  a  tissue  be 
endowed  with  an  important  function  which  cannot  be  assumed  by  another 

1  Professors  Goltz  and  Ewald  showed  (at  the  International  Physiological  Congress  held 
at  Berne  18. '.5)  a  dog  in  which  the  spinal  cord  from  the  last  cervical  segment  downwards 
had  been  removed.  The  muscles  of  the  bladder  and  rectum  preserved  their  tonus,  and 
there  were  no  trophic  changes  in  the  skin,  hair,  and  nails  ;  but  of  course  all  the  striped 
muscles  of  the  lower  limbs  had  completely  wasted.  Inasmuch  as  the  spinal  ganglia  and 
sympathetic  ganglia  had  not  been  destroyed,  it  may  be  inferred  that  the  absence  of 
changes  in  the  skin  and  appendages  depended  upon  integrity  of  the  former,  and  the 
preservation  of  the  smooth  muscle  fibres  of  the  viscera  on  the  integrity  of  the  latter. 


170  SYSTEM  OF  MEDICINE 


tissue,  then  tlie  whole  of  the  tissues  of  the  body  would  suffer  either  from 
the  effects  of  mal-assimilation  or  non-removal  of  the  waste  products ;  and 
the  local  disease  would  then  cause  a  derangement  of  nutrition  of  the 
whole  organism  and  perhaps  a  general  dissolution. 


REFERENCES 

In  the  chapter  upon  nutrition  the  following  authors  have  been  consulted :  — 
1.  Foster.  Text-book  of  Physiology,  5th  ed.  —  2.  Waller.  Huniun  Physiology, 
2nded. — 3.  Bunge.  Physiological  and  Pathological  Chemistry .  Translated  by  Woold- 
ridge. — 4.  Bernard,  C.  Physiologic  Generale ;  Les  pitenomeiies  de  lavie. — 5.  Pavy. 
Physiology  of  the  Carbo-hydrates. — 6.  Duval.  Cours  de  Physiologic. — 7.  Gamgee. 
Physiological  Chemistry.  —  8.  Halliburton.  The  Animal  Cell.  Goulstonian  Lecture, 
1893;  Chemical  Physiology  and  Pathology.  —  9.  Virchow.  Cellular  Pathologic.  — 10. 
CoHNHEiM.  Al'gemeine  Pathologic.  — 11.  Bouchard.  Les  Maladies  de  ralcntissement 
di  Nutrition;  Le<;ons  dans  les  auto-intoxications  dans  les  Maladies.  — 12.  Charcot, 
Bouchard,  and  ]3rissaud.  Traite  de  medccine,  vol.  i.  — 13.  Roger.  "  Quelques 
Travaux  re'cents  sur  le  Role  du  Foie  dans  les  auto-iiitoxications,"  Revue  generale  des 
sciences.  — 14.  Schafer.  Presidential  Address  Physiological  Section  of  the  British 
AssociatioH,  Oxford,  1894.  — 15.  Barlow,  Dr.  Infantile  Scurvy  and  its  Relation  to 
Rickets.  Bradshaw  Lecture,  B.  31.  J.,  Nov.  19th,  1894.  —  IG.  Schafer  and  Oliver. 
"Effects  of  Suprarenal  Extract,"  Journal  of  Physiology,  July  1895. 


Pkogressive  and  General  Failure  of  ISTutrition" 

General  arrest  of  nutrition  of  the  tissues  of  the  body  will  produce 
somatic  death.  General  wasting  or  inanition  may  arise  from  diseases  such 
as  cancer  or  stricture  of  the  oesophagus ;  destructibn  of  the  mucous 
membrane  of  the  stomach  by  corrosive  fluids  or  disease ;  uncontrollable 
vomiting  and  hj'sterical  anorexia ;  pressure  of  growths  upon  the  thoracic 
ducfc ;  cancer  of  the  pyloric  end  of  the  stomach,  and  cancer  of  the  pan- 
creas. Whether  cancer  produces  its  characteristic  cachexia  by  interfering 
with  digestion  and  assimilation,  or  whether  some  products  escape  from 
the  growth  into  the  blood,  or  some  substance  is  taken  from  the  blood 
by  the  growth,  thus  altering  its  composition,  is  at  present  matter  of 
speculation ;  but  certainly  the  sarcomata,  which  are  of  mesoblastic 
origin,  do  not  produce  the  same  marked  effect  upon  nutrition  as  car- 
cinomata. 

There  are  a  number  of  diseases  which  produce  general  wasting  by 
increased  destructive  metabolism  accompanied  by  fever,  by  hgemorihages, 
or  by  exhaustive  discharges  from  the  body,  in  none  of  which  the  process 
of  repair  is  adequate,  and  a  progressive  failure  of  nutrition  ensues ; 
such  are  fevers,  phthisis,  diabetes,  prolonged  suppuration,  dysentery  and 
albuminuria. 

General  wasting  from  exhaustive  diseases  is  always  attended  by  a 
certain  amoimt  of  tissue  metam.orphosis  and  degeneration,  as  in  coagu- 
lation necrosis,  hyaline  degeneration,  fatty  degeneration,  lardaceous 
degeneration,  etc.,  —  the  location  of  the  tissue  change  depending  upon 
the  nature  of  the  disease  and  the  ability  of  the  organ  or  tissue  imder 


THE    GENERAL  PATHOLOGY  OF  NUTRITION  171 

abnormal  conditions  of  nutrition  to  maintain  the  equilibrium  between 
repair  and  waste. 

In  general  wasting  of  the  body  from  starvation  the  various  tissues 
are  affected  unequally :  97  per  cent  of  the  fat  is  lost,  oO  per  cent  of  the 
muscle,  28  per  cent  of  the  blood,  and  of  the  heart  only  2  per  cent. 
Wilks  and  Moxon  point  out  that  in  cancer  the  heart  usually  wastes  very 
much,  in  one  case  being  reduced  to  4  oz. ;  whereas  in  phthisis  it  does 
not  atrophy,  although  there  may  be  extreme  emaciation  of  the  body. 
Perhaps  in  the  former  it  is  partly  disuse-atrophy,  owing  to  the  pro- 
gressive diminution  of  the  amount  of  blood  and  tissue. 

In  old  age  there  is  a  gradual  wasting  of  all  the  tissues  of  the  body 
(the  heart  sometimes  excepted).  There  may  be  a  smp?e  atrophy  of  cell 
elements  without  structural  modification,  due  to  a  lowering  of  the  vital 
activities  of  all  the  tissues,  or  various  degenerative  processes  common  to 
senile  decay. 

Retrogressive  Disturbances  op  Nutrition 

A.  Necrosis  or  Tissue  Death. — Necrosis  of  a  tissue  may  be  partial 
or  complete.  The  essential  specialised  cells  of  an  organ  or  tissue  may 
die,  while  the  mechanical  supporting  tissues  remain  and  undergo  pro- 
liferation. Since  the  former  cannot  regenerate,  the  latter  fill  up  the 
gap.  If  tissue  death  or  necrosis  occur  in  situations  favourable  to  the 
presence  or  introduction  of  micro-organisms,  then  we  have  no  longer  an 
aseptic,  but  a  septic  necrosis,  or  gangrene  ;  of  this  there  are  two  varieties, 
moist  or  spreading,  and  dry.  In  the  former  the  conditions  are  favourable 
to  the  growth  and  spread  of  the  putrefactive  microbes,  in  the  latter  they 
are  not ;  hence  the  process  is  usually  limited  by  a  "  line  of  demarcation." 

Causes  and  Pathogeny 

Traumatic.  —  (1)  Mechanical  injury,  such  as  violent  contusions  or 
tight  bandaging.  (2)  Heat  and  cold.  (3)  Chemical,  such  as  strong 
corrosives,  acid  or  alkaline.  (4)  Electricity.  These  causes  produce 
complete  death  of  the  tissue  as  a  rule,  and  are,  at  any  rate  at  the  onset, 
aseptic. 

Mechanical  injury  produces  death  of  the  tissue  by  inducing  blood 
stasis,  and  by  its  direct  effect  upon  the  tissue  elements. 

Heat  produces  death  by  coagulation;  several  very  important  al- 
buminous substances,  e.g.  myosinogen  and  fibrinogen  are  coagulated  at 
56°  C.  This  would  indicate  that  the  tissues  and  fluids  of  the  body 
exposed  to  this  temperature  would  solidify,  and  thus  inevitably  be  killed. 
Temperatures  below  16°-18°  C.  destroy  living  protoplasm ;  the  nature 
of  the  tissue  and  the  period  of  time  to  which  it  is  exposed  to  abnormal 
conditions  of  temperature  will  determine  whether  it  can  be  restored  to 
functional  activity. 

Corrosive  Fluids.  —  Strong  acids  produce  immediate  death  by  coagula- 


172  SYSTEM   OF  MEDICINE 

tion  of  the  blood  and  tissues.  Strong  alkalis  disorganise  the  tissues  by 
liquefaction  producing  a  soft  eschar. 

Electrolysis.  —  At  the  negative  pole  the  eschar  is  soft  and  resembles 
the  destruction  produced  by  alkalis,  whereas  at  the  positive  pole  the 
eschar  is  dry,  yellowish,  and  similar  to  the  effect  produced  by  acids. 

B.  Necrosis  by  Disturbance  of  the  Circulation.  —  All  causes  which 
bring  about  stasis  of  the  blood  in  the  capillaries,  such  as  inflammation, 
pressure,  haemorrhage,  or  blocking  of  the  venous  outflow  of  a  part,  will 
cause  necrosis  by  arrest  of  nutrition.  Again,  if  the  arterial  supply  of  a 
part  be  cut  off  by  ligature,  embolism,  thrombosis,  or  slow  degeneration 
and  obliteration  of  the  vessel,  anaemic  necrosis  results.  The  arrest  of  the 
circulation  need  not  be  permanent ;  it  suffices  if  it  persist  a  certain  time. 
The  more  highly  specialised  a  tissue  the  briefer  its  vitality  when  deprived 
of  blood.  The  gray  matter  of  the  central  nervous  system,  the  epithelium 
of  the  intestine  and  the  kidneys,  can  live  but  a  short  time  (one  to  two 
hours,  Cohnheim)  without  their  blood-supply.  So  if  one  of  the  above 
causes  should  lead  to  antemia  of  a  specialised  tissue,  death  of  the  special- 
ised cell-elements  has  generally  occurred  before  the  circulation  can  be  re- 
established. This  is  particularly  liable  to  happen  in  organs  having 
terminal  arteries.  [  Vide  arts.  Thrombosis,  Acute  Perforating  Ulcer  of 
Stomach  and  Duodenum.]  Direct  injury,  if  severe,  produces  tissue- 
necrosis  by  complete  arrest  of  nutrition  of  a  part;  but  those  remoter 
causes  which  consist  in  the  weak  defence  of  the  organism  against  in- 
jury, although  subsidiary,  are  quite  as  important.  Thus  comparatively 
trivial  immediate  causes  may  produce  a  spreading  necrosis  and  circulatory 
disturbances  of  nutrition,  which  in  a  healthy  individual  could  easily  be 
overcome.     The  predisposing  causes  are  :  — 

(a)  Disturbances  of  Innervation. — We  have  argued  that  division  of 
the  fifth  nerve  proves  no  more  than  that  the  loss  of  innervation  of  the 
cornea  causes  sloughing,  by  abolishing  the  reflex  defensive  mechanism  of 
the  tissue  against  microbes.  Section  of  the  posterior  roots  in  monkeys 
produces  sores  upon  the  feet,  but  section  of  an  equal  number  of  roots 
supplying  the  upper  limb  produces  no  sores  upon  the  hands  ;  the  hand 
is  not  subjected  to  the  same  direct  injurious  influences  of  pressure  and 
microbic  infection.  Charcot  maintained  that  acute  decubitus  occurring 
upon  the  buttock  of  the  paralysed  side  in  some  cases  of  apopletic  hemi- 
plegia was  a  proof  of  the  existence  of  direct  trophic  influence.  He  stated 
that  when  certain  patients  had  only  lain  on  the  non-paralysed  side,  and 
every  precaution  had  been  taken  about  the  urine  and  faeces,  yet  within 
some  hours  or  days  a  purplish  erythematous  rash  might  appear,  and 
bullae  form  and  burst,  leaving  a  red,  sore  surface  followed  by  an  eschar 
and  usually  by  sloughing  out  of  the  mortified  part.  Local  infection 
may  then  ensue  and  become  general.  In  acute  myelitis  the  bed-sores 
occur  over  the  sacrum  and  heels.  Dejerine  and  Leloir,  also  Pitres  and 
Yaillard  have  shown  that  changes  in  the  peripheral  nerves  often  occur 
in  cases  of  hemiplegia  with  acute  bed-sores. 

Trophic  changes  occur  in  Morvan's  Disease  and  syringomyelia ;  of 


THE    GENERAL  PATHOLOGY  OF  NUTRITION  173 

the  former  painless  whitlows  are  an  essential  feature.  The  perforating 
ulcer  of  locomotor  ataxy  is  another  example  of  tissue-necrosis  due  to 
changes  in  the  peripheral  sensory  nerves.  Herpes  has  been  observed  as 
a  complication  of  gangrene.  Whatever  view  be  taken  of  the  existence  of 
trophic  nerves,  the  important  fact  remains  that  disturbances  of  the  normal 
nervous  influences,  vaso-motor  and  sensory,  of  the  skin  directly  modify 
the  nutrition  of  the  parts,  and  interfere  with  the  defensive  action  of  the 
organism  against  microbic  invasion. 

Raynaud's  Disease  is  a  local  asphyxia  which  is  often  followed  by 
symmetrical  dry  gangrene  of  the  extremities.  The  observer  after  whom 
the  disease  is  named  considered  it  to  be  due  to  constriction  of  the  small 
arteries  owing  to  vaso-motor  spasm.  A  number  of  cases,  however,  have 
been  brought  forward  showing  endarteritis  obliterans.  [Vide  art. 
Raynaud's  Disease.]  It  is  possible  also  that  acute  perforating  ulcer  of 
the  stomach  may  be  induced  by  reflex  vaso-motor  spasm. 

(b)  Loivered  Vitality  of  the  Tissues.  — Age  is  relative ;  the  vital  reaction 
of  cells  is  partially  dependent  upon  inherited  specific  properties  and 
partially  upon  present  conditions  of  nutrition.  Premature  decay  of  tissue 
may  be  inherited  or  acquired,  and  death  ensues  as  soon  as  the  vital  energy 
is  unable  to  cope  with  the  antagonistic  influences  of  its  environment. 
Senile  decay  and  death,  however,  come  sooner  or  later  to  the  healthiest 
tissues  in  the  most  favourable  surroundings  ;  it  comes  when  the  original 
vital  capacity  is  exhausted,  when  the  mainspring  of  life  is  worn  out. 
Whether  then  the  lowered  vitality  of  the  tissues  be  premature  or  natural, 
the  tendency  to  necrosis  and  gangrene  is  much  greater  when  an  im- 
mediate cause  exists,  such  as  direct  injury  or  disturbance  of  nutrition. 
Many  diseases  are  specially  liable  to  be  followed  by  gangrene  and  bed- 
sores. Gangrene  of  the  scrotum,  penis,  and  even  of  the  nose,  has  been 
known  to  occur  in  cholera  (Fagge).  In  typhoid  fever,  Liebermeister 
points  out  that  gangrene  and  necrosis  of  bone  may  occur ;  chancres  may 
lead  to  spreading  gangrene,  and  gonorrhcea  to  sloughing  of  the  penis. 
Bed-sores  are  very  apt  to  arise  even  during  convalescence.  During  and 
following  typhus  fever  gangrene  is  not  infrequent,  and  noma  of  the 
cheek  and  vulva  is  not  uncommon  after  measles.  Gangrenous  dermatitis 
occasionally  occurs  in  ill-nourished,  tuberculous  or  syphilitic  children. 
[Vide  arts.  Varicella,  Vaccinia.]  All  these  consequences  are  due  to 
lowered  vital  resistance  engendered  by  the  disease,  to  lowered  defence 
of  the  tissues  against  microbic  infection  and  multiplication,  so  that 
microbes  gaining  entrance  to  the  tissue  find  a  suitable  soil  for  develop- 
ment. 

Gangrene  of  the  Lung  [vide  art.  Lung]  ;  Gangrene  of  Extremities  [vide 
Diabetes].     See  also  Phagadoina  Tropica. 

The  entra,nce  of  certain  poisons  into  the  blood  —  e.g.  ergot  of  rye, 
anthrax,  snake  poison,  plague  micro-organisms  —  is  followed  by  necrosis. 
With  regard  to  ergot  it  has  been  supposed  that  this  is  due  to  constric- 
tion of  the  small  arterioles  by  the  poison ;  but  instead  of  the  arterial 
pressure  being  increased,  it  is  diminished.     Ko  doubt  many  factors  are 


174  SYSTEM   OF  MEDICINE 


at  work  in  the  gangrene  of   ergotism.     Acute  necrosis  of  the  jaw  in 
phosphorus  poisoning  may  also  be  mentioned. 

Secondary  Gangrenes.  —  The  presence  of  gangrene  in  one  part  of  the 
body  may  be  folio  wed  by  secondary  foci  elsewhere.  They  generally  appear 
in  the  lung  conveyed  by  an  embolic  process.  It  is  obvious  that  the 
parts  most  open  to  infection  by  the  microbes  present  in  the  environ- 
ment are  most  liable  to  a  gangrenous  inflammation.  Therefore  gangrene 
especially  occurs  when  the  parts  affected  are  in  relation  to  the  alimentary 
canal,  the  respiratory  tract,  and  the  external  skin.  It  only  occurs 
in  the  nervous  system  in  cases  where  profound  infective  ulceration 
has  penetrated  the  dura  mater.  It  hardly  ever  occurs  in  the  liver, 
si)leen,  kidneys  or  bones :  it  generally  spreads,  but  its  progress  may  be 
arrested  by  antiseptics  and  the  actual  cautery.  Eschars  produced  by 
physical  or  chemical  agents  in  healthy  people  do  not  spread,  as  a  rule, 
because  the  tissues  are  destroyed  or  form  an  unsuitable  soil  for  the 
development  of  micro-organisms. 


MoBBiD  Anatomy  axd  Pathology  of  the  Differext  Forms 

OF  Necrosis 

I.  Coagulation  Necrosis. — Weigert  has  shown  that  when  a  part  of 
the  body  rich  in  protoplasm  dies,  it  usually  undergoes  coagulation 
necrosis.  In  order  that  coagulation  may  take  place  a  coagulable 
material  must  be  present.  In  all  parenchymatous  tissues,  except  the 
brain,  the  intercellular  fluid  is  coagulable  lymph.  When  cells  die  from 
arrest  of  nutrition,  as  in  embolism  and  thrombosis,  the  first  evidence  of 
death  is  a  change  in  the  appearance  of  the  nucleus  and  chromatic  sub- 
stance :  when  the  organ  has  been  washed  free  from  blood  by  normal 
saline  solution  there  are  practically  no  naked  eye  appearances  of  a  recent 
infarct ;  but  examined  microscopically  it  is  found  that  the  cells  or  cellular 
structures  do  not  stain  with  haematoxylon,  and  that  the  nuclei  have  either 
altered  in  appearance  or  disappeared.  Halliburton  has  shown  that  he 
can  prepare  from  many  tissues  a  nucleo-albuminous  substance,  which 
rapidly  brings  about  coagulation  of  blood  or  lymph.  The  cells  deprived 
of  nutrition  die,  liberating  a  nucleo-albuminous  material,  and  this  reacting 
upon  the  coagulable  lymph  that  has  penetrated  from  without,  produces  a 
coagulation  within  the  cell.  Cohnheim,  who  gave  the  name  of  coagulation 
necrosis  to  this  necrotic  change,  considered  it  to  be  due  to  the  interaction 
of  the  fibrino-plastin  and  fibrinogen.  The  process  of  arrest  of  nutrition 
must  not  be  too  protracted,  or  degenerative  processes,  such  q,s  fatty  change, 
may  ensue  and  render  the  process  of  coagulation  impossible.  The  pro- 
toplasm of  the  cells  which  have  undergone  coagulation  necrosis  somewhat 
resembles  coagulated  fibrin  in  appearance.  Often  small,  transparent, 
hyaline  masses  are  seen,  and  sometimes  the  cells  have  a  homogeneous 
appearance.  The  nucleus  may  be  indistinct,  absent,  swollen  up,  finely 
granular,  or  confused  with  the  contents  of  the  cell.    Later  the  products  of 


THE    GENERAL  PATHOLOGY  OF  NUTRITION  175 

necrosis  disintegrate  and  are  absorbed.  According  to  Weigert,  these 
appearances  are  found  in  white  infarcts,  atheroma,  caseous  degeneration 
of  tumours  and  glands,  waxy  degeneration  of  muscle,  and  the  superfi- 
cial necrosis  of  the  tissues  in  diphtheria. 

Waxy  degeneration  of  muscle  (Zenker)  is  an  example  of  coagulation 
necrosis.  After  death  muscle  fibre  invariably  coagulates,  but  preserves 
its  striation.  Under  various  pathological  conditions,  such  as  continued 
fever,  certain  muscles  (e.g.  rectus  abdominis)  undergo  a  peculiar  change. 
To  the  naked  eye  the  fibres  appear  dull  and  semi-opaque;  micro- 
scopically they  are  found  to  have  lost  their  striated  appearance,  the 
contents  of  the  sarcolemma  are  broken  up  into  lustrous  homogeneous 
lumps,  and  between  the  fibres  there  is  a  proliferation  of  the  connective 
tissue  cells.' 

2.  Colliquative  Necrosis.  —  Sometimes  the  dead  tissue  elements  are  in- 
filtrated with  a  serous  effusion,  and  then  undergo  liquefaction.  In  a  burn 
the  cells  are  killed  by  the  action  of  the  heat,  and  with  them  the  ferment 
that  would  produce  coagulation  of  the  transudation  of  the  blood.  The 
dead  cells  absorb  the  fluid  and  swell  up,  forming  a  vesicle ;  or,  if  the 
blood  be  coagulated  in  the  vessels,  non-coagulable  serum  will  escape  and 
produce  liquefaction  of  the  tissues.  Colliquation  may  follow  upon 
coagulation.  In  croupous  pneumonia  the  liquefaction  of  the  coagulated 
products  is  probably  owing  to  the  action  of  organised  ferments. 
Thrombi  also  break  down  and  liquefy.  In  the  brain  colliquative  necrosis 
occurs  as  the  result  of  vascular  occlusion  ; .  the  tissues  undergo  softening 
and  are  rapidly  destroyed.  The  cerebro-spinal  fluid,  which  probably 
represents  the  lymph  of  the  central  nervous  system,  is  a  non-coagulable 
fluid.  Hence  liqiiefaction  instead  of  coagulation  of  the  tissues  results, 
and  the  final  part  of  the  process  may  be  the  formation  of  a  cyst  or 
cicatrix. 

3.  Fat  Necrosis.  —  Balzer  first  described  this  condition  in  the 
pancreas  and  surrounding  mesentery.  Fitz  has  shown  that  it  is  con- 
nected with  acute  pancreatitis.  Whether  it  be  due  to  a  change  pro- 
duced by  the  steapsin  on  the  fat  and  to  the  extension  of  inflammation 
from  the  pancreas,  or,  as  Rolleston  suggests,  trophic  in  origin  and  due  to 
disturbance  of  the  abdominal  sympathetic,  is  not  decided ;  but  I  am  of 
opinion,  from  two  cases  which  I  have  recently  seen  of  acute  pancreatitis 
with  fat  necrosis,  that  the  process  is  due  to  infective  micro-organisms. 

4.  Caseation  or  Tyrosis  is  a  mode  of  termination  of  necrosis. 

5.  Gangrene  or  Septic  Necrosis,  of  whatever  form,  is  preceded  or 
accompanied  by  abnormal  sensations  in  the  part.  It  may  be  coldness  or 
a  dull  aching,  not  infrequently  severely  lancinating  or  burning.  When 
the  integument  is  involved  the  pain  is  more  intense,  and  when  an  in- 
ternal organ  is  affected  it  may  be  absent. 

Varieties  of  Gangrene.  — Dry  — or  mummification.  Spontaneous  gan- 
grene is  very  liable  to  occur  in  old  people  with  atheromatous  or  calcified 
arteries.  It  is  limited  in  extent  and  chronic  in  progress.  Several  causes 
usually  combine  to  bring  about  the  morbid  process :  of  these  are  enfeebled 


176  SYSTEM   OF  MEDICINE 

circulation,  due  to  cardiac  failure  in  a  remote  and  dependent  part  of  the 
body,  as  the  toes  or  foot,  rarely  the  fingers ;  and  the  diseased  condition  of 
the  arterial  wall,  by  which  a  gradually  extending  thrombosis  is  favoured. 
The  thrombus  may  extend  as  far  as  the  popliteal  artery,  and  yet  the 
gangrene  be  limited  to  the  toes  or  a  portion  of  the  foot.  Stasis  in  the 
arteries  and  capillaries  of  the  part,  due  to  feebleness  of  propulsion,  pro- 
duces the  gangrene;  and  this  stasis  may  be  determined  by  slight  injury 
or  abrasion,  the  cutting  of  a  corn,  or  any  such  cause  of  local  inflamma- 
tion. Putrefactive  organisms  may  be  present  in  the  skin,  but  they 
require  moisture  to  develop  in  the  tissues :  this  they  do  not  get,  be- 
cause it  evaporates  from  the  surface,  especially  when  the  skin  separates 
and  peels  off.  As  putrefaction  cannot  take  place  there  is  little  or  no 
odour  in  this  form  of  gangrene.  Frost-bite  and  ergotism  lead  to  mummi- 
fication, and  a  physiological  example  of  the  process  is  the  necrosis  of  the 
umbilical  cord.  The  affected  part  is  generally  livid,  owing  to  the  con- 
tained blood,  and  the  changes  in  colour  are  due  to  its  alteration :  it  be- 
comes withered,  black  and  dry  because  no  more  fluid  reaches  the  part, 
and  the  remainder  evaporates.  An  inflammatory  zone  —  the  line  of 
demarcation  —  separates  the  dead  part  from  the  healthy.  Occasionally 
dry  gangrene  may  go  on  to  moist  gangrene;  the  latter  is  a  necrosis 
accompanied  by  putrefaction,  and  is  especially  apt  to  occur  in  situa- 
tions which  are  in  direct  or  in  indirect  communication  with  the  air,  e.g. 
in  the  lungs,  the  alimentary  canal  or  the  integuments.  When  septic 
micro-organisms  reach  a  necrotic  part  rich  in  blood,  or  other  fluid,  de- 
composition rapidly  sets  in,  and  changes  occur  in  the  colour  of  the  part, 
which  assumes  a  bluish,  livid  appearance ;  the  epidermis  is  frequently 
raised  into  bullse  and  blebs,  and  a  very  foul  odour  arises,  due  to  the 
formation  of  various  gases  which  sometimes  produce  emphysema. 

One  form  of  gangrene,  the  acute  spreading,  is  due  to  a  specific  micro- 
organism. The  tissues  undergo  destruction  unequally :  the  blood  and 
softer  tissues  are  first  broken  up ;  and,  if  examined  microscopically, 
broken  up  blood  corpuscles  are  found,  colouring  the  part,  and  undergo- 
ing transformation  into  granular  pigmentary  derivatives  of  haemoglobin. 
The  cell-nuclei  disappear,  and  the  protoplasm  is  turbid  and  breaking  up 
into  granules.  Muscle  fibres  lose  their  striation,  and  the  sarcolemma 
contains  only  fatty  and  granular  matters.  The  connective  tissue  fibres, 
owing  to  the  swelling  up  of  the  interfibrillary  substance,  break  up  into 
their  primitive  fibrillae. 

Nerves,  owing  to  their  fibrous  tissue  sheaths,  resist  dissolution  much 
longer  than  muscles ;  but  the  nerve  fibres  themselves  at  a  very  early 
period  undergo  changes  in  the  myelin  sheath  similar  to  degeneration. 
Among  the  chemical  products  of  decomposition  are  large  quantities  of 
fat  which  arise  even  in  tissues  where  there  is  no  *fat,  such  as  the  lung. 
Fatty  acids  —  caproic,  caprylic,  butyric,  valerianic — are  formed  to  which, 
and  to  ammonium  sulphide  and  hydrogen  sulphide,  the  foul  odour 
is  in  great  measure  due.  Microscopic  examination  of  the  dirty  gray, 
grayish  black,  or  yellowish  gray  semi-fluid  mass  into  which  the  tissues 


THE    GENERAL  PATHOLOGY  OF  NUTRITION  \>j'j 

are  eventually  changed,  might  show  crystals  of  tirosin,  leucin  balls, 
characteristic  needles  of  margarine,  and  triple  phosphates  with  gran, 
ules  of  black  or  brown  pigment.  Virchow  has  shown  that  a  rosy  colour 
can  be  obtained  by  the  action  of  nitric  acid  upon  a  gangrenous  part  — 
the  "  erythro-proteid  reaction."  Unless  surgery  intervene,  the  powers 
of  the  individual  to  cope  with  moist  gangrene  are  insufficient;  the 
organisms  are  diffused  by  the  lymphatics,  and  finding  a  suitable  soil 
with  warmth  and  moisture,  they  grow  more  rapidly  than  they  can  be 
destroyed  by  the  phagocytes. 

Impaired  Nutrition.^  —  It  has  been  shown  that  permanent  arrest 
of  nutrition  causes  cessation  of  function  and  death  of  a  tissue.  We 
have  now  to  consider  those  morbid  processes  in  which  impairment  of 
nutrition  and  a  proportional  diminution  of  function  ensues.  "  A  cell  is 
not  nourished,  but  nourishes  itself."  Tissues  will,  therefore,  undergo 
atrophy  or  degeneration  when  their  component  cells  are  unable  to 
maintain  equilibrium  between  repair  and  waste.  The  main  factors  of 
impaired  nutrition  of  tissues  are  — 

1.  Absence  or  recession  of  the  normal  physiological  stimulus. 

2.  Inherent  defect  of  the  cell  elements  to  nourish  themselves,  therefore 
premature  decay. 

3.  Deficiency  in  the  quality  or  quantity  of  the  blood  and  lymph  supply. 
Any  of  these  factors,  singly  or  combined,  may  lead  to  a  rapid  or 

gradual  retrogressive  change  of  the  tissue  elements  terminating  in  atro- 
phy and  degeneration  (both  stages  towards  death)  ;  and  in  some  cases 
the  nutritional  changes  are  so  extreme  that  death  of  the  tissue  elements 
does  occur.  Morbid  retrogressive  nutritional  changes  occurring  in  the 
master  tissues  —  glandular,  muscular,  or  nervous  —  and  in  the  vessels, 
must  of  necessity  be  progressive  and  cumulative,  and  sooner  or  later 
lead  to  somatic  death. 

Several  abnormal  products  may  arise  in  the  tissues  as  the  result  of 
impaired  nutrition.  These  substances  may  originate  within  the  cell  ele- 
ments of  the  tissue  from  the  destructive  metabolism  of  its  protoplasm, 
or  be  brought  by  the  blood  and  deposited  in  the  tissue ;  thus  the  pro- 
cesses of  degeneration  are  divided  into  two  groups  —  metamorphoses,  or 
degenerations  proper,  and  infiltrations.  The  two  conditions  are  often 
associated,  and  to  draw  a  hard  and  fast  line  between  them  is  difficult. 

The  metamorphoses  are  fatty,  mucoid,  colloid,  and  lardaceous  or 
amyloid.  The  normal  metabolism  of  the  cell  is  altered,  resulting  in 
chemical  and  histological  changes  of  its  protoplasm,  and  the  metamor- 
phosis may  continue  until  the  cell  is  entirely  destroyed.  In  the  earlier 
stages  function  is  impaired,  and  in  the  later  stages  it  may  be  completely 
arrested. 

The  infiltrations  are  fatty,  calcareous,  and  pigmentary ;  the  new 
material  is  not  a  product  of  the  cell  protoplasm,  but  a  deposition  from 

1  For  the  effect  upon  nutrition  of  inflammatory  processes,  vide  article  "Inflamma- 
tion "  ;  in  which  also  atrophic  processes  arising  from  inflammatory  action  are  dealt  with. 

VOL.   I  N 


178  SYSTEM   OF  MEDICINE 

the  blood.  Since  the  change  is  not  usually  accompanied  by  destruction 
of  the  histological  elements,  the  structure  and  function  of  the  tissues  are 
much  less  altered  than  in  the  metamorphoses. 

ATROPHY  AND  FIBROSIS.  —  The  various  examples  of  arrested 
development — such  as  microcephaly,  anencephaly,  amyelia,  and  con- 
genital malformations  —  are  not,  properly  speaking,  atrophic  processes 
due  to  impaired  nutrition,  but  rather  to  an  inherited  developmental 
defect ;  so  that  to  them  the  term  Agenesis  is  more  appropriate.  The 
peculiar  condition  termed  by  Virchow  Hypoplasia  or  Aplasia,  observed 
frequently  in  chlorotic  girls,  is  associated  with  imperfect  development 
of  the  aorta  and  larger  arteries,  accompanied  by  a  remarkable  degree  of 
elasticity.  The  heart  is  frequently  dilated  and  the  left  ventricle  hyper- 
trophied.  These  cardio-vascular  conditions  are  associated  with  imper- 
fect development  of  the  uterus  and  genital  organs. 

AtrojjJiy  frojn  absence  or  recession  of  the  normal  physiological  stimulus. 
—  There  are  many  examples  of  physiological  disuse  atrophies,  e.g.  of  the 
ductus  arteriosus,  the  ductus  venosus,  the  thymus  gland,  and  the  invo- 
lution of  the  gravid  uterus  after  parturition.  Nutrition  and  functional 
activity  are  interdependent,  the  two  falling  off  together.  The  muscles 
and  glands  offer  excellent  examples  of  tissues  which  undergo  atrophy 
from  disuse ;  and  bones  likewise  which  no  longer  subserve  the  statical 
purposes  of  the  organism  —  a  familiar  example  of  which  is  the  wasting 
of  the  alveolar  portion  of  toothless  jaws.  An  example  of  disuse  atrophy 
in  the  viscera  is  afforded  after  left  lumbar  colotomy  by  the  dwindling  of 
the  large  bowel  to  a  scarcely  pervious  cord. 

Cohnheim  states  —  "  Nor  is  it  all  important  whether  the  failure  of  a 
muscle  to  contract  or  of  a  gland  to  secrete  be  caused  by  defective  inner- 
vation or  by  occlusion  of  its  duct."  He  attributes  the  greatest  share  in 
the  atrophy  to  the  abeyance  of  functions.  No  doubt  the  falling  off  in 
volume  of  the  thigh  muscles  which  occurs  in  ankylosis  of  the  knee-joint 
is  very  great,  but  experiments  upon  animals  made  by  Dr.  Sherrington  ^ 
and  myself  lead  us  to  believe  that  the  atrophy  of  the  muscles  and 
reaction  of  degeneration  which  occur  iu  infantile  paralysis  are  some- 
thing more  than  the  effect  of  disuse ;  and  that  the  muscles  depend  for 
their  nutrition  upon  a  physiological  stimulus  which  is  continually  pass- 
ing from  the  anterior  horn  cells  of  the  spinal  cord  by  the  anterior  roots 
and  motor  fibres  of  the  muscles.  If  the  posterior  roots  of  the  lumbo- 
sacral plexus,  or  of  the  cervico-brachial  plexus,  be  divided  proximal  to 
the  ganglion,  the  apsesthetic  limb  is  not  moved  by  the  animal  (even  after 
the  lapse  of  months),  there  is  loss  of  toniis  in  the  muscle,  and  a  disuse 
atrophy,  yet  apparently  no  degeneration  occurs ;  the  muscles  can  still  be 
made  to  contract  by  stimulation  of  appropriate  regions  of  the  cortex 
cerebri,  or  of  the  nerves  going  to  the  muscles,  as  readily,  if  not  more  so, 
than  on  the  uninjured  side.     If  the  anterior  roots  had  been  divided  the 

1  "  Experiments  upon  the  influence  of  sensory  nerves  upon  movement  and  nutrition 
of  the  limbs,"  Proceedings  of  the  Royal  Society,  vol.  Ivii.,  by  F.  W.  Mott,  M.D.,  and 
C.  S.  Sherrington,  M.D.,  JF.R.S. 


THE    GENERAL  PATHOLOGY   OF  NUTRITION  179 

muscles  would  have  degenerated  more  rapidly,  and  no  such  results  from 
stimulation  could  have  been  obtained.  The  atrophic  effects  are  still 
more  marked  if  both  anterior  and  posterior  roots  are  divided. 

It  is  necessary  to  mention  a  few  examples  of  correlative  atrophy  due 
to  absence  or  recession  of  the  normal  physiological  stimulus  after  ampu- 
tation of  limbs,  especially  when  this  has  occurred  in  utero.  Atrophy  of 
the  tracts  and  centres  in  the  spinal  cord  and  brain,  which  are  concerned 
with  the  innervation  of  the  part,  may  occur.  Thus  there  is  atrophy  of 
the  posterior  column  of  the  same  side  and  of  the  antero-lateral  of  the 
opposite,  and  of  that  portion  of  the  cortex  cerebri  which  is  normally 
concerned  in  voluntary  movements  of  the  limb.  Atrophy  of  the  frontal 
lobe  of  the  left  hemisphere  has  been  found  associated  with  atrophy  of 
the  opposite  lateral  lobe  of  the  cerebellum.  Atrophy  of  the  fillet  and 
the  posterior  column  nuclei  has  resulted  from  porencephalon  of  the  cen- 
tral convolution  of  the  cortex  cerebri. 

Atrophy  of  structures  which  undergo  premature  decay  owing  to 
inherent  defect  of  the  cell  elements  adequately  to  nourish  themselves.  — 
E-eference  to  the  articles  on  "  Primary  Progressive  Myopathic  (Pseudo- 
hypertrophic) Paralysis,"  and  to  "  Friedreich's  Disease,"  will  show  that 
the  only  etiological  factor  which  has  been  definitely  shown  to  have 
a  causal  .relation  to  atrophy  of  muscle  and  nervous  elements  in  these 
diseases  respectively  is  heredity.  Facial  hemiatrophy  and  scleroderma 
from  their  distribution  would  suggest  a  tropho-neurosis,  although  some 
authorities  consider  the  condition  as  a  primary  wasting  of  the  connec- 
tive tissue  structures  for  which  no  reason  is  known. 

It  is  probable  that  inherent  defect  of  the  cells  to  nourish  themselves 
is  the  determining  cause  of  atrophy  and  degeneration,  when  the  nutrient 
supply  of  the  tissue  is  deficient  in  quantity  or  altered  in  quality.  These 
two  factors  co-exist,  and  may  occasion  a  general  atrophic  or  degenerative 
process  in  one  or  more  of  the  master  tissues  of  the  body. 

When  glandular,  muscular,  or  nervous  tissues  begin  to  undergo 
nutritional  change  and  decay,  the  effects  become  progressive  and  cumu- 
lative in  proportion  to  the  functional  importance  of  the  organ  or  tissue 
to  the  general  nutrition  of  the  body :  for  this  reason  in  death  from  dis- 
ease we  seldom  find  the  morbid  change  limited  to  one  organ. 

In  all  those  chronic  degenerative  affections  of  tissues  occasioned  by 
such  extrinsic  causes  as  alcohol,  accumulation  of  nitrogenous  waste  prod- 
ucts in  the  blood,  syphilis,  and  other  toxic  agencies  (e.g.  lead,  etc.), 
the  degenerative  process  may  commence  simultaneously  in  a  number  of 
different  tissue  elements  —  glandular,  muscular,  nervous  and  cardio- 
vascular :  as  we  have  less  reason  to  believe  that  the  above-mentioned 
extrinsic  factors  vary  than  the  intrinsic,  we  must  look  to  other  causes 
for  determining  the  seat  in  which  the  toxic  agent  will  primarily  produce 
the  atrophy  and  decay.  These  causes  may  be  found  in  the  occupation 
and  habits  of  the  individual.^     Given  stress  upon  an  organ  or  tissue,  plus 

1  Edinger  has  lately  pointed  out  the  importance  of  the  occupation  and  habits  of  the 
Individ lial  in  determining  the  primary  seat  of  the  degenerations  of  the  nervous  system. 


l8o  SYSTEM  OF  MEDICINE 

defective  quality  and  quantity  of  nutrient  supply,  degeneration  ensues. 
When,  therefore,  owing  to  changes  in  the  blood  and  changes  in  the 
cardio-vascular  system,  waste  is  in  excess  of  repair,  atrophy  and  degen- 
eration must  occur. 

Hereditary  factors  play  a  very  important  part  in  determining  the 
primary  seat  of  decay ;  and  experience  teaches  that  the  more  these  fac- 
tors enter  into  the  equation  of  life,  the  more  the  value  of  x  (the  life  of 
the  individual)  proportionately  sinks ;  by  no  art  of  the  physician  can 
they  be  removed  or  modified.  On  the  other  hand,  toxins  can  be  coun- 
teracted by  antitoxins,  and  injurious  occupations  and  habits  can  be 
modified  or  abandoned.  Rarely  does  one  of  these  etiological  factors  act 
alone ;  as  rarely  are  degeneration  and  atrophy  found  limited  to  a  single 
organ  or  tissue,  and  the  present  discussion  among  pathologists  whether 
atrophy  of  nervous,  glandular  or  muscular  elements  be  primary  or  be 
secondary  to  the  fibrous  and  vascular  change,  is  of  value  in  showing  that 
the  older  pathologists  were  wrong  in  assuming  that  the  associated  fibrous 
and  vascular  changes  are  in  all  cases  the  primary  cause  of  the  atrophy ; 
it  is  probably  as  erroneous  to  assume  that  the  converse  is  invariably  the 
order. 

As  inflammatory  stasis,  thrombosis  and  embolism  may  cause  necrosis, 
so  may  chronic  degenerative  changes  in  the  cardio-vascular  system  be 
the  primary  factor  in  many  instances  of  impaired  nutrition  and  decay ; 
although  here  again  we  are  met  by  the  argument  that  arterio-sclerosis 
is  itself  a  primary  degenerative  process,  and  the  associated  inflamma- 
tory changes  secondary.  Cirrhosis  of  the  liver  is  usually  cited  as  an 
example  of  an  organ  which  undergoes  a  primary  irritative  hyperplasia 
of  the  fixed  connective  tissue  elements,  by  the  cicatrisation  of  which  the 
epithelial  cells  are  gradually  strangled  and  undergo  atrophy  from  default 
of  nutrition.  Even  in  the  hypertrophied  stage,  however,  degenerative 
changes  may  have  begun  in  the  liver  cells,  and  this  is  likely  enough, 
seeing  that  they  are  only  separated  by  delicate  capillary  walls  from 
the  blood  containing  the  toxic  agent.  It  must,  however,  be  conceded 
that  the  liver  cells  depend  upon  the  portal  blood  (which  contains  the 
toxic  agent)  for  their  functional  activity,  and  upon  the  blood  of  the 
hepatic  artery  for  nutrition.  The  liver  is  accordingly  a  debateable 
ground  of  these  rival  views.  I  am  in  favour  of  the  view  that  the 
greater  proportion  of  atrophic  degenerative  processes  are  due  to  primary 
retrogressive  nutritional  changes  of  the  specialised  cell  elements.  The 
more  highly  specialised  in  function  an  organ  or  a  tissue  the  larger  the 

more  especially  in  tabes  and  neuritis.  He  instances  the  frequency  of  ataxy  in  occupations 
involving  much  standing ;  as  in  officers,  railway  officials,  etc.  The  relations  of  overwork 
of  the  brain  to  the  production  of  general  paralysis  has  often  been  asserted.  Amyotrophic 
lateral  sclerosis  very  frequently  commences  in  the  legs,  but  recently  I  have  investigated 
two  cases  in  which,  apparently,  occupation  determined  the  seat  of  the  initial  symptons  in 
the  hand  and  arm  of  the  right  side.  One  patient  was  a  cooper  who  wielded  all  day  long 
a  4-lb.  hammer ;  the  other  a  woman  who  earned  her  living  by  sewing.  It  is  usually  the 
Tight  hand  which  is  first  affected  in  lead  palsy  with  wrist  drop.  I  have  lately  emphasised 
the  importance  of  rest  in  preventing  a  localised  paralysis  in  diphtheria  from  becoming 
generalised. —  Vide  International  Journal  of  Clinics,  1895. 


THE    GENERAL   PATHOLOGY   OF  NUTRITION  i8i 

supply  of  nutriment,  and  the  more  likely  are  tissues  of  great  physiologi- 
cal activity  to  undergo  degeneration.  The  cell  elements  of  special  func- 
tion, when  destroyed,  are  unable  to  regenerate,  and  repair  by  fibrous 
tissue  takes  place.  This  is  particularly  well  shown  in  the  central  nervous 
system.  Systemic  sclerosis  of  a  small  but  defined  tract  of  the  spinal 
cord  or  brain  can  be  produced  experimentally  by  cutting  off  the  fibre  of 
an  afferent  or  efferent  tract  from  the  cells  of  which  these  fibres  are  but 
outgrowths  —  e.g.  ablation  of  the  thumb  area  of  the  cortex  cerebri  of 
the  monkey  produces  atrophy  of  a  definite  number  of  fibres  of  the  op- 
posite pyramidal  tract,  which  is  followed  by  a  corresponding  sclerosis 
extending  only  as  far  as  did  the  degenerated  fibres,  viz.,  to  the  second 
dorsal  segment  of  the  cord.  Section  of  posterior  roots  proximal  to  the 
ganglion  is  followed,  in  uncomplicated  cases,  by  degeneration  and  subse- 
quent sclerosis  of  the  posterior  column  of  the  same  side.  The  area  of 
fibrosis  is  limited  to  the  defined  area  which  may  be  microscopic,  and  has 
absolutely  no  tendency  to  spread :  it  is  an  attempt  at  repair ;  the  useless 
waste  products  of  degeneration  are  removed  by  phagocytes,  and  fibrous 
tissue  fills  up  the  gap.  Many  authors  now  believe  that  the  primary  sys- 
temic degenerative  processes  of  the  central  nervous  system  —  such  as 
locomotor  ataxy,  general  paralysis  of  the  insane,  lateral  sclerosis,  amyo- 
trophic lateral  sclerosis,  progressive  muscular  atrophy,  and  the  sclerosis 
met  with  in  pellagra,  pernicious  anaemia  and  ergotism  —  are  caused  by 
nutritional  changes  in  the  ganglion  cells  of  the  spinal  ganglia,  spinal 
cord  and  brain.  Golgi  ^  has  shown  that  every  nerve  cell  possesses  one 
process,  the  "  neuron,"  which  becomes  the  axis  cylinder  process  of  a 
nerve ;  and  a  number  of  protoplasmic  processes,  or  dendrons,  which  serve 
a  nutritive  function  by  absorbing  the  necessary  products  from  the 
lymph  space  in  which  they  lie. 

Degenerative  changes  of  the  cell  are  manifested  by  alterations  in  the 
number  and  complexity  of  the  "  dendrons,"  and,  in  the  neuron,  by  a 
reversion  to  the  embryonic  character  and  type,  followed  by  degeneration 
commencing  in  its  terminals  and  collaterals. 

Atrophic  Degeneration  of  Afferent  Tracts  of  the  Central  Nervous  Sys- 
tem. —  Tabes  dorsalis  is  the  best  example,  and  there  is  much  to  support 
the  theory  of  Marie,  that  the  primary  change  is  a  nutritional  de- 
fect of  the  ganglion  cells  on  the  posterior  root.  In  this  disease  the 
afferent  fibres  of  the  peripheral  and  central  nervous  system  suffer,  which 
suggests  impaired  nutrition  of  the  ganglion  cells,  the  outgrowths  of 
which  form  the  sensory  tracts.  In  alcoholic  neuritis  both  motor  and 
sensory  fibres  suffer ;  and  if  we  explain  the  changes  of  the  peripheral 
nerves  in  locomotor  ataxy  by  chronic  inflammatory  changes,  why  do 
the  motor  fibres  which  are  bound  up  with  the  sensory  escape  ?  why,  if  it 

1  According  to  Ramon  y  Cajal  and  Lenhossek,  the  dendrites  play  the  part  of  con- 
ductors the  same  as  the  axis  cylinder  process.  The  dendrites  are,  however,  receptive  in 
function,  whereas  the  axis  cylinder  processes  are  cellulifugal,  and  if  the  dendrites  do 
represent  agents  of  nutrition,  they  would  only  act  by  increasing  the  surface  of  absorption 
of  the  cell  to  which  they  belong. 


SYSTEM   OF  MEDICINE 


Cortical  Pyramidal  Cell  with 
Neuron,   and  Den-drvns. 


Cal. 


be  due  to  a  primary  vascular  change  in  the  spinal  cord,  should  it  be  con- 
fined to  definite  tracts  of  the  posterior  column  ?  It  is  more  probable  that 
the  etiological  factor  syphilis  and  the  inherited  want  of  durability  of  the 
sensory  nerve  cells  determine  the  seat  of  this  morbid  change. 

Atrophic  Degeneration  of  Efferent  Tracts  of  the  Nervous  System.  — 
Progressive  muscular  atrophy,  Idiopathic  (?)  lateral  sclerosis.  Amyo- 
trophic lateral  sclerosis  are  all  dis- 
eases affecting  efferent  tracts,  and 
the  primary  change  is  impaired  nu- 
trition, degeneration,  and  atrophy 
of  one  or  both  of  two  sets  of  gan- 
glion cells  and  of  their  outgrowths, 
viz. :  — 

1.  The  large  multipolar  cells  of 
the  anterior  horns  of  the  spinal  cord 
and  their  axis  cylinder  processes 
which  form  the  motor  nerves. 

2.  The  large  pyramidal  cells  of 
the  central  convolutions  of  the  cor- 
tex cerebri  and  their  axis  cylinder 
processes  which  form  the  pyramidal 
fibres  of  the  spinal  cord. 

If  the  lower  segment  of  the 
motor  path  be  affected  the  muscles 
also  undergo  progressive  atrophy. 
In  most  cases  of  progressive  mus- 
cular atrophy  the  nutritional  deg- 
radation of  the  spinal  nerve  cell  is 
primary,  and  the  pyramidal  tract 
changes  are  secondary.  In  amyo- 
trophic lateral  sclerosis  the  two  pro- 
cesses coexist :  they  are,  however, 
pathologically  one  and  the  same. 
The  degeneration  of  the  pyramidal 
tracts  in  amyotrophic  lateral  sclero- 


FiG.  5.  —  Diaorrainmatic  representation  of  Cortical   „•     „  t      i  ■>    ■        n  i 

Pyramidal  Cell,  with   n,  neuron,  and  d,  den-   SIS  Can  Only  be  explained  by  SUppOS- 

drons  representing  the  7tpp«r  .'>v,!7;ft«;ii!  of  the  ino-  that  thp    fli'^paqp    k    n    nrimn-pv 
voluntary  motor-path ;  Cvl.,  collateral  passing   ^  ^    ''^^'^^    ^^^^    Uisease    IS    a    primary 

to  corpus  callosum      Neuron  passing  through,    impairment      of     nutritiou      of     the 

I.  C,  mternal  capsule  ;    (7.  C,  crus  cerebri  \   P.  ^     . .  ^ 

pons;    J/,  medulla,  where  decussation  occurs.    gaUgllOn     CCUs.         CaseS    have    been 

The  neuron  is  seen  to  give  off  collaterals  in„„j„i'  i,-i_iii.i_  j. 

its  course,  and  to  termiSate   in  a  fine  brush-   TCCOrded  in  whlch  all  the  SVmptomS 

■  exaggerated, 
superficial,  and  deep  reflexes  — 
occurred,  and  yet  no  sclerosis  of  the  pyramidal  tracts ;  probably  only 
the  collaterals,  in  which  the  axis  cylinder  processes  terminate,  were  de- 
generated, and  thus  the  physiological  connection  between  the  cortical 
centres  and  the  spinal  centres  was  interrupted.  (a)  Cases  have  been 
observed  in  which  the  degeneration  could  only  be  traced  (Fig.  5)  as 


work  of  collaterals  around  the  dendrons  of  the   rif     la+OTol     onlofrioic! 
anterior  cornual  cell.  "^     lateral    SCierOSlS  ■ 


THE    GENERAL   PATHOLOGY   OF  NUTRITION 


183 


Figs,  fi  and  7.  —  Microphotopraphs  of  two  Pyramidal  Cells  from  a  case  of  General  Paral.ysis  of  the  Insane, 
magnified  400  diameters.  The  specimen  is  stained  by  the  Gol(?i  quick  method,  and  the  two  cells 
were  found  in  the  same  section  at  no  frreat  distance  from  one  another.  Fig-.  6  rejiresents  a  large 
Pyramidal  Cell  with  its  branchinj;  flsndronH  in  a  fairly  healthy  condition  ;  these  are  connected  with 
moHHy-looHng  glia  cells  (or  rather  lymph  spaces  surrounding  cells),  which  are  seated  upon  a  perivas- 
cular lymphatic.  According  to  fJajal,  these  cells  mav  act  as  local  vano-dilatorH  by  contraction  of 
their  pseiidopodia.  From  the  middle  of  the  base  of  the  cell  is  seen  a  neuron  (fivine  otf  a  collateral. 
fig.  7  is  a  large  Pyramidal  Cell  undergoing  atrojiliic  degeneration. 


.  neuron  giving  otf  a  collateral.    I 


1 84  SYSTEM  OF  MEDICINE 

far  as  the  medulla,  (6)  in  others  as  far  as  the  pons,  (c)  in  others  as  far 
as  the  cms  cerebri,  (d)  in  others  whither  the  fibres  of  the  internal 
capsule  were  atrophied  and  the  cortical  cells  had  in  part  disappeared  or 
atrophied. 

These  facts  become  intelligible  if  we  suppose  that  the  most  remote 
parts  of  the  cell  will  be  the  first  to  suffer  from  impaired  nutrition. 

General  paralysis  of  the  insane  is  probably  a  similar  patholo- 
gical process  to  tabes  and  amyotrophic  sclerosis,  but  one  affecting 
also  the  higher  centres  of  the  brain.  The  periencephalitis  by  many 
authorities,  however,  is  considered  as  primary  \yide  article  "  General 
Paralysis  "]. 

Atroiiiliy  of  the  cell  elements  of  glands,  as  of  the  kidney,  may  be  due 
to  defective  blood-supply  consequent  on  change  in  the  arterial  walls ; 
the  very  conditions  which  are  said  to  give  rise  to  changes  in  the  arterial 
walls  may  likewise  cause  degenerative  change  of  the  epithelial  elements : 
yet  in  those  cases  in  which  the  kidney  is  not  much  shrunken,  but  in 
which  the  arterial  changes  are  great,  the  primary  degeneration  is  prob- 
ably in  the  arteries,  e.g.  syphilitic  renal  disease.  In  the  granular  con- 
tracted kidney  the  opinion  that  the  primary  change  is  a  fibrosis,  causing 
atrophy  of  the  epithelium  of  the  uriniferous  tubules,  is  being  given  up  in 
favour  of  the  inference  that  a  retrograde  nutritive  change  with  secondary 
fibrosis  occurs. 

Atrophic  Changes  of  Muscle.  —  In  the  heart  fibrous  tissue  is  frequently 
found  replacing  muscidar  tissue;  and  this  condition  is  iQvmQA.  fibroid 
heart,  as  if  the  fibrous  tissue  overgrowth  were  the  morbid  change  that 
produced  the  atrophy  of  the  muscular  fibres.  On  the  contrary,  most  of 
such  cases  are  primary  degenerative  atrophy  of  the  muscular  fibre  owing 
to  impaired  nutrition.  When  a  branch  of  the  coronary  artery  is  blocked 
by  thrombosis  or  embolism,  coagulation  necrosis  of  muscular  fibres  takes 
place,  and  myomalacia  results.  Although  insufficient  for  the  specialised 
elements,  the  nutrient  supply  of  the  fibrous  tissue  is  unaffected;  it 
receives  in  fact  excess  of  nutriment,  and  undergoes  a  compensatory 
hyperplasia,  which  really  amounts  to  a  process  of  repair,  and  should  be 
considered  as  a  healing  process  as  much  as  the  fibrous  tissue  formation 
which  unites  the  two  parts  of  a  severed  muscle.  Perhaps  the  best 
example  of  primary  atrophy  of  muscle  with  secondary  fibrous  over- 
growth of  connective  tissue  and  fat  is  afforded  by  Duchenne's  paralysis, 
in  which  pseudo-hypertrophy  occurs.  Erb's  paralysis  is  the  same  disease 
in  the  atrophic  form ;  in  it  there  is  no  overgrowth  of  fibrous  tissue,  but 
atrophy  of  the  muscle  only,  —  a  clear  proof  that  the  muscular  atrophy  in 
the  former  is  not  consecutive  to  the  fibrous  overgrowth. 

Looking  upon  tissues  as  composed  of  living  protoplasmic  units 
specialised  and  non-specialised  in  function  —  the  former  endowed  with 
high  metabolic  activities,  the  latter  with  low  —  nearly  all  the  nutriment 
which  goes  to  healthy  gland,  muscle  or  nervous  matter,  is  utilised  by  the 
special  cell  elements.  Where  fibrous  connective  tissue  exists  alone  the 
blood-supply  is  extremely  small  and  the  metabolic  exchange  trifling; 


THE    GENERAL  PATHOLOGY  OF  NUTRITION  185 

consequently  the  connective  tissue  of  an  organ  with  a  large  vascular 
supply  would,  by  receiving  excess  of  nutriment,  undergo  hyperplasia 
{vide  Hypertrophy)  if  the  specialised  element  were  unable  to  utilise 
that  nutriment.  Thus  coexistent  with  atrophy  of  one  there  is  hyper- 
trophy of  the  other ;  the  latter  resulting  from  the  former,  and  not  the 
converse.  For  the  microscopical  changes  observed  in  these  organs  and 
tissues  the  reader  is  referred  to  the  special  articles.  Pulmonary  emphy- 
sema may  be  mentioned  as  an  example  of  atrophy  of  blood-vessels  and 
interalveolar  connective  tissue  (particularly  the  elastic);  but  this  is 
always  associated  with  changes  in  the  epithelium,  and  generally  with 
degenerative  conditions  in  other  organs. 

Mechanical  Congestion  is  by  some  authors  regarded  as  a  cause  of 
atrophy  of  the  specialised  cell  elements  by  un-  ^^ 

due  pressure,  e.g.  cyanotic  atrophy  of  the  liver  ^l(;      ^* 

in  prolonged  mitral  disease. 

Fatty  Infiltration,  vide  article  "  Obesity." 


FATTY  METAMORPHOSIS.— Eattydegen-  

eration  is  one  of  the  most  frequent  and  most  ^j^   s.— Atrophic   Liver  Ceiis 
important  of  the  pathological  conditions  asso-        i^?^  Cyanotic  Atrophy  of  the 

.•'■  f  pp  •  IT  Liver  in  different  Stages  of  de- 

Ciated  with   lowering   of    function   and   destrUC-  generation  (x  400  diameters). 

tion  of  cell  protoplasm.    It  is  of  especial  interest        ~   '^"*'  "^' 

to  the  physician,  as  it  often  affects  vital  organs  and  tissues,  and  is  the 

cause  of  death  in  many  diseases  and  in  certain  forms  of  poisoning. 

Fatty  metamorphosis  of  the  cell  protoplasm  may  be  a  physiological 
process  —  as  when  the  uterus  undergoes  involution  after  parturition ;  or 
the  cells  of  the  ruptured  Graafian  follicle  undergo  fatty  degeneration, 
forming  the  corpus  luteum ;  or  the  central  cells  of  the  acini  of  the  mam- 
mary glands  form  colostrum  corpuscles.  The  above-mentioned  instances 
of  fatty  degeneration  show  that  rapidly  proliferating  cells  will  undergo 
retrogressive  nutritional  change  unless  supplied  with  a  proportionate 
supply  of  nutriment.  The  uterus  undergoes  this  retrogressive  meta- 
morphosis because  the  foetus  —  the  physiological  stimulus  which  deter- 
mines the  increased  flow  of  blood  to  the  organ  —  has  been  expelled. 
The  central  cells  of  the  mammary  acinus  undergo  fatty  degeneration 
because  the  peripheral  cells  require  and  take  all  the  nutriment.  For 
the  same  reason,  probably,  fatty  degeneration  occurs  in  the  centre  of 
new  growths,  especially  when  they  are  of  rapid  formation. 

It  is  probable  that  the  cells,  thus  deprived  of  adequate  nutriment, 
behave  like  the  starving  animal,  and  liberate  vital  energy  by  using  up 
their  own  protoplasm.  In  the  starving  animal,  however,  there  is  no  de- 
position of  fat  granules  in  the  cell,  but  atrophy  only.  If,  however,  a 
j)oison,  such  as  yjhosphorus  or  CO,  be  administered  to  starving  animals, 
then  the  urea  eliminated  is  increased  and  fat  is  formed.  Both  these 
poisons  interfere,  as  we  shall  see,  with  oxidation  processes ;  the  former 
by  a  process  not  satisfactorily  explained,  the  latter  by  turning  out  the 
oxygen  from  its  combination  with  haemoglobin.    The  fat  which  accumu- 


SYSTEM  OF  MEDICINE 


lates  in  muscle  fibres  undergoing  fatty  degeneration  is  formed  for  the 
most  part  out  of  organ  proteid  by  the  splitting  up  of  the  latter  into  an 
amido  product  which  will  be  oxidised  into  urea,  fat  remaining  behind  if 
there  be  insufficient  oxygen  for  its  combustion.  Another  source  of  fat 
may  be  the  decomposition  of  lecithin ;  concerning  this  source,  however, 
there  is  a  difference  of  opinion. 

Experimental  Pathology  of  Fatty  Degeneration.  —  Voit  and  Bauer 
showed  that  animals  which  had  been  starved,  and  were  eliminating  a 
constant  of  N  in  the  form  of  urea,  after  the  administration  of  small  doses 
of  P,  suddenly  eliminated  a  great  increase  of  N ;  while  at  the  same  time 
the  oxygen  taken  in  and  the  CO2  given  out  were  considerably  diminished. 
These  facts  are  clearly  associated  with  the  macroscopic,  microscopic,  and 
chemically  demonstrable  fatty  degeneration  of  the  striped  muscles,  the 
heart,  the  liver  and  kidneys.  In  100  parts  of  the  dry  substance  the 
ether  extract  is 

Healthy  Dog.  Phosphorismus  Dog. 

Muscle         .         .        16-7  per  cent  42-4  per  cent 

Heart  .         .  9-2       ,,  20-4       ,, 

Liver  .        ,         10-4      „  30-0      „ 

It  might  be  said  that  the  diminution  of  0  intake  and  COo  output  was 
due  to  blood  destruction,  but  the  experimenters  were  unable  to  find 
evidence  of  this. 

According  to  Gaille,  some  of  the  fat  may  arise  from  the  formation 
of  lecithin.  He  maintains  that  the  primary  change  in  phosphorus 
poisoning  is  in  the  nucelus.  According  to  Krehl,  only  a  very  inconsider- 
able portion  of  the  fat  in  fatty  degeneration  of  the  heart  arises  from  this 
source,  and  the  lecithin  is  not  appreciably  increased.  Slow  poisoning  by 
carbon  monoxide  produces  fatty  degeneration.  This  gas  turns  out  the 
oxygen,  forming  a  more  stable  compound  with  haemoglobin  than  does 
oxygen,  and  produces  the  same  effect  on  the  tissues  as  profound  anaemia, 
viz.,  deprivation  of  oxygen.  But  prolonged  insufficiency  of  oxgyen  means 
also  a  lowered  vitality  of  the  cell  elements ;  and  it  may  be  that  the  cause 
of  the  fatty  metamorphosis  of  the  cell  protoplasm  in  this  form  of  poison- 
ing as  well  as  in  phosphorus  poisoning  can  be  thus  explained.  The  fact 
that  CO,  administered  to  starving  dogs,  increases  the  urea  output,  shows 
that  there  is  an  increase  in  destruction  of  organ  proteid  and  deposition 
of  fat  owing  to  insufficiency  of  oxygen.  The  object  of  using  starved 
animals  is,  of  course,  to  prove  that  the  increased  N  must  come  from 
tissue  metamorphosis.  But  in  phosphorismus  the  same  result  is  not 
explained  by  alteration  of  the  blood ;  and  in  my  opinion  too  little  stress 
has  been  laid  upon  tissue  respiration.  We  have  seen  that  the  cells  nour- 
ish themselves  and,  probably  by  virtue  of  nucleo-albumins  combined 
with  ferric  oxide,  they  have  the  power  of  taking  up  oxygen  and  storing 
it  in  the  protoplasm.  It  is  possible  that  P  may  interfere  with  this 
oxygen  storage  by  the  tissues ;  hence  less  oxygen  could  be  taken  up  by 
the  blood,  less  CO2  given  off,  and  no  appreciable  change  in  the  haemo- 


THE    GENERAL  PATHOLOGY  OF  NUTRITION  iZ-j 

globin  value  would  be  evident.  Starving  animals  from  whom  large  quan- 
tities of  blood  have  been  abstracted  pass  an  increased  amount  of  urea.^ 

Litten  showed  that  rabbits  and  guinea-pigs,  which  had  been  kept  three 
to  six  days  in  an  atmosphere  of  36°  C,  showed  fatty  degeneration  of 
the  heart,  the  striped  muscles,  the  liver  and  kidney.  This  would  seem 
to  indicate  that  a  high  temperature  maintained  continuously  in  animals 
which  have  a  relatively  low  capacity  of  heat  dissipation  (thermolysis), 
produces  fatty  degeneration,  and  supports  the  view  that  fever  may  pro- 
duce fatty  degeneration.  Experiments  npon  such  animals  as  rabbits  are 
not  always  to  be  accepted  as  conclusive  ;  and  Kaunyn  has  shown  that  such 
animals  may  be  kept  thirteen  days  at  a  temperature  of  36°  to  40°  without 
any  fatty  metamorphosis,  provided  they  receive  abundance  of  green 
food  and  the  warm  chamber  be  properly  ventilated.  In  fever  there  is  cer- 
tainly increased  organ  proteid  destruction ;  but  according  to  Krehl,  there  is 
no  parallelism  in  man  between  the  height  of  the  fever  and  the  fatty  degen- 
eration of  the  muscles.  Much  would  depend  upon  the  effect  of  the  toxins 
upon  the  muscles,  the  nerves,  and  their  endings  in  the  muscles. 

Diseases  in  which  Fatty  Degeneration  Occurs.  —  In  the  different  grave 
forms  of  anaemia,  particularly  pernicious  anaemia  and  Jicemorrhagic  pur- 
pura, fatty  degeneration  of  the  muscular  substance  of  the  heart  occurs, 
whereas  other  muscles  in  the  body  are  not  affected.  It  may  occur  after 
severe  haemorrhage.  We  may  then  ask.  Why  should  the  heart  undergo 
this  degeneration  and  other  muscles  escape  ?  Several  factors  seem  to  be 
at  work  in  prx)ducing  the  metamorphosis  of  the  cell  protoplasm.  In 
chlorotic  anaemia  the  haemoglobin  value  of  the  blood  may  fall  as  low  as  in 
pernicious  anaemia ;  yet  in  the  former  fatty  metamorphosis  seldom,  if  ever, 
occurs,  whereas  in  fatal  cases  of  the  latter  it  is  never  absent.  Other 
factors  then  are  present  besides  deficiency  of  oxygen.  In  both  diseases 
the  work  done  by  the  heart  is  increased.  In  pernicious  anaemia  there 
must  be  other  causes,  possibly  one  or  more  of  the  following :  the  dim- 
inution of  the  quantity  of  blood ;  the  alteration  in  the  quality  as  shown 
by  the  great  diminution  of  the  specific  gravity ;  the  great  deficiency 
of  iron  in  the  pigment  of  the  blood,  and  consequent  diminution  of  the 
oxygen  carrying  value  ;  and  the  presence  of  toxins  in  the  blood.  That 
many  of  these  factors  act  together  in  producing  the  metamorphosis  of 
the  cell  protoplasm  is  clear,  and  that  the  heart  muscle  is  selected,  and 
the  voluntary  muscles  spared,  proves  that  not  the  least  important  factor 
is  work  with  inadequate  repair  of  waste;  for  while,  on  the  one  hand,  the 
feeling  of  languor  and  indisposition  to  work,  which  is  a  prominent 
symptom  of  anaemia,  imposes  rest  upon  the  voluntary  muscles,  and  there- 
fore a  lowered  metabolism  in  conformity  with  the  depressed  vital  activities 
of  these  tissues,  the  heart  on  the  other  hand  must,  by  its  automatic 
activity,  do  even  more  work  in  order  to  supply  the  necessary  oxygen  and 

1  Araki,  working  in  Hoppe  Seyler's  laboratory,  showed  that  one  effect  of  lessened  oxy- 
gen supply  was  the  presence  of  lactic  acid  in  the  urine,  sometimes  of  sugar  and  albumin. 
Poisoning  by  CO,  curare,  and  strychnine  gave  corresponding  results,  as  also  after  epileptic 
seizures  when  the  respiration  was  retarded.  Diminution  of  oxidation  processes  is  a  factor 
common  to  all  these  conditions,  and  doubtless  a  primary  cause  of  the  abnormal  metabolism. 


1 88  SYSTEM  OF  MEDICINE 

nutrition  for  tlie  nervous  system.  It  would  be  of  interest  to  see  if  the 
diaphragm  is  similarly  affected  -^  for  on  account  of  the  "  air  hunger  "  it 
must  do  proportionately  more  work  than  other  striped  muscles.  There 
are,  moreover,  certain  other  facts  in  pernicious  anaemia  which  support  the 
theory  of  the  origin  of  fat  by  the  disintegration  of  organ  proteid,  viz., 
the  abundance  of  subcutaneous  fat  and  the  large  amount  of  N  eliminated 
by  the  urine  —  generally  more  than  can  be  accounted  for  by  the  food. 

Another  frequent  cause  of  fatty  degeneration  of  the  heart  is  partial 
occlusion  of  the  coronary  arteries  by  atheroma.  A  large  proportion  of  the 
cases  of  fatty  degeneration  of  the  heart  in  people  who  have  passed  middle 
age  are  of  this  origin.  Sometimes  one  or  both  coronary  arteries  may  be 
obstructed  with  or  without  valvular  disease,  and  the  occlusion  may  be  so 
great  that  the  artery  may  admit  a  bristle  with  difficulty.  As  one  cor- 
onary artery,  or  a  branch  of  one,  may  be  obstructed,  the  fatty  degener- 
ation may  be  local,  affecting  only  one  side  of  the  heart  —  more  often 
the  left  which  has  the  most  work  to  do ;  but  the  auricles  are  usually 
not  affected  in  such  cases. 

Certain  toxic  agencies,  besides  phosphorus  and  carbon  monoxide,  pro- 
duce fatty  degeneration,  viz.,  arsenic,  antimony,  sulphuric  acid,  nitric  acid, 
chronic  alcoholism  and,  lastly  and  most  importantly,  toxins  —  the  prod- 
ucts of  microbic  infection  and  growth. 

Finally,  fatty  degeneration  may  be  the  expression  of  the  gradual  run- 
ning down  of  the  vital  mechanism  :  we  have  supposed  that  every  particle 
of  living  protoplasm  is  endowed  with  a  certain  amount  of  endurance, 
and  when  the  limit  of  the  life  of  the  cell  is  approached,  fatty  degeneration 
occurs :  in  this  way  we  can  explain  the  senile  fatty  metamorphosis  of 
cartilage  cells  and  the  excess  of  fuscous  pigmentation  of  the  ganglion 
cells  of  the  central  nervous  system  ;  most  of  such  pigment  being  really 
of  a  fatty  nature.  We  thus  see  that  fatty  degeneration  is  the  result  of  a 
lowered  vital  activity  of  the  cell  or  fibre,  and  the  conditions  which  give 
rise  to  it  are  complex,  but  depend  essentially  upon  —  (1)  Failure  of 
nutrition  of  the  cell,  which  makes  it  unable  to  compensate  the  waste  by 
repair;  (2)  Breaking  down  of  the  cell  protoplasm  and  formation  of 
araido  antecedents  of  urea  and  of  fat  out  of  organ  proteid ;  (3)  Insuffi- 
ciency of  oxygen-supply  by  the  blood,  or  incapability  of  the  cell  itself 
to  take  up  sufficient  oxygen  to  oxidise  the  fat,  hence  accumulation  of  a 
deposit  within  the  cell  or  fibre. 

Fatty  Degeneration  of  the  Nervous  System.  —  We  have  seen  how  fat 
can  be  formed  from  proteid ;  can  it  be  formed  from  lecithin,  an  important 
constituent  of  nervous  matter  ?  To  this  subject  I  have  given  particular 
attention,  and  I  shall  therefore  set  forth  at  some  length  the  reasons  why 
I  cannot  agree  with  Cohnheim  in  assuming  that  lecithin  cannot  be  so 
split  up  as  to  form  a  neutral  fat.  We  know  that  muscle  fibres,  when 
separated  from  their  motor  nerves,  are  unable  to  nourish  themselves,  and 
are  said  to  undergo  fatty  degeneration.     If  such  muscles  be  hardened  in 

1  Just  before  going  to  press  I  have  examined  the  diaphragm  in  a  well-marked  case  of  per- 
nicious anaemia,  and  found  a  considerable  number  of  fibres  undergoing  fatty  degeneration. 


THE    GENERAL  PATHOLOGY  OF  NUTRITION  189 

Muller's  fluid,  and  then  placed  in  Marchi's  fluid,  the  fatty  deposit  will  be 
stained  black.  Ordinary  adipose  tissue  treated  in  the  same  manner  stains 
black.  The  fatty  matter  of  the  healthy  central  nervous  system  does  not, 
but  if  a  nerve  fibre  be  cut  off  from  the  cell  of  which  it  is  an  outgrowth, 
that  nerve  fibre  undergoes  Wallerian  degeneration,  and  both  axis  cylinder, 
and  myelin  sheath,  when  treated  by  the  method  mentioned  above,  stain 
intensely  black.  The  myelin  has  undergone  a  chemical  change,  and  the 
staining  reaction  would  seem  to  show  that  the  product  was  the  same  as 
that  of  degenerated  muscle,  viz.,  neutral  fat.  We  know  that  lecithin 
can  easily  be  decomposed  into  glycero-phosphoric  acid,  stearic  acid  and 
cholin ;  the  radicle  glyceryl  may  unite  with  stearic  acid  to  form  fat,  the 
phosphoric  acid  combine  with  alkalies,  and  the  cholin  be  decomposed. 

It  appeared  to  me  that  if  phosphorus  were  diminished  in  degenerated 
nervous  tissue  this  decomposition  had  very  likely  occurred.  I  resolved, 
therefore,  to  ascertain  whether  this  were  the  case.  To  obtain  absolutely 
fair  comparison,  I  had  estimated^  the  organic  phosphorus  contained  in 
two  halves  of  spinal  cords  in  which  unilateral  degenerations  had  been 
produced  in  one  case  experimentally,  in  the  other  by  disease.  A  man 
with  left  hemiplegia  from  thrombosis  of  the  right  middle  cerebral  artery 
died  three  weeks  after  the  onset.  The  spinal  cord  was  stripped  of  its 
membranes,  and  divided  longitudinally  down  the  middle.  The  right 
half  contained  10-74  per  cent  of  lecithin  in  the  dried  ethereal  extract: 
the  left  half  8-15  per  cent.  If  we  allow  for  the  direct  pyramidal  tract, 
which  was  well  marked,  the  loss  of  lecithin  in  the  degenerated  pyra- 
midal tract  coming  from  the  right  hemisphere  would  be  about  3  per  cent. 

This  chemical  change  is  not  complete  at  once  after  section  of  the 
nerve  fibre  ;  it  takes  from  six  to  twelve  days  to  obtain  the  black  staining, 
which  shows  that  there  is  a  slow  process  of  disintegration  and  death. 
In  the  neighbourhood  large  numbers  of  leucocytes  can  be  seen  carrying 
away  the  granules  of  fat.  It  is  possible  that  extensive  degeneration 
may  produce  an  auto-intoxication ;  and  in  many  chronic  brain  diseases 
—  such  as  alcoholic  insanity  and  general  paralysis  of  the  insane  —  the 
lecithin  of  the  brain  tissue  is  greatly  reduced  in  amount  (Kowalewsky), 
and  the  perivascular  lymphatic  sheaths  and  subarachnoid  are  filled  with 
fatty  products  of  its  disintegration,  staining  by  the  Marchi  method  like 
degenerated  nervous  matter. 

Toxins,  the  chemical  products  of  certain  pathogenic  micro-organisms, 
sometimes  produce  fatty  degeneration  of  the  muscles.  Dr.  Sidney  Mar- 
tin has  found  intense  fatty  degeneration  of  the  muscles  and  segmental 
degeneration  of  the  nerves  to  result  from  injection  of  the  diphtheritic 
toxin.  I  have  observed  intense  fatty  degeneration  of  the  heart  in  a  case 
of  diphtheritic  paralysis,  but  I  could  find  no  degeneration  of  the  uerve 
trunks.  It  has  seemed  to  me  that  toxins  which  produce  degeneration 
act  either  upon  the  motor  endplate  like  curare,  or  upon  the  nerve  cell ; 
but  the  effect  of  the  poison  is  manifested  in  the  former  case  by  fatty 

1  I  am  indebtofl  to  Mr.  Percy  Richards,  F.C.S.,  for  making  these  examinations  ;  the 
results  will  be  published  jointly,  and  full  details  given. 


•  190 


SYSTEM  OF  MEDICINE 


change  of  the  muscle,  in  the  latter  by  degeneration  of  the  outgrowth  of 
the  nerve  cell  (viz.,  the  nerve  fibre),  as  well  as  of  the  muscle.  Acute 
atrophy  of  the  liver  is  probably  due  to  microbial  infection,  and  acute 
fatty  degeneration  of  the  cells  occurs. 

Naked  Eye  and  Microscopical  Appearances  of  Fatty  Degeneration. 
Tlie  Arteries.  — Fatty  degeneration  in  this  situation  is  not  of  importance 
clinically  except  when  it  occurs  in  the  vessels  of  the  central  nervous 
system  and  retina,  as  it  may  in  poisoning  from  phosphorus,  etc.,  and  in 
the  grave  anaemias,  when  it  may  lead  to  rupture  and  haemorrhage. 

The  cells  in  the  adventitia  of  the  small  vessels  of  the  brain  are  the 
first  to  show  fat  granules  collected  around  their  nuclei.  Fatty  degener- 
ation is  seldom  met  with  in  the  middle-sized  arteries,  especially  those  of 
the  limbs ;  it  is  very  common  in  the  aorta,  occurring  as  opaque,  whitish 


Fig.  9  —  Microphotograph  of  Heart  from  a  fatal  case  of  Diphtheritic       Fig.  10.  — A  few  fibres  more  highly 
Paralysis,  stained  by  the  Marchi  method,  ebowinfr  early  fatty  magnified, 

degeneration.    The  fine  Mack  grayiules  in  the  fibres  are  parti- 
cles of  fat  stained  by  the  osmic  acid.     Mag.  250. 

streaks  or  spots  scarcely,  if  at  all,  elevated  above  the  surface.  The  fatty 
change  occurs  in  the  stellate  cells  of  the  subendothelial  coat;  and  the 
tissue  thus  degenerated  may  give  way  so  that  a  very  shallow  breach  of 
the  lining  surface  is  produced. 

The  Heart.  —  As  before  said,  the  whole  muscle  substance  may  be 
affected,  or  only  the  inner  surface  of  the  heart,  which  then  assumes  a 
peculiar  pale,  streaked  appearance,  seen  especially  in  the  musculi  papil- 
lares  and  columnae  carneae  of  the  left  ventricle,  sometimes  in  the  right 
ventricle,  never  in  the  auricle.  This  form  of  degeneration  is  produced 
by  less  severe  nutritional  defects  of  the  organ ;  but  when  there  is  marked 
obstruction  of  the  main  branches  of  the  coronary  artery  by  atheroma, 


THE    GENERAL   PATHOLOGY  OF  NUTRITION 


191 


idiopathic  anaemia,  or  phosphorvis  poisoning,  the  general  form  of  degen- 
eration of  the  organ  exists.  The  walls  of  the  organ  have  a  yellowish 
appearance  instead  of  dark  red ;  they  are  flabby,  lacerable,  and  frequently 
present  a  "  tahhy-cat "  or  "  thrush  breast "  appearance.  From  a  large  expe- 
rience in  the  examination  of  hearts,  I  am  certain  that  fatty  degeneration 
may  be  overlooked  unless  a  microscopical  examination  be  made  after 
staining  with  osmic  acid.  I  once  thus  found  the  organ,  in  a  case  of 
fatal  syncope  occurring  in  diphtheritic  paralysis,  extremely  degener- 
ated; yet  the  heart  had  been  passed  as  normal  on  macroscopic  exami- 
nation. It  was  rather  pale  and  tough  but,  examined  microscopically, 
the  muscle  fibres  were  found  to  be  extremely  degenerated :  the  tough- 
ness was  possibly  due  to  coagulation  necrosis. 


Fig.  11 .  —  Microphotograph  of  a  Section  of  Liver  froin  a  case  of  Per- 
nicious Antemia,  stained  by  the  Mavchi  method.  The  black 
granulets  and  droplets  of  very  varying  size  seen  witliin  the 
liver  cells  consist  of  fat  stained  by  the  osniic  acid.     Mag.  300. 


Fig.  12.  —  A  few  cells  much  more  highlj 
magnified. 


Microscopical  Changes  in  Fatty  Degeneration  of  Muscle  Fibres, 
etc.  — The  fat  granules  occur  first  as  fine  molecules  scattered  through  the 
fibre  ;  only  in  advanced  cases  do  they  run  together  in  droplets,  and  even 
there  they  never  form  drops  (vide  Figs.  9  and  10).  At  first  the  muscle 
fibres  do  not  lose  their  striation,  but  as  the  process  advances  the  striae 
become  less  marked,  until  eventually  they  may  be  entirely  lost.  Ober- 
steiner  has  recently  described  a  peculiar  form  of  interfibrillary  fatty 
degeneration  of  the  muscles  of  the  tongue  in  a  case  of  tabes  dorsalis  :  the 
nypoglossal  nucleus  was  intact.  In  the  liver  cells  and  renal  epithelium 
the  fat  droplets  vary  greatly  in  size,  from  fine  granules  up  to  drops  which 
nearly  fill  the  cell;  so  that  it  is  sometimes  extremely  difficult  to  deter- 


192  SYSTEM  OF  MEDICINE 

mine  whether  the  liver  cells  be  the  seat  of  fatty  infiltration  or  degenerar 
tion  (vide  Figs.  11  and  12). 

Fatty  changes  in  the  kidney  are  common,  due  to  secondary  degenera- 
tion of  the  epithelium  and  inflammatory  products,  e.g.  large  white  and 
small  white  kidneys  [vide  article  "  Diseases  of  Kidney  "].  Primary  fatty 
degeneration  of  the  cells  of  the  liver  and  kidney  occurs  in  phosphorus, 
arsenic,  and  antimony  poisoning,  especially  in  the  first  named. 

Ziegler  has  pointed  out  that  fatty  degeneration  may  accompany 
lardaceous  disease. 

As  the  cells  of  the  fixed  tissues  may  undergo  fatty  metamorphosis, 
so  may  the  cells  of  fluids,  e.g.  pus  cells ;  and  of  coagulated  fluids,  e.g. 
casts.  It  was  once  believed  that  fatty  degeneration  was  the  same  process 
as  the  formation  of  adipocere,  but  Kraus  has  shown  that  aseptic  tissues 
can  be  kept  a  considerable  time  without  appreciable  increase  of  fat. 
Adipocere  is  the  result  of  the  action  of  living  organisms  upon  dead  tissues, 
like  the  ripening  of  cheese;  here  compounds  of  the  fatty  acid  series  — 
caprylic,  caproic,  and  butyric  acids  —  are  formed  which  unite  with  am- 
monia and  alkalies  to  form  soaps ;  whereas  in  fatty  degeneration  a  neu- 
tral fat  is  formed. 

Fatty  degeneration  occurs  in  atheroma  {vide  article  "Diseases  of 
Arteries  "].  The  arcus  senilis  is  usually  considered  a  sign  of  degeneration. 
It  was  formerly  thought  to  be  a  fatty  degeneration  occurring  in  the  cornea ; 
but  it  is  shown  to  be  a  deposit  of  matter  (fat  or  colloid  material  staining 
black  with  osmic  acid)  in  the  lymph  spaces.  It  very  probably  comes 
from  elsewhere ;  as  it  has  been  met  with  in  fat  young  women,  it  is  not 
a  definite  sign  of  degeneration.  Fat  in  cells  or  tissues  can  be  recognised 
microscopically  by  the  colourless,  highly  refractive  droplets  with  a  dark 
contour,  insoluble  in  acetic  acid,  soluble  in  alcohol  and  ether.  They 
stain  black  with  osmic  acid.  There  is  no  reliable  means  of  distinguishing 
fatty  accumulation  within  a  cell  from  fatty  degeneration.  In  the  latter 
stages  of  fatty  degeneration,  when  the  cells  are  dead  and  in  great  part 
destroyed,  the  whole  tissue  may  be  broken  down  into  an  opaque  yellowish 
white  detritus  such  as  occurs  in  atheroma.  In  the  debris  are  found 
characteristic  crystals  of  cholesterine  —  rhombic  in  shape,  with  a  corner 
notched  out  —  and  feathery  crystals  of  margarine. 

Cloudy  Swelling,  parenchymatous  or  granular  degeneration  or  albumi- 


Fig.  13.  —  Cloudy  Swelling  of  Liver  Cells  Fig.  14.  —  Same  treated  with  acetic  acid, 

(x  850  diameters). — Hamilton.  — Hamilton. 

nous  infiltration,  is  a  condition  which  often  precedes  fatty  degeneration, 
and  was  first  described  by  Virchow  as  affecting  the  special  cell  elements  of 


THE    GENERAL   PATHOLOGY   OF  NUTRITLON  193 

organs  in  a  state  of  parencliymatous  inflammation.  It  is  a  chemical  and 
structural  change  in  the  protoplasm  of  the  cell,  or  fibre,  which  becomes 
swollen  and  indistinct  in  outline  and  structure;  the  nucleus  also  is  ob- 
scured by  the  precipitation  of  fine  granules  of  an  albuminous  nature 
(vide  Figs.  13  and  14).  These  granules  are  feebly  reactive  to  light, 
hence  dusky  in  appearance ;  they  are  not  stained  by  osmic  acid,  nor  are 
they  soluble  in  ether,  but  they  dissolve  in  dilute  acetic  acid  and  caustic 
potash :  they  cannot  be  fat  therefore,  although  fat  granules  often 
coexist  as  the  morbid  process  advances.  It  occurs  with  especial  fre- 
quency in  the  specific  fevers  —  typhoid,  diphtheria,  scarlet  fever,  etc.  — 
and  especially  affects  the  liver,  kidneys,  heart,  and  voluntary  muscle 
fibres ;  but  probably  all  protoplasmic  structures  suffer.  The  change  is 
not  due  to  the  pyrexia  per  se,  but  in  all  probability  to  the  action  of  the 
toxins  which  are  producing  the  fever.  Cloudy  swelling  is  the  first 
change  noticeable  in  poisoning  by  phosphorus,  arsenic,  antimony,  carbon 
monoxide,  and  the  mineral  acids,  thus  preceding  the  fatty  degeneration. 
To  the  naked  eye  the  organs  appear  swollen  and  frequently  anaemic ; 
the  tissue  often  has  a  lustreless  appearance,  but  it  is  softer  than  natural. 
The  change  is  well  marked  in  the  liver,  but  its  most  serious  effect  is 
upon  the  heart:  the  muscle  fibres  become  slightly  opaque,  pale,  soft, 
finely  granidar,  and  their  striae  indistinct ;  such  a  condition  is  frequently 
found  in  acute  myocarditis. 

In  acute  desquamative  nephritis  the  epithelial  elements  of  the  urin- 
iferous  tubules,  especially  of  the  cortex,  undergo  cloudy  swelling  which 
terminates  very  often  in  fatty  degeneration. 

Calcareous  Degeneration.  —  The  blood,  the  lymph,  and  most  of  the 
tissues  of  the  body  contain  lime  salts ;  two-thirds  of  the  weight  of  bone 
is  made  up  of  earthy  matter.  Calcareous  deposition  in  a  tissue  may, 
therefore,  be  due  to  precipitation  of  the  lime  contained  in  the  tissue,  to 
precipitation  of  lime  normally  contained  in  the  blood  and  lymph,  or  to 
excess  of  lime  circulating  therein,  derived  from  disintegrative  processes 
occurring  in  bone  (e.g.  caries,  osteomalacia,  or  senile  atrophy).  Deposi- 
tion from  this  last  cause  is  termed  metastatic. 

Calcification  of  a  tissue  is  most  frequently  a  sign  of  senescence;  it 
occurs  generally  in  dead  or  dying  tissue.  It  is  not,  however,  exclusively 
an  attribute  of  old  age,  for  it  has  been  known  to  occur  in  early  life  or 
childhood;  a  remarkable  case  has  been  described  of  calcification  of 
the  middle-sized  and  smaller  arteries  in  a  lad  the  subject  of  dorsal 
caries :  calcification  does  not  indeed  necessarily  depend  upon  the  age 
of  the  part,  as  it  may  occur  in  the  foetal  tissues  of  the  placenta. 
It  is  very  prone  to  occur  in  dead  tissue,  and  Litten  has  shown  that 
the  process  of  calcification  is  intimately  associated  with  coagulation  of 
the  albumin  of  the  tissue.  ''If  the  renal  artery  in  an  animal  be 
ligatured,  and  the  ligature  removed  after  an  hour  and  a  half,  so  as  to 
allow  the  circulation  to  return,  the  only  noticeable  change  is  an  exuda- 
tion of  albuminous  substance  into  the  Malpighian  bodies.  When  the 
blood  has  continued  to  flow  for  twenty-four  hours  there  is  a  precipita- 

VOL.    I  o 


194  SYSTEM  OF  MEDICINE 

tion  of  calcareous  salts  to  such  an  extent  that  the  organ  may  become 
as  hard  as  stone." 

Calcareous  deposits  contain  calcium  phosphate  (Ca32P04)  traces  of 
carbonate  and  minute  quantities  of  magnesium  phosphate  and  carbonate 
—  sometimes  very  minute  quantities  of  fluoride  of  calcium  and  oxide 
of  iron.  The  mineral  matter,  therefore,  corresponds  closely  with  that 
of  bone.  Calcified  tissues  are  readily  distinguished  from  true  bone  by 
the  fact  that  when  acted  upon  by  HCl  and  the  lime  salts  thus  dissolved 
out,  bone  corpuscles  and  lamellae  are  seen  to  be  absent. 

Appearances :  (1)  Macroscopic  Examination.  —  Calcified  tissue  often 
feels  and  looks  like  bone ;  it  breaks  with  an  irregular  surface,  and  presents 
a  yellowish  and  grayish  aspect;  this  is  the  case  when  it  occurs  in  plates 
or  spicules,  but  owing  to  simultaneous  fatty  degeneration  of  the  tissue 
it  may  have  a  mortar-like  appearance  and  consistence :  small  whitish  or 
yellowish  concretions  of  varying  size  and  form  may  be  seen  and  felt  in 
the  soft  detritus  (e.g.  in  caseating  glands  and  atheroma). 

(2)  Microscopic  Examination. — The  infiltration  of  the  lime  salts  occurs 
both  within  the  cells  and  in  the  intercellular  substance,  especially  in 
the  latter  situation,  where  they  first  made  their  appearance  as  a  fine 
precipitate  of  opaque,  round  or  irregular  granules,  which  look  black  by 
transmitted  light.  As  the  process  advances  these  increase  in  number, 
until  ultimatel}^  the  structure  of  the  tissue  may  be  lost.  Thus  portions 
of  tissue  may  be  converted  into  masses  having  a  black,  irregular  outline 
and  a  homogeneous,  glistening  appearance.  Usually  the  cell  elements 
of  the  tissue  are  enclosed  and  obscured  by  the  precipitated  lime  salts ; 
but  in  some  situations  (e.g.  the  brain)  the  ganglion  cells  are  the  seat  of 
deposition.  The  deposition  within  cells  is  best  studied  in  this  situation. 
The  granules  look  like  highly  refractive  particles,  and  are  soluble  with- 
out development  of  gases  in  HCl.  The  nucleus  remains  free  from  the 
deposit,  but  gradually  diminishes  in  size  as  the  lime  accumulates  within 
the  cell.  The  dendrons  are  often  affected,  the  neuron  very  seldom. 
Calcification  of  the  ganglion  cells  has  been  found  in  fractures  of  the 
skull,  not  due,  however,  to  excess  of  lime  in  the  blood  (metastasis)  so 
much  as  to  death  of  the  nerve  cells  and  alterations  in  the  circulation. 

Causes  of  Calcareous  Precipitation.  — If  the  lime  salts  be  held  in  solu- 
tion by  the  carbon  dioxide  present  in  the  blood  and  lymph,  then  lowered 
metabolism  of  the  tissues,  and  enfeebled  circulation,  such  as  occur  in 
senile  decay,  would  by  default  of  carbonic  acid  favour  precipitation  of 
the  calcareous  salts  of  the  lymph ;  there  is  some  evidence  in  favour  of 
this  hypothesis :  arteries  are  extremely  liable  to  calcification  of  their 
walls,  veins  are  not.  Incrustation  of  the  walls  of  the  left  heart  is  com- 
mon, of  the  right  heart  not;  calcification  of  the  renal  glomeruli  Avhich 
normally  contain  arterial  blood  is  common.  Since  the  CO2  tension  in  the 
pulmonary  veins  is  extremely  low,  and  yet  calcification  is  never  seen  in 
them,  there  must  be  other  factors  which  cause  precipitation  of  the  lime 
salts  in  arteries;  such  are  all  conditions  which  lower  or  destroy  the 
vital  endurance  of  the  tissues  forming  the  walls  —  occupation  involv- 


THE    GENERAL   PATHOLOGY   OF  NUTRITION  195 

ing  mechanical  strain,  diseases  associated  with,  high  arterial  tension, 
toxic  conditions  of  the  blood  {e.g.  alcohol  and  syphilis),  and  lastly  old 
age. 

Calcification  is  very  liable  to  occur  in  dead,  dying  or  decaying 
tissues ;  it  is  often  found  associated  with  or  folio  wing /ai^y  degeneration, 
especially  caseation ;  e.g.  atheroma,  caseous  tubercular  glands,  caseating 
foci  in  the  lungs,  and  old  infarctions.  Many  new  growths  undergo 
calcification  in  the  centre,  where  nutrition  is  impaired,  e.g.  sarcoma 
of  muscle,  fibro-niyomata  of  uterus,  carcinomata,  psammomata  and 
endotheliomata  of  the  dura  mater.  Calcification  of  old  inflammatory 
products,  especially  when  occurring  on  serous  membranes,  is  not  un- 
common ;  and  we  can  thus  account  for  the  calcareous  plates  met  with 
in  the  pleura,  pericardium  and  peritoneum.  The  muscular  walls  of  the 
heart  and  granulations  resulting  from  valvular  endocarditis  often  are 
the  seat  of  calcareous  deposition ;  likewise  phleboliths  of  varicose  veins 
are  probably  calcified  granulations  or  thrombi. 

Dead  tissues  lying  in  the  midst  of  living  tissues  are  prone  to  calcifi- 
cation and  petrification,  e.g.  lithopaedium  of  extra-uterine  gestation. 

Calcareous  infiltration  occurs  in  process  of  time  in  abnormal  or 
vitiated  secretions  of  organs.  Calcareous  concretions  are  thus  met  with 
in  the  salivary  glands,  pancreas,  tonsil,  articulations,  and  synovial 
sheaths ;  and  in  the  interior  of  cysts  (particularly  colloid  cysts)  of  the 
thyroid  and  kidney. 

Results.  —  As  a  rule  calcification  is  associated  with  death  of  the 
tissue  and  loss  of  function ;  it  is  not  a  cause,  but  an  effect,  and  always 
means  lowered  vitality  if  not  death  of  the  tissue.  Calcification  of 
muscle  fibres  does  not  necessarily  mean  necrosis,  but  it  indicates  great 
depression  of  function. 

Calcareous  deposition  may  be  salutary,  e.g.  when  calcification  of  the 
inflammatory  products  surrounding  parasites  (such  as  trichinae  of  muscle, 
pentastoma  dent.,  and  echinococcus  of  the  liver)  encapsulate  the  parasite, 
and  either  render  it  inert  until  the  capsule  is  dissolved  in  the  stomach  of 
another  animal,  or  until  it  is  actually  infiltrated  with  lime  and  destroyed. 

Calcification  of  the  cartilages  of  old  people  is  not  at  all  uncommon ; 
it  is  met  with  in  the  larynx,  trachea  and  rib  cartilages ;  it  is,  however, 
a  provisional  process  prior  to  ossification.  Likewise  inflammation  or 
disease  of  cartilage  may  be  followed  by  vascularisation  and  ossification. 
The  comparatively  frequent  occurrence  of  bony  anchylosis  in  old  people 
proves  clearly  enough  that  if  the  joints  once  become  fixed  from  patho- 
logical causes,  ossification  of  the  articular  cartilages  will  occur. 

Pigmentary  Degeneration.  — The  pigments  found  in  the  tissues  are  — 
(1)  Intrinsic  —  those  which  normally  exist  in  the  body  or  arise  from  pig- 
ments already  in  the  body.  These  pigments  are  either  derived  from  the 
colouring  matter  in  the  blood  —  Jujematogenous,  or  are  non-Jioi'matogenous. 

(2)  Extrinsic  —  those  which  enter  the  body  by  the  lungs,  skin,  or 
alimentary  canal. 

A  jjigment  containing  sulphur,  wTiich  is  probably  non-hsematogenous, 


196  SYSTEM   OF  MEDICINE 

is  a  normal  constituent  of  the  skin  in  some  races  and  individuals,  and 
consists  of  blackish  or  brownish  granules  contained  in  the  deeper  cells 
of  the  "rete  Malpighii."  Under  certain  circumstances  this  pigment  is 
increased ;  for  instance,  round  the  nipples  in  pregnancy  and  in  parts  of 
the  skin  exposed  to  the  air,  and  especially  to  the  sun's  rays.  Intensi- 
fication of  the  normal  pigment  of  the  skin  is  met  with  in  certaii* 
pathological  conditions;  notably  in  Addison's  disease,  scleroderma, 
leprosy,  tuberculosis,  and  the  cancerous  cachexia.  In  wasting  diseases 
generally  the  fat  has  a  deep  yellow  colour,  and  the  muscle  assumes  a 
deep  brownish-red  appearance,  due  to  intensification  of  the  normal 
pigment.  The  pigmentation  of  the  skin  in  Addison's  disease,  in 
leprosy,  and  in  scleroderma  is  probably  due  to  changes  in  the  nervous 
system  {vide  special  articles).  Leloir  has  shown  that  an  atrophy  of 
nerve  fibres  occurs  in  parts  affected  with  vitiligo. 

According  to  Unna,  the  epidermis  may  take  on  a  brown  colour  by 
keratinization,  a  process  in  which  water  and  oxygen  are  taken  from  the 
cells,  and  the  sulphur  relatively  increased  thereby.  He  thus  accounts 
for  the  pigmented  appearance  presented  by  the  skin  in  icthyosis  and 
xeroderma. 

ficemafogfeuows  pigmentation. — A  certain  number  of  pigments  met 
with  in  the  body  are  certainly  derived  from  the  blood  pigment,  viz.,  the 
bile  pigments,  bilirubin  and  biliverdin,  urobilin  (which  is  identical  with 
hydrobilirubin)  and  haematoidin.  In  pernicious  anaemia  the  peculiar 
old  wax  appearance  is  in  part  due  to  urobilin  jaundice.  All  these  pig- 
ments are  iron  free,  and  give  a  play  of  colours  with  fuming  nitric  acid. 
When  blood  corpuscles  undergo  destruction,  as  in  large  extravasations 
of  blood,  two  substances  may  be  formed  —  (a)  Hcemosiderin  and  (6) 
Hmmatoidin.  The  former  substance,  containing  iron,  turns  black  with 
ammonium  sulphide,  and  gives  the  prussian  blue  reaction  with  ferro- 
cyanide  of  potassium  acidulated  with  hydrochloric  acid ;  it  takes  the 
form  of  granules  of  varying  size  which  are  frequently  found  within 
leucocytes.  Hemosiderin  may  also  be  found  in  the  renal  epithelium, 
in  the  fixed  cells  of  the  connective  tissue,  and  also  in  lymph  channels 
and  lymphatic  glands,  whither  it  is  carried  by  leucocytes.  Organs 
which  are  allowed  to  undergo  putrefaction,  and  contain  a  large  quantity 
of  haemosiderin,  turn  black  owing  to  formation  of  sulphide  of  iron. 
This  often  happens  in  pernicious  anaemia,  where  a  very  large  amount 
of  this  substance  is  found  in  the  liver  owing  to  disintegration  of  the  red 
corpuscles.  Haemosiderin  in  large  quantities  may  be  found  in  the  liver 
and  spleen  in  severe  forms  of  malaria,  owing  to  the  destruction  of  the 
red  corpuscles,  and  from  the  action  on  the  blood  of  certain  poisons,  such 
as  arseniuretted  hydrogen  and  toluyl-endiamine. 

Hcematoidin,  a  pigment  which  is  iron  free,  may  be  formed  from 
extravasated  blood,  e.g.  in  apoplexy.  The  brain  substance  in  the 
neighbourhood  of  the  haemorrhage  is  stained  an  orange-red  colour, 
and  microscopical  examination  reveals  minute  orange  rhombic  plates  or 
granules  of  haematoidin.     The  deposit  of  pigment  in  the  skin  from 


^ 


^•iU 


Fig'.l.  Haematoidiiv  CrystaL- 
from  old  haemorrhage 
into  the  brain  •*  400 Biams. 


Fi^.2    Haematoidin  grrarvuLes  in 
U  Ver  cells,  Cyanotic  atrophy 
of  liver  ^  400  Diams. 


Fig. 3.  Cells  from  a  melanatic 
sarcoma,   >•  400  Diams 


Fi^.4'.  Entranoous  pigrrventation. 
Particles  of  coal  &  soot  /?-om- 
a  coal -mincer's  luny  alony 
with  some  pigmented  catarr- 
hal cells.  -^  400  Diams 


"FroinHamiltoTii  Patholoc/y. ' 


THE    GENERAL   PATHOLOGY  OF  NUTRITLON  197 

changes  in  the  extravasated  blood  is  the  cause  of  the  characteristic 
colour  of  syphilitic  eruptions  and  ulceration.  Recently  Treacher  Collins 
has  shown  that  haemorrhage  into  the  anterior  chamber  of  the  eye  is 
followed  by  a  rusty  staining  of  the  cornea,  due  to  imbibition  by  osmosis 
of  blood  pigment,  and  conversion  of  the  same  into  its  derivatives 
hoemosiderm  and  hcematoidin. 

In  malaria,  in  consequence  of  the  destruction  of  the  red  corpuscles 
by  the  plasmodium  malarias,  two  kinds  of  pigments  are  formed:  a  pig- 
ment contained  within  the  organism  itself,  black  in  colour,  which  does 
not  give  the  iron  reaction;  another,  haemosiderin,  found  in  the  liver, 
spleen,  and  marrow  of  bone. 

Melanin  is  a  pathological  pigment  which  does  not  arise  from  the 
blood ;  it  can  only  be  formed  by  the  action  of  living  protoplasm,  and 
melanotic  tumours  are  found  usually  to  have  originated  in  some  tissue 
the  cells  of  which  normally  contain  pigments,  e.g.  the  choroid  coat  of 
the  eye.  Melanin  contains  no  iron,  it  has  a  black  appearance  in  mass, 
but  examined  microscopically  by  transmitted  light  it  is  of  a  brownish 
or  sepia  colour ;  it  is  soluble  in  alcohol,  ether,  mineral  acids  and 
solution  of  caustic  potash,  and  is  bleached  by  chlorine ;  these  tests 
serve  to  distinguish  granules  of  melanin  from  particles  of  carbon,  etc. 
[vide  Plate]. 

Various  pigments  are  found  normally  in  the  cells  of  the  central 
nervous  system,  e.g.  the  locus  caeruleus  and  locus  niger ;  and  the  gan- 
glion cells  of  the  brain,  spinal  cord,  and  sympathetic  ganglia  of  human 
adults  contain  a  fuscous  pigment  which  occurs  in  the  body  of  the  cell, 
usually  in  the  neighbourhood  of  the  nucleus.  This  pigment  is  seldom 
present  in  children,  and  I  have  not  been  able  to  find  it  in  monkeys  and 
other  animals.  In  young  adults  it  is  of  a  bright  yellow  colour ;  in  old 
people  it  is  darker  and  usually  more  abundant :  it  stains  black  by  the 
Marchi  method,  and  is  therefore  a  fatty  derivative.  Whether  it  be 
really  increased  in  certain  diseases,  or  only  more  evident  on  account  of 
atrophy  of  the  rest  of  the  cell  substance,  we  do  not  yet  know ;  in  pro- 
gressive muscular  atrophy  many  of  the  cells  appear  infiltrated  through- 
out with  pigments. 

Pigments  derived  from  extraneous  sources  are  introduced  into  the 
tissues  of  the  body  by  the  respiratory  and  alimentary  systems.  Anthra- 
cosis  is  the  pigmentation  of  the  lungs  and  bronchial  glands  caused  by  the 
inhalation  of  fine  particles  of  carbon  which  are  taken  into  the  lymphatics 
by  leucocytes.  Most  adults  have  their  lungs  somewhat  pigmented  from 
this  cause,  but  when,  owing  to  occupations  such  as  coal  mining,  etc., 
enormous  quantities  of  coal  dust  are  inhaled,  the  lungs  may  be  abso- 
lutely black  in  colour. 

Argyria,  a  condition  of  bluish  discoloration  of  the  skin,  was  occasion- 
ally seen  in  times  gone  by  when  nitrate  of  silver  was  used  for  long 
periods  in  the  treatment  of  epilepsy. 

HYPERTROPHY.  —  An  organ  is  said  to  be  hypertrophied  when  all 


SYSTEM   OF  MEDICINE 


parts  of  it  undergo  an  abnormal  increase,  not  due  to  degeneration  or  to 
elements  foreign  to  its  normal  structure. 

The  term  hypertrophy  should  not  be  applied  to  malformations,  such 
as  a  large  finger;  or  to  excessive  development  of  the  organism  as  a 
whole,  the  result  of  congenital  influences ;  but  rather  to  "  the  enlarge- 
ment of  an  organ,  partial  or  complete,  beyond  its  usual  limits  as  the 
result  of  increased  function  or  of  some  unusual  condition  of  the  corre- 
sponding or  correlated  organ  "  (Bland  Sutton). 

Hypertrophy  should,  moreover,  be  distinguished  from  simple  over- 
growth, as  of  uncut  hair  or  nails. 

Without  increased  blood-supply  to  the  part  hypertrophy  cannot 
take  place,  but  increased  functional  activity  implies  increase  of  nutri- 
tion brought  about  by  vaso-dilation ;  this  in  its  turn  is  induced  by  the 
stimulus  acting  on  the  vaso-motor  nerves  of  the  small  arteries.  In 
glands  there  exist  definite  vaso-dilator  nerves ;  when  the  gland  is  active 
the  vessels  dilate  by  the  excitation  of  these  nerves. 

Functional  and  Compensatory  Hypertrophy.  —  The  increased  size  of 
a  hypertrophied  organ  may  depend  upon  two  factors ;  namely,  numeri- 
cal hypertrophy  or  hyperplasia,  and  simple  hypertrophy  or  the  increase 
in  size  of  its  constituent  elements.  The  two  may  go  hand  in  hand; 
for  example,  the  development  and  increased  size  of  the  muscles  used 
in  particular  occupations  or  exercises  are  the  result  of  an  increase  in 
size  of  the  fibres  clue  to  increased  nutrition.  "  Work-hypertrophy  "  is 
a  natural  attribute  of  working  organs. 

Another  example  of  physiological  hypertrophy  is  the  gravid  uterus, 
wherein  muscular  fibres  of  the  organ  increase  both  in  number  and  in 
size.  Kolliker  showed  that  these  unstriped  muscle  fibres  are  eleven 
times  longer  and  four  times  broader  than  in  the  normal  state.  Another 
example  is  the  mammary  gland  cell,  the  elements  of  which,  owing  to 
the  physiological  stimulus  of  gestation,  undergo  hyperplasia. 

Compensatory  Hypertrophy  in  Disease.  —  Of  this  there  are  many 
familiar  examples.  In  dual  organs  —  as  the  kidneys,  testicles,  lungs, 
and  ovaries  —  when,  either  from  congenital  absence  of  one  of  the  pair 
from  disease  or  from  removal,  the  whole  of  the  particular  fimction  is 
carried  on  for  some  considerable  time  by  the  other,  the  latter  undergoes 
compensatory  hypertrophy. 

Hollow  viscera  with  muscular  fibres  in  their  walls  afford  examples 
of  hypertrophy  of  muscular  substance;  e.g.  the  walls  of  the  general 
cavities  of  the  heart  undergo  compensatory  hypertrophy  when  increased 
functional  activity  is  demanded  by  increased  resistance  in  front :  such 
is  the  hypertrophy  of  the  left  ventricle  in  chronic  Bright's  disease,  and 
of  the  right  ventricle  in  pulmonary  obstruction  and  mitral  stenosis. 
The  hypertrophy  of  the  left  ventricle  in  aortic  regurgitation  may  be 
explained  by  the  increased  functional  activity  and  proportionally  in- 
creased quantity  of  blood  driven  into  the  coronary  arteries  at  each 
systole.  Hypertrophy  of  the  muscular  coat  of  the  bladder  in  stricture 
of  the   urethra,  of  the  stomach  in  stricture   of   the  pylorus,  of   the 


THE    GENERAL   PATHOLOGY   OF  NUTRLTLON  199 

intestines  above  a  permanent  stricture,  serve  as  further  examples  of 
compensatory  hypertrophy  of  hollow  viscera. 

Enlargement  of  the  left  lobe  of  the  liver,  when  the  right  has  been 
destroyed  or  its  growth  checked,  is  an  example  of  partial  hypertrophy  of 
an  organ. 

An  increase  of  the  lymphatic  glands  after  removal  of  the  sjjleen 
affords  an  example  of  compensatory  liypertrophy  of  a  correlative  structure. 
Two  factors  are  concerned  in  all  these  functional  compensatory  hyper- 
trophies :  increase  of  ni;trition,  owing  to  increased  blood-supply,  and 
the  physiological  stimulus  Avhich  excites  the  constituent  cells  or  fibres 
of  the  organ  to  assimilate  more  nutriment.  A  cell  is  not  nourished, 
but  nourishes  itself. 

The  forms  of  hypertrophy  so  far  described  may  be  looked  upon  as 
beneficial  —  even  as  physiologically  normal ;  but  examples  of  hyper- 
trophy occur  which  are  essentially  abnormal,  e.g.  enlargement  of  the 
thyroid  in  Graves'  disease,  of  the  spleen  in  leucocythemia,  of  the 
lymphatic  glands  in  Hodgkin's  disease. 

I  can  but  allude  to  a  number  of  curious  pathological  forms  of 
hypertrophy,  namely,  leontiasis  ossea  of  Virchow,  which  is  characterised 
by  multiple  hyperostosis  of  the  face  and  cranium;  osteitis  deformans, 
in  which  there  is  general  increase  of  size  with  a  marked  morbid  change 
of  structure,  in  the  form  of  a  curious  combination  of  condensation  and 
hardening  with  softening  and  rarefaction;  hypertrophic  pneumic 
osteo-arthropathy,  a  curious  disease  described  by  Marie.  Hypertrophy, 
or  perhaps  a  pseudo-hypertrophy  of  the  pituitary  body,  is  frequently 
associated  with  an  enlargement  of  certain  parts,  such  as  the  hands,  the 
feet,  and  lower  part  of  the  face,  due  to  an  osseous  proliferation  and  new 
formation  of  spongy  bone  {vide  descriptions  of  these  morbid  states  in 
their  respective  chapters).  The  causes  antecedent  to  these  peculiar 
morbid  hypertrophies  are  not  understood.  It  is  possible  that  some  are 
due  to  the  irritation  of  living  organisms ;  for  microbes  may  act  upon 
animal  cells,  not  only  in  a  destructive  manner,  but  as  formative 
stimuli. 

Friction  or  pressure,  giving  rise  to  hyperaemia  of  the  cutis  vera, 
causes  increased  cell  proliferation  of  the  epidermis ;  but  certainly  this 
hyperplasia  would  not  occur  if  the  nerves  to  the  part  were  destroyed. 
The  irritation  of  the  nerve  ending  serves  not  only  to  determine  an  in- 
creased flow  of  blood  to  the  part,  but  also  increased  formative  activity 
on  the  part  of  the  cells  of  the  rete  Malpighii. 

Increased  blood-supply  to  a  limb  may  cause  lengthening  of  a  bone, 
of  which  an  epiphysis  remains  ununited.  Further,  a  chronic  venous 
obstruction  leads  to  excessive  transudation  from  the  blood;  this  does 
not  give  rise  to  hypertrophy  of  muscular  or  glandular  tissues,  but  to  a 
fibrous  hyperplasia  which,  as  it  progresses,  may  lead  to  shrinking  of  the 
organ  at  the  expense  of  the  essential  cell  elements.  In  obstruction  tfi 
the  return  of  lymph  from  a  lower  limb,  as  in  elephantiasis  commenc- 
ing in  infancy,  the  limb  not  only  increases  in  bulk  generally,  but,  rein- 


SYSTEM   OF  MEDICINE 


tively  to  those  of  the  opposite  limb;  the  bones  become  manifestly 
augmented  both  in  thickness  and  in  length. 

Hypertrophy  of  bone  has  also  been  produced  experimentally  in 
animals  by  prolonged  administration  of  small  doses  of  phosphorus ; 
and  this  eifect  has  been  attributed  to  diminished  waste :  it  might  also 
be  explained  by  this  substance  acting  as  an  irritant,  thereby  causing 
increased  formative  action.  "Hyperplasia"  is  applied  only  to  increased 
growth  of  pre-existing  elements,  normal  in  type  and  situation.  Eegen- 
eration  can  only  occur  when  matricular  cell  elements  still  exist  to  pro- 
liferate, and  it  must  be  borne  in  mind  that  highly  specialised  cell- 
structures  —  e.g.  muscle,  glands,  and  the  central  nervous  system  —  show 
very  little  power  of  regeneration  when  injured.  It  is  especially  the 
fibrous  connective  tissues  and  epithelial  tissues  which  possess  capacities 
of  proliferation  and  regeneration.  Large  areas  of  epithelium  may  be 
destroyed  and  yet  regeneration  occur;  and  skin  grafting  is  a  familiar 
example  of  the  inherent  formative  activity  of  the  cells  of  the  epidermis. 

Cartilage  offers  an  example  of  a  non-vascular  connective  tissue  which 
is  incapable  of  self-repair ;  losses  of  substance  are  tilled  up  by  fibrous 
tissue.  The  periosteum,  on  the  other  hand,  may  be  looked  upon  as  the 
best  example  of  the  regenerative  capacity  of  fibrous  tissue. 

F.  W.  MOTT. 

REFERENCES 

1.  ViRCHOW.  Cellular  Pathology.  —  2.  Cohnheim.  Allgemeine  Pathologie. — 
.'!.  Billroth.  Surgical  Pathology.  Sydenham  Translation.  —  4.  Ziegler.  General 
Pathol.  Anatomy.  Translation  by  M'Alister.  —  5.  Paget.  Lectures  on  Surgical 
Pathology.— tS.  Halliburton.  Text-hook  of  Chemical  Physiology  and  Pathology. — 
7.  Klebs.  Allgemeine  Pathologie. — 8.  Charcot  and  Brissaud.  Traite  demedecine. — 
".».  Hamilton.  Text-hook  of  Pathology.  — 10.  Hallopeau.  Pathologie  generate.  — 11. 
CoRNiL  and  Ranvier. — Manual  of  Pathological  Histology.  — 12.  Wilks  and  MoxoN. 
Pathological  Anatomy.  — 13.  Lancereaux.  Traite  d' anatomic  pathologique.  — 14. 
GowBRS.  DisowiCf  of  the  Nervous  System,  —  15.  Fagge.  Edited  by  Pye-Smith. 
Principles  and  Practice  of  Medicine.  — 16.  Dejerine.  Anatomic  des  Centres  Nerveux. 
— 17.   Journal  of  Pathology. 

Specl\.l  Articles 

1.  Bauer.  Sitz.-Ber.  d.  Munchener  Akad. — 2.  Fraenkel.  "  Einfluss  der  vermin- 
derten  Sauerstoff-Zufulir  auf  den  Eiweiss-Zerfall,"  Virchoio's  Archiv,  67  Bd.  — .3.  Kebhl. 
"  Ueber  fettige  Degeneration  des  Herzens,"  Deutsche  Archiv  fiir  klinische  Medecin, 
vol.  11.  —  4.  Collins,  Treacher.  Transactions  of  the  Ophthalniological  Society  \895, 
vol.  XV.  —  5.  Marie.  Lerons  sur  les  maladies  de  la  moelle.  — 6.  Grasset  and  Rauzibr. 
Traits  des  maladies  du  systeme  nerveux. — 7.  Pilcz,  A.  "  Beitrag  zur  Lehre  von  der 
Pigmententwickelung  in  der  Nerven-Zellen,"  Arbeiten  aus  dem  Institut  fiir  Anatomie 
unci  Physiologic  des  Centralnerven.'iystem.  Obersteiner.  —  8.  Unna.  Lehrhuch  der  spe- 
ciellen  pathologisch  Anat.  d.  Hautkrankheiten.  —  9.  Litten.  Archiv  f.  path.  Anat. 
vol.  Ixxxiii.  p.  508.  — 10.  Weigert.  "  Coagnlationsnekrose,"  Centralh.  f.  path.  Anat. 
October  1891.  — 11.  Marie  and  Marinesco.  "  Sur  I'anatomie  path,  de  rAcromegalie," 
Archiv  de  m4d.  exp.  1891.  — 12.  Martin,  S.  "Discussion  on  Diphtheria,"  Medicine 
Section,  Brit.  Med.  Association,  1895.  — 1.3.  Gowers.  Article,  "  Hypertrophy  and 
Dilatation,"  Section,  Diseases  of  the  Heart,  Rei/nold's  System  of  Medicine.  — 14.  Roux. 
Der Kampfder  Theile  imOrganismus:  Ein Beitraq zur  Vervollstiindigunq der  Ziveckmass- 
igkeitslehre.  Leipzig,  1881.  —  15.  Weigert.  "  Die  Lebensauserrungen  der  Zellen  unter 
pathologischen  Verhaltnissen,"  Jahreshericht  der  Senckenbergischen  naturforschenden 


GENERAL  PATHOLOGY   OF  NEW   GROWTHS 


GeseUschaft,  1886,  S.  75  Iff.  —  Ifi.  Edinger.  "  Eine  neue  Theorie  iiber  die  Ursachen 
einiger  Nervenkrankheiten  insbesondere  der  Neuritis  und  der  Tabes,"  Sammhmg 
klinischer  Vortriif/e.  N.  F.,  Nr.  106.  1894.  — 17.  Ramon  y  Ca.jal.  "  Algunas  con- 
jeturas  sobre  el  mecanismo  anatomico  de  la  ideacion  asociation  y  atencion,"  Nearolo- 
glsches  Centralblatt,  Nr.  18,  1895.  Referat.  — 18.  Ara.ki.  "Formation  of  Lactic  Acid 
and  Sugar  in  the  Urine,"  Zeitschriftfur  phyaiol.  Chemie,  vol.  xv.  pp.  335-370. 

F.  W.  M. 


GENEEAL  PATHOLOGY  OF  NEW   GROWTHS 

Syllabus.  —  General  Remarks  on  the  Pathological  Anatomy  of 
Tumours;  their  Classification;  Limitation  of  the  term  ^'■Epithelium''' 
Metaplasia;  Heterology;  Sarcoma;  Carcinoma. 

PATHOGENESIS.  —  Definition  of  Tumour  impossible  ;  Relation  to 
^^Variations'';  the  three  chief  Hypotheses,  viz.  (1)  Spermatic  influence, 
(2)  Embryonic  residua,  (3)  Irritation;  Objections  to  the  first;  Illustra- 
tions of  the  second ;  the  Parasite  doctrine ;  Compo.rison  beticeen  the  clini- 
cal course  of  Malignant  Tumour  and  Tuberculosis ;  Auto-inoculation ; 
Grafting  and  Feeding  Experiments;  Koch' s  four  Postulates ;  Attempts  to 
cultivate  a  specific  Microphyte;  Protozoic  theory;  Koch's  first  Postulate, 
the  histological  demonstration  of  a  Micro-organism  in  the  Tissue;  Koch's 
second  Postulate;  Remarks  on  Treatment. 

General  Pathology  of  New  Growths.  —  (1)  General  Considerations 
on  their  Structure.  —  In  no  subdivision  of  Pathology  is  the  contrast 
between  Pathological  Histology  and  Pathogenesis  more  striking  than 
in  the  case  of  tumours. 

Of  their  histology  little  remains  uninvestigated  and  unknown ;  of 
their  pathogenesis,  though  much  may  be  surmised,  nothing  can  be  said 
to  be  known.  For  this  reason  the  classification  of  tumours  can  at  pres- 
ent be  constructed  only  upon  an  histological  foundation.  The  clinical 
course  of  tumours  raises  a  primary  division  between  the  benign  and  the 
malignant,  but  nothing  is  known  of  the  etiological  difference  underlying 
the  two ;  it  is  not  inconceivable,  indeed,  that  the  difference  in ,  clinical 
history  may  be  referred  to  a  mere  histological  or  anatomical  basis. 

Histologically  all  new  growths  may  be  classed  in  two  series,  viz., 
those  of  mesoblastic  and  those  of  epithelial  origin.  In  this  classification 
it  is  most  convenient  to  understand  by  epithelium  tissue  of  epiblastic 
or  hypoblastic  descent ;  such  new  growths  as  arise  from  endothelium  are 
included  in  the  category  either  of  endothelioma  or  sarcoma.  Although 
there  is  not  a  universal  agreement  amongst  histologists  so  to  limit  the  use 
of  the  word,  in  the  case  of  tumours  such  a  limitation  is  of  considerable 
value. 

The  source  of  a  tumour  is  the  pre-existing  tissue  —  more  precisely,  the 
cells  of  the  part  in  which  it  arises.     Among  normal  tissues  a  transforma- 


SYSTEM   OF  MEDICINE 


tion  of  one  variety  into  another  has  long  been  recognised,  and  has  received 
from  Virchow  the  distinctive  name  of  metaplasia.  This  terin  is  of  especial 
use  in  the  present  subject,  since  it  serves  to  divide  such  a  process  from 
one  of  degeneration.  Such  mutations  are  met  with  in  the  whole  series 
of  connective  tissues,  as  exemplified  between  cartilage  and  common  con- 
nective tissue,  or  between  connective  tissue  and  bone. 

One  variety  of  epithelium,  again,  may  undergo  conversion  into 
another ;  of  this  many  illustrations  are  furnished  during  embryonic 
development,  and  in  after  life  under  various  circumstances  of  irritation 
or  exposure ;  as,  for  instance,  when  in  cases  of  inversion  and  prolapse 
within  or  beyond  the  vagina,  the  columnar-celled  epithelium  of  the  uter- 
ine mucosa  becomes  transmuted  into  one  of  the  stratified  squamous-celled 
kind.  It  is  important,  however,  to  notice  that  elements  of  epiblastic  or 
hypoblastic  descent  are  never,  after  their  full  development  or  evolution 
is  reached,  converted  into  any  of  the  forms  of  connective  tissue.  In  the 
case  of  new  formations  a  tumour  constructed  of  one  variety  of  connective 
tissue,  say  cartilage,  may  arise  from  another  ;  under  these  circumstances 
the  resulting  cell  growth  does  not  precisely  repeat  the  character  of  the 
mother  tissue. 

Sometimes  the  ''heterology"  (Virchow)  (1)  is  apparent  only,  and  is 
due  to  the  origin  of  the  growth  in  the  embryonic  or  developmental  resi- 
dues of  a  tissue  with  which  the  new  formation  is  really  homologous. 

Of  this  nature  may  be  the  striped  muscle  fibre  (muscle  plates)  in 
certain  sarcomata  of  the  kidney,  of  cartilage  (Meckel's  or  pinnal)  in 
tumours  of  the  parotid  gland,  and  in  chondromata  arising  within  the 
cancellous  tissue  of  bone. 

The  most  extreme  instances  of  heterology  is  afforded  by  the  growth  of 
epithelium  in  connective  tissue  which  is  witnessed  in  the  metastasis  of  car- 
cinoma. Under  these  circumstances,  however,  the  metastatic  formations 
do  not  arise  from  the  organ  in  which  they  appear,  but  from  the  epithelial 
elements,  perhaps  chromatiniferous  fragments  of  them,  transported  to  it. 

Clinically  the  great  division  of  tumours,  as  alreadj''  noticed,  is  indi- 
cated by  the  terms  innocent  and  malignant  —  or  simple  and  infective. 
The  marks  characterising  malignancy  are  the  infiltration  of  the  surround- 
ing tissues  by  the  grovv'th,  and  the  production  of  new  foci  in  the  neigh- 
bourhood of  the  primary  tumour,  or  in  parts  far  distant ;  and,  as  a 
consequence  of  this,  the  local  recurrence  after  operative  removal  of  the 
primary  tumour,  or  the  reappearance  of  the  disease  in  lymphatic  glands 
or  internal  organs.  Certain  of  these  characters,  however,  or  others 
clinically  allied  to  them,  are  encountered  occasionally  in  the  case  of 
benign  growths.  The  multiplicity  of  some  benign  tumours  —  e.g.  soft 
fibromata,  lipomata,  cutaneous  papillomata,  etc.  —  may  equal  that  of  the 
most  malignant.  In  such  cases,  however,  it  is  to  be  observed  that  the 
growths  in  any  given  instance  are  confined  to  a  particular  system  or 
extension  of  tissue  such  as  the  subcutaneous,  the  skin,  the  nerves,  the 
bones,  etc. ;  they  do  not  arise  by  metastasis  from  a  primary  tumour,  as 
they  do  in  sarcoma  or  carcinoma,  but  indicate  a  predisposition  confined  to 


GENERAL  PATHOLOGY  OF  NEW   GROWTHS  203 

a  particular  tissue,  or  mark  the  incidence  of  a  wide-spread  irritation 
affecting  it.  Nor  is  circumscription  invariably  met  with  in  simple  as 
contrasted  with  malignant  new  growths ;  some  soft  fibromata  are  as 
continuous  with  the  skin  and  subcutaneous  tissue  as  sarcomata,  and 
certain  lipomata  are  altogether  indefinable  from  the  surrounding  fat. 

The  rate  and  degree  of  the  secondary  infection  or  metastasis  is 
extremely  variable,  both  in  sarcoma  and  carcinoma ;  and  depends  (so  far 
as  can  be  at  present  judged)  upon  the  anatomical  relations,  vascular  and 
lymphatic,  of  the  primary  growth :  in  the  case  of  "  rodent  ulcer " 
metastasis,  whether  glandular  or  other,  is  unknown,  howsoever  long 
the  local  disease  persist,  and  however  wide  and  deeply  spread  it 
may  be. 

Under  malignant  tumours  are  comprised  the  anatomical  forms  of 
sarcoma  and  carcinoma.  A  sarcoma  may  be  defined  as  a  malignant 
tumour  of  connective  tissue  origin,  the  blood-channels  of  which  ramify 
between  its  cells  ;  secondary  infection,  as  a  rule,  takes  place  through  the 
blood  stream  as  distinguished  from  the  lymphatic.  The  histological 
structure  of  sarcomata  varies  within  wide  limits.  In  their  most  typical 
forms  they  consist  throughout  of  embryonic  connective  tissue,  round  or 
spindle  celled;  but  this  may  undergo  partial  conversion  into  fibrous 
tissue,  cartilage,  or  bone  —  the  sarcoma  being  designated  accordingly, 
fibrifying,  chondrifying,  or  ossifying.  This  complex  character  may  arise 
in  another  manner,  namely,  by  the  production  of  embryonic  or  sarcoma- 
tous tissue  out  of,  that  is  through  the  division  of  the  elements  of  a 
previously  simple  tumour. 

In  either  of  these  circumstances  the  histological  determination  of 
such  a  new  growth  becomes  extremely  difficult ;  it  may  be  impossible  to 
decide  whether  it  should  be  named  a  sarcoma,  or  regarded  as  a  fibroma 
in  process  of  rapid  growth.  The  only  histological  criterion  at  present 
available  lies  in  its  cellularity ;  if  this  be  pronounced,  and  the  concomi- 
tance of  a  proper  inflammatory  process  can  be  excluded,  the  border  line 
of  simple  growths  is  crossed. 

By  a  carcinoma  is  most  conveniently  understood  a  malignant  tumour 
of  which  epithelium  forms  the  essential  constituent,  i.e.  tissue  of  epi- 
blastic  or  hypoblastic  descent.  Such  new  formations  are  characterised 
by  an  alveolar  construction,  the  blood-vessels  being  confined  to  the  stroma 
of  connective  tissue  which  forms  the  walls  of  the  alveoli  holding  the 
epithelium.  It  is  for  this  anatomical  reason  that  secondary  infection 
takes  place,  not  by  the  blood-vessels,  but  the  lymphatics.  When  the 
growth  arises  from  an  investing  epithelium  the  alveoli  are  themselves 
lymph  spaces  into  which  the  epithelium  has  bored,  and  equally  so  when 
a  carcinomatous  glandular  epithelium  is  no  longer  confined  by  the  base- 
ment membrane  of  acini  or  ducts. 

As  a  rule  the  epithelium  of  a  carcinoma  retains  the  type  of  the 
normal  tissue  from  which  it  arises,  and  the  cells  even  their  physiological 
y^roperties.  Carcinomata  arising  in  the  ducts  of  the  breast  are  of  the 
columnar  celled  variety ;  in  the  acini,  spheroidal  celled ;  from  the  in- 


204  SYSTEM   OF  MEDICINE 

vesting  epithelium  of  the  nipple,  squamous  celled :  and  these  characters 
are  repeated  in  the  metastatic  growths. 

Pathogenesis.  —  As  in  other  problems  of  biology,  so  in  the  case  of 
tumours,  when  the  basis  of  any  classification  is  critically  examined 
definition  is  found  impossible ;  at  the  best  it  is  merely  an  artifice  by 
which  the  mind  is  aided  in  the  apprehension  of  facts.  So,  at  the  outset 
it  is  impossible  to  define  what  is  to  be  and  what  is  not  to  be  reckoned  as 
a  tumour. 

The  relation  of  inflammation  to  tumour  production  will  be  referred  to 
later.  But  apart  from  this,  tumours  pass  by  insensible  gradations  into 
what  are  by  general  consent  regarded  as  morphological  variations.  The 
line  between  highly  accentuated  anatomical  tubercles  of  the  bones  and 
osteoma  can  only  be  dra^vn  arbitrarily  ;  and  certain  new  formations  may 
be  referred  to  the  class  of  "  variations,"  even  though  unrepresented  in 
normal  morphology. 

The  life  history  of  many  osteomata  Avill  justify  this.  For,  unlike 
most  other  tumours,  their  period  of  formation  and  groAvth  coincides  with 
that  of  the  rest  of  the  skeleton :  they  do  not  exhibit  the  independence 
which  is  so  remarkable  in  the  great  majority  of  tumours  whether  simple 
or  infective ;  and  they  may  be  held  as  allied  in  their  nature  to  the  ab- 
normal masses  of  tissue  classed  as  accessory  thyroids,  supernumerary 
mammae,  and  the  like. 

Perhaps  the  best  illustration  of  this  is  afforded  by  the  fatty  accumu- 
lations on  the  buttocks  of  the  Eushwoman.  Arising  sporadically  in  a 
European  such  would  undoubtedly  be  classed  as  diffuse  lipomata;  the 
buttock,  in  fact,  is  a  recognised  seat  of  fatty  tumours.  Yet  they  are  so 
common  among  the  females  of  the  race  mentioned  as  to  rise  almost  to  an 
anthropological  feature.  The  protuberance  itself  is  regarded  as  a  mark 
of  beauty,  which  is  perpetuated  and  increased  by  sexual  selection,  and 
probably  arose  as  a  variation  confined  in  the  first  place  to  a  few 
individuals  (2). 

Setting  aside  such  a  class  of  new  formations,  which  may  be  explained 
as  variations  not  surpassing  many  of  those  encountered  in  the  progess 
of  mammalian  descent,  the  theories  of  pathogenesis  may  be  reduced  to 
the  three  following :  — 

1.  Spermatic  influence. 

2.  Embryonic  residua. 
•^.  Irritation. 

1.  Spermatic  Injiuence.  —  The  first  theory  views  the  growth  of  a 
tumour  as  due  to  the  spermatic  influence  of  certain  cells  upon  those  con- 
tiguous, the  latter  being,  as  it  were,  fecundated  and  incited  to  subdivision 
by  the  former.  Assuming  this  view  to  be  correct,  it  would  explain  only 
the  method  of  extension,  not  the  origin  of  a  new  growth.  Whence  come 
the  cells  which  possess  the  supposed  influence?     Although  difficult  to 


GENERAL  PATHOLOGY  OF  NEW   GROWTHS  205 

disprove  in  the  case  of  tuinours  of  the  connective  tissue  series,  a  fatal 
objection  to  this  view  is  furnished  by  carcinomata.  The  explanation  of 
the  secondary  formation  of  squamous-celled  or  columnar-celled  carci- 
noma in  a  lymphatic  gland  by  transformation  of  the  leucocytes  or  cells 
of  the  stroma  into  squamous  or  columnar  epithelium  cannot  be  admitted; 
there  is  no  histological  evidence  of  it,  and  it  is  contrary  to  the  funda- 
mental observations  of  normal  histology.  Klebs  (3)  has  suggested  that 
the  leucocytes,  which  are  not  infrequently  met  with  between  and  in  the 
cells  of  malignant  tumours,  are  the  spermatic  elements.  But  it  is  in- 
calculably more  probable  that  such  leucocytes  are  engaged  in  a  process 
of  phagocytosis  (they  are  met  with  in  abui;idance  about  the  necrosed 
epithelium  of  a  squamous-celled  carcinoma)  ;  or  that  they  have  been 
ingested  by  the  larger  more  vigorously  growing  cells  of  the  tumour,  a 
fate  they  meet  in  the  formation  of  scar  tissue  where  they  are  consumed 
by  the  connective  tissue  corpuscles. 

2.  Emhryonic  Residua.  —  This  view,  originally  foreshadowed  by 
Virchow  in  regard  to  chondromata  of  bone,  was  extended  by  Cohnheim 
so  as  to  cover  the  whole  field  of  tumour  production  ;  on  this  account  it 
is  often  spoken  of  as  Cohnheim's  theory  (4). 

It  assumes  that,  during  the  process  of  embryonic  development,  more 
cells  may  be  generated  than  are  actually  necessary  for  the  formation  of 
a  particular  organ  or  tissue ;  and  that  in  such  cells,  which  may  remain 
long  dormant,  tumours  have  their  source  —  the  embryonic  residua  re- 
taining their  biological  potentiality  for  multiplication. 

The  theory  relates  the  growth  of  a  tumour  to  a  physiological  cause, 
viz.,  to  the  inherent  capacity  which  embryonic  tissue  in  general  possesses 
for  growth.  That  certain  tumours  so  arise  can  scarcely  be  denied :  the 
growth  of  central  chondromata  of  bone  is  an  instance,  though  here  the 
redundance  may  affect  the  growing  parts  after  the  date  of  birth. 

We  may  cite,  again,  the  growth  of  chondromata  from  the  synovial 
membranes  of  joints  ('' Pedunculated  bodies"),  where  the  new  forma- 
tions arise  in  the  groups  of  cartilage  cells  contained  in  the  secondary 
processes  of  the  fringes  ;  for  these  elements  may  themselves  be  regarded 
as  relics  of  the  cartilaginous  matrix  about  the  sites  of  primitive  joint- 
formation,  the  articular  cavities  being  formed  by  the  solution  of  the 
mesoblastic  tissue  intervening  between  the  primordial  cartilage  of  the 
future  bones.  Such  chondromata  are  unknown  in  connection  with 
the  synovial  sheaths  of  tendons  or  bursse,  or  known  only  in  rare  cases 
that  allow  of  explanation.  The  large  adenomata,  again,  which  lie 
between  the  rectum  and  coccyx  (sacral  or  coccygeal  tumour),  and  have 
their  origin  in  the  post-anal  gut,  may  be  cited  as  another  example ;  or 
the  cystic  epithelial  tumours  of  the  jaws  which,  as  evidenced  by  their 
structure,  almost  as  certainly  arise  in  redundant  portions  of  enamel 
organ  :  or,  among  malignant  new  formations,  the  melanotic  sarcomata 
which  appear  in  congenital  moles,  the  latter  being  visible  excesses  in 
the  development  of  normal  tissue.'  Beyond  the  category  of  solid  forma- 
tions, or  tumours  properly  so  called,  a  large  number  of  cysts  have  their 


2o6  SYSTEM    OF  MEDICINE 

source  in  the  remains  of  canals  wliicli  should  normally  disappear  or 
undergo  atrophy  during  development  or  growth :  such  are  the  cysts  of 
the  parovarium,  of  the  par-epididymis,  of  Gartner's  duct  in  the  female, 
or  Mliller's  duct  in  the  male,  of  the  urachus,  the  post-anal  gut,  the 
thyro-lingual  duct,  and  others. 

The  hypothesis  receives  confirmation,  too,  in  the  woody  masses  or 
xylomata  which  arise  in  the  dormant  buds  of  exogenous  trees.  Thus 
it  is  satisfactory  in  a  certain  number  of  instances,  but  unconvincing 
when  applied  to  the  whole ;  for  it  not  only  assumes  the  presence  of 
such  residual  elements  in  every  case,  but  it  ignores  the  equally  possible 
action  of  a  continuously  working  irritant,  such  as  an  animal  or  vegetable 
parasite  would  furnish,  for  which  there  are  equally  apt  analogies  in  the 
various  galls  of  the  vegetable  kingdom,  some  of  which  display  a  high 
grade  of  organisation. 

3.  Irritation.  —  Under  this  heading  may  be  comprehended  irritative 
causes  in  the  wider  sense,  without  attempting  to  draw  a  line  between 
irritation  and  inflammation.  It  is  not,  indeed,  possible  to  separate  tissue 
overgrowth  which  arises  out  of  inflammation  from  the  class  of  tumours ; 
hyperplasia  is  the  immediate  result  in  both.  It  is  in  this  connection  that 
trauma  becomes  included  in  the  pathogenesis  of  new  growths.  There  is, 
for  example,  none  but  an  arbitrary  distinction  between  osteoma  affecting 
the  facial  bones  and  the  diffuse  hyperplasia  which  Virchow  has  named 
leontiasis  ossea.  Some  such  formations  have  a  traumatic  history;  others, 
of  recurrent  attacks  of  erysipelas.  The  local  hyperplasias  which  result 
from  purely  mechanical  causes  pass  insensibly  into  the  new  formations 
known  as  tumours.  In  this  sense  tumours  may  even  form  around  foreign 
bodies.  One  of  us  has  described  a  large  example  of  lamellar  fibroma, 
found  between  the  bladder  and  rectum,  in  the  centre  of  which  was  a 
small  piece  of  steel,  evidently  the  immediate  cause  in  its  etiology :  the 
other  factor  was  probably  the  accident  of  a  position  which  the  functions 
of  the  bladder  and  rectum  make  one  of  incessant  movement. 

Undoubtedly,  however,  the  most  modern  development  of  this  irrita- 
tive theory  and  the  most  definite  is  the  parasitic.  In  the  matter  of 
malignant  growths  more  particularly  it  has  much  to  recommend  it,  and 
from  this  aspect  the  hypothesis  may  be  discussed  more  fully  than  either 
of  the  preceding.  It  has  been  urged  that,  if  true  of  malignant  formar 
tions,  benign  growths  must  be  relegated  to  a  like  cause.  This  by  no 
means  follows.  Cohnheim's  theory  is  equally  adequate  to  account  for 
certain  new  formations ;  and  there  is  no  a  priori  reason  why  all  should 
arise  from  an  identical  cause.  The  great  feature  of  malignant  tumours 
is  their  metastasis,  or,  to  adopt  the  parallel  furnished  by  the  infective 
granulomata,  their  infectiveness.  The  clinical  history  of  a  case  of  sar- 
coma or  carcinoma  is  so  closely  like  that,  for  example,  of  tuberculosis, 
that  it  is  quite  within  the  truth  to  assert  that  there  is  no  feature  in  the 
last-named  disease  which  is  not  paralleled  in  the  others,  as  will  appear 
from  the  following  considerations  :  — 

The  primary  tumour  in  the  case  of  carcinoma  is  seated  most  fre- 


GENERAL   PATHOLOGY   OE  NEW   GROWTHS  207 

quently,  as  statistics  show,  at  sites  where  an  infection  from  without 
would  most  readily  take  place.  The  metastasis  by  lymphatics  or  blood- 
vessels in  carcinoma  and  sarcoma  is  such  as  occurs  in  tuberculosis ; 
and  it  may  be  restricted  to  the  lymph-glands,  or  be  as  wide-spread  as  a 
generalised  tuberculosis  (general  sarcomatosis  or  carcinomatosis). 

Even  the  glandular  infection  which  occurs  at  times  in  tuberculosis 
without  primary  lesion  has  its  counterpart  in  the  squamous-celled  carci- 
noma of  the  inguinal  glands  in  chimney  sweeps,  in  whom  there  may  be 
no  discoverable  primary  growth  on  the  penis,  scrotum,  or  lower  limbs. 
And  the  latency  of  glandular  infection  is  equally  repvesented  in 
tuberculosis  and  carcinoma :  a  breast,  for  example,  is  removed  for  mam- 
mary carcinoma,  and  four  years  later,  without  any  local  recurrence,  the 
axillary  glands  may  be  found  diseased.  A  tubercular  lesion  may  result 
from  direct  infection,  or  may  appear  primarily  in  an  internal  part,  i.e.  in 
a  situation  other  than  cutaneous  or  mucous  surface.  The  sarcoma 
that  grows  at  the  end  of  a  long  bone  after  injury  is  comparable  with  the 
tubercular  osteitis  ensuing  under  similar  circumstances.  Injury  is  the 
determining  cause  ;  the  other  factor  is  a  "  constitutional  "  one.  Whether 
the  latter  named  be  held  to  consist  in  a  congenital  want  of  resistance  to 
an  infective  virus,  or  in  the  actual  presence,  acquired  or  inherited,  of  the 
virus  in  a  resting  or  latent  condition,  the  hypothesis  equally  suits  both 
forms  of  disease.  In  short,  the  abstruse  problems  of  predisposition 
and  heredity  offer  the  same  difficulties  in  malignant  neoplasms  and  in 
tuberculosis. 

Auto-inoculation  from  one  carcinomatous  labium  to  the  other  has 
long  been  recognised;  and  an  instance  is  authenticated  of  the  trans- 
ference of  carcinoma  from  an  ulcerating  tumour  of  the  breast  to  the 
skin  of  the  paralysed  arm  in  contact  with  it.  The  many  examples  of 
intestinal  {e.g.  csecal)  carcinoma  associated  with  numerous  lesser  growths 
in  the  colon ;  of  gastric  carcinoma  associated  with  similar  disease  of  the 
bowel ;  of  oesophageal  carcinoma  associated  with  that  of  the  stomach,  or 
of  multiple  growths  in  the  oesophagus  itself,  point  also  to  the  possibility 
of  an  auto-inoculation  of  the  same  kind  as  that  of  the  intestine  witnessed 
in  tubercular  phthisis.  Strictly  speaking,  hoAvever,  such  facts  only  show 
that  the  disease  is  transferable  in  the  same  individual  without  proving 
that  a  parasitic  virus  is  present  in  the  cells  transferred.  Although  both 
carcinoma  and  sarcoma  have  been  grafted  from  one  animal  to  another, 
success  has  as  yet  only  attended  the  experiments  made  between  animals 
of  the  same  species.  No  authentic  instance  {i.e.  none  satisfying  modern 
criticism)  is  at  present  forthcoming  of  the  grafting  of  human  carcinoma 
upon  any  of  the  lower  animals.  One  of  the  best  examples  of  transference 
from  animal  to  animal  is  recorded  by  Hanau  of  Zurich,  who  has  success- 
fully engrafted  squamous-celled  carcinoma  from  a  rat,  with  such  a  growth 
on  the  vulva,  upon  a  series  of  other  rats,  by  inserting  portions  of  the 
tumour  into  the  peritoneal  cavity.  In  one  case,  where  death  ensued 
after  three  months,  the  abdominal  cavity  was  filled  with  nodules  which 
presented  the  typical  histological  structure  of  squamous-celled  carcinoma. 


2o8  SYSTEM   OF  MEDICINE 

We  have  ourselves  carried  out  a  considerable  number  of  sucli  experi- 
ments between  the  human  subject  and  lower  animals  (5).  Oar  method 
consisted  in  transplanting  portions  of  tumours  recently  removed  by 
operation  into  the  abdominal  cavity,  subcutaneous  tissue  or  muscles. 
The  tumours  used  were  twenty-three  scirrhous  carcinomata  of  the  breast 
and  six  sarcomata :  the  animals  were  monkeys,  dogs,  rabbits,  white  rats, 
three  sheep  and  one  cat.  At  times  the  entire  tumour  was  placed  in  the 
peritoneal  cavity  after  the  superfluous  fat  had  been  removed  from  its 
exterior.  On  other  occasions  portions  were  cut  from  it  and  pushed  in 
different  directions  into  the  abdomen.  The  tumour  after  its  removal 
was  kept  at  the  body  temperature  in  an  incubator,  and  transferred  to 
the  animal  in  from  half  an  hour  to  an  hour  and  a  half  after  removal. 
Sometimes  pieces  of  as  many  as  three  different  tumours  were  placed  at 
different  dates  into  the  same  animal. 

The  result  of  all  these  experiments  was  negative.  The  pieces  of 
transplanted  tumour  invariably  underwent  coagulation  necrosis,  in  one 
case  subsequent  calcification,  and  were  found  either  lying  encapsuled 
in  the  tissues,  or  to  have  been  completely  absorbed.  In  two  instances 
an  entire  scirrhous  carcinoma  of  the  breast  inserted  into  the  peritoneal 
cavity  (dog)  entirely  disappeared,  the  abdominal  wound  having  itself 
healed  without  discharge  of  the  graft.  In  the  first  of  these  the  tumour 
was  one  and  a  half  by  three-quarters  of  an  inch ;  the  animal  was  quite 
well  700  days  after  the  experiment,  and,  on  its  being  killed,  all  the  viscera 
were  found  healthy. 

The  same  negative  results  attended  certain  feeding  experiments 
carried  out  on  white  rats.  We  fed  two  white  rats,  male  and 
female,  with  fourteen  fresh  scirrhous  carcinomata.  The  experiments 
extended  over  a  period  of  seven  months,  during  which  the  animals 
remained  well  and  several  litters  of  ^''oung  were  born.  They  -were 
undertaken  to  ascertain  whether  infection  of  the  stomach  or  intestines, 
such  as  ensues  in  some  instances  from  the  ingestion  of  tuberculous 
material,  could  be  induced.  On  killing  the  rats  the  pylorus  and  other 
parts  of  the  alimentary  tract  were  found  to  be  quite  normal.  In  one 
experiment  a  small  piece  of  the  growing  edge  of  a  recently  removed 
scirrhus  of  the  breast  was  inserted  into  the  anterior  chamber  of  a  rabbit's 
eye.  The  corneal  incision  healed  perfectly,  but  the  graft,  after  under- 
going slight  diminution  in  bulk,  remained  unchanged;  two  months 
later,  on  killing  the  animal,  it  was  found  adherent  to  the  iris  by  one 
aspect  and  to  the  back  of  the  cornea  by  the  other.  In  all  this  the  experi- 
ments, both  negative  and  positive,  indicate  not  the  common  order  of 
infection,  but  that  of  grafting,  whether  in  animal  or  vegetable  tissues. 
They  do  not  prove,  when  successful,  that  the  cause  of  cancer  is  a  para- 
sitic virus,  but  only  that  a  portion  of  a  malignant  tumour  will  continue  to 
grow  in  the  body  of  a  second  individual  as  it  would  have  done  in  the 
body  of  the  first.  Even  when  the  spot  has  been  previously  prepared 
by  an  experimentally  caused  inflammation,  no  other  result  has  yet  been 
obtained ;  as  in  Mr.  D'Arcy  Power's  experiments  of     lacing  pieces  of 


GENERAL   PATHOLOGY   OF  NEW   GROIVTILS  209 

human  scirrhus  into  the  vaginae  of  rabbits  previously  kept  irritated  or 
inflamed  by  the  application  of  linimentum  iodi. 

Finally,  if  the  positive  results  attained  do  not  prove  the  existence 
of  a  parasite,  it  must  be  borne  in  mind  likewise  that  the  negative  do 
not  disprove  it.  The  method  of  transmission  in  infective  diseases  is 
not  always  so  direct  and  simple  as  such  grafting  experiments  presuppose. 
It  has  been  shown,  for  example,  that  malaria  cannot  be  transmitted 
between  birds  by  the  injection  of  blood  containing  the  haematozoon; 
and  we  ourselves  had  found  that  psorospermosis  could  not  be  induced  in 
the  scarified  skin  of  the  rabbit  by  rubbing  in  psorospermial  material 
obtained  direct  from  the  livers  of  other  rabbits. 

The  endemic  location  of  cancer,  comprehending  sarcoma  and  carci- 
noma, is  a  highly  remarkable  fact  in  the  history  of  malignant  tumours. 
One  of  the  most  noteworthy  instances  of  it  is  recorded  by  Mr.  Law  Webb. 
In  a  group  of  cottages  forming  a  certain  village  in  Shropshire  nine 
cases  of  cancer  had  been  treated  in  fifteen  years.  The  dwellings  are 
grouped  together,  and  do  not  occupy  much  more  than  an  acre  of  ground. 
All  the  inhabitants  use  water  from  a  certain  pump  situate  by  the  road- 
side, and  close  to  a  very  fi^lthy  hovel.  There  are  twenty  houses  in  all ; 
one  cottage,  enjoying  a  bad  pre-eminence  for  dirt  and  discomfort,  fur- 
nished three  of  the  nine  cases.  In  none  of  the  whole  series  were  the 
patients  related  by  blood. 

In  the  neighbourhood  of  this  hamlet  are  two  houses  under  one  roof 
with  a  drain  system  and  water-supply  common  to  both.  Calling  these 
Nos.  1  and  2,  twenty-six  years  ago  a  man,  get.  28,  living  at  No.  1,  suf- 
fered from  cancer  of  the  rectum,  of  which  he  died.  The  house  was  next 
occupied  by  a  man  and  wife.  The  former,  two  years  after  the  death  of 
the  previous  tenant,  was  treated  for  cancer  of  the  stomach,  to  which 
malady  he  succumbed.  His  widow  continued  to  live  in  the  same  house, 
and  died  ten  years  later  from  cancer  of  the  rectum.  Before  her  death 
a  woman  in  house  No.  2  was  found  to  be  suffering  from  carcinoma  of 
the  breast,  which  proved  fatal  in  eight  months.  The  first  house  was 
next  occupied  by  three  spinsters,  one  of  whom  died  of  cancer  of  the 
uterus,  and  a  second  with  cancer  of  the  stomach. 

In  connection  with  the  high  mortality  which  obtains  in  Devonshire 
we  may  cite  a  remarkable  instance,  the  details  of  which  were  communi- 
cated to  us  by  Dr.  R.  Ackerley  of  Surbiton.  In  a  large  house  in  Ashbur- 
ton,  situated  on  low  ground,  the  cellars  of  which  are  below  the  level  of 
a  small  stream  which  runs  through  the  town  about  twenty  yards  from  the 
liouse,  four  cases  of  cancer  have  occurred  in  the  last  thirteen  years :  (1) 
A  lady  who  had  occupied  the  house  for  many  years  died  from  cancer  of 
the  breast ; .  (2)  The  next  occupant,  after  residing  at  least  seven  years  in 
the  same  house,  died  from  the  same  disease;  (3)  her  husband  died 
two  years  ago  of  carcinoma  of  the  larynx ;  (4)  the  second  wife  of  the 
last  mentioned,  whom  he  married  five  years  ago,  has  lately  had  her  breast 
removed  for  scirrhus.    Four  other  deaths  from  cancer  have  been  certified 

VOL.    I  p 


SYSTEM  OF  MEDICINE 


in  the  last  four  years  in  persons  who  had  long  resided  within  a  hundred 
yards  of  the  same  house. 

Cancer  has,  moreover,  a  certain  geographical  distribution.  Its  dis- 
tribution in  England  and  Wales  has  been  carefully  drawn  out  by  Mr.  Havi- 
land  (7).  His  conclusions  are  that  the  disease  is  most  prevalent  along  those 
river  courses  which  seasonally  flood  their  banks,  such  as  the  Thames,  the 
Severn,  the  Mid  Devon  and  Yorkshire  rivers ;  and  that  wherever,  from 
the  nature  of  the  rocks  forming  the  water-shed,  the  floods  are  much  dis- 
coloured by  alluvium,  and  where,  froua  the  flatness  of  the  country,  the 
floods  are  retained  and  not  easily  drained  off,  there  is  found  the  greatest 
mortality  from  cancer.     [_Vide  art.  on  Med.  Geography  of  Cxr.  B.] 

Koch's  Four  Postulates.  — Notwithstanding  the  negative  results  of  the 
inoculations  detailed,  the  parasitic  theory  of  malignant  new  growths  is 
so  well  grounded  that  during  the  past  few  years  the  whole  of  the  work 
on  the  subject  has  been  directed  by  it. 

After  the  rise  of  modern  bacteriology  the  first  attempts  made  were 
to  cultivate  a  specific  microphyte  from  such  tumours.  In  this  country 
we  undertook  a  considerable  series  of  such  experiments  (8).  We  con- 
fined ourselves  to  the  use  of  spheroidal-celled  carcinoma  of  the  mamma, 
for  the  reason  that  in  external  carcinomata  the  problem  is  complicated  by 
the  chances  of  a  saprophytic  or  adventitious  infection ;  in  three  instances, 
however,  sarcomata  were  employed.  The  media  comprised  nutrient 
■gelatine,  nutrient  agar,  human  blood  serum  obtained  from  placentae,  etc., 
and  fluid  media,  such  as  hydrocele  fluid  and  human  placental  blood  serum. 
Portions  of  the  tumour  immediately  after  its  removal  were  cut  by  means 
of  knives  previously  sterilised  by  heat,  and  transferred  to  the  tubes  of 
nutrient  media  on  the  loop  of  platinum  wire.  In  some  cases  the  tubes 
were  incubated  at  the  body  temperature ;  in  others  kept  at  that  of  the 
room.  The  results  were  uniformly  negative,  with  a  few  exceptions 
due  to  accidental  contamination  from  the  air  or  otherwise  during  the 
manipulations  the  experiments  involved. 

Although  different  conclusions  have  been  reached  by  certain  con- 
tinental observers,  it  is  now  universally  admitted  that  these  were  based 
on  experimental  error.  Up  to  the  present  time  no  specific  microphyte 
has  been  cultivated  from  malignant  tumours. 

The  failure  of  evidence  in  this  direction  led  to  the  suggestion  that 
the  hypothetical  microparasite  might  belong  to  the  animal  series,  and  be 
a  protozoon. 

In  considering  this  new  phase  of  the  problem,  the  fulfilment  of  Koch's 
four  postulates  must  equally  be  insisted  upon.  In  the  case  of  malaria,  it 
is  true,  no  culture  of  the  haematozoon  has  at  present  been  accomplished, 
and  yet  the  causative  role  of  the  latter  is  accepted ;  but  here  the  exist- 
ence of  a  living  protozoon  in  the  blood  does  not  allow  of  denial.  In  the 
case  of  cancer,  on  the  other  hand,  this,  KocWs  first  postulate,  namely,  the 
demonstration  of  a  microzoon  in  the  blood,  juices,  or  tissues,  is  itself 
in  dispute.  In  sections  of  carcinoma  there  are  certain  appearances 
which  are  interpreted  by  different  observers  as  indicating  the  presence  of 


GENERAL  PATHOLOGY  OF  NEW   GROWTHS  211 

a  protozoon.  A  full  historical  account  of  the  minute  histology  of  carci- 
noma in  this  relation  is  given  by  Noeggerath  up  to  the  close  of  1891. 
The  more  important  observations  since  then  arc  those  of  Soudakewitch, 
Foa,  and,  in  this  country,  of  Ruffer.  The  work  of  Ludwig  Pfeiffer  is 
an  attempt  to  compile  the  life  history  of  a  protozoon  from  the  study  of 
sections  of  malignant  tumours,  but  the  histological  misinterpretations 
it  contains  are  so  numerous  as  to  destroy  whatever  value  it  might 
otherwise  have.  Rulfer  has  simplified  the  subject  by  reducing  the 
hypothetical  parasite  to  a  very  fow  definite  forms,  and  we  may  here 
cite  his  description,  to  the  accuracy  of  which  we  can  ourselves  testify. 
As  seen  in  the  protoplasm  of  the  epithelial  cells  of  the  growing  edge,  say 
of  a  mammary  scirrhus,  the  fully-grown  parasite  consists  essentially  :  — 

(1)  Of  a  central  round,  oval,  or  slightly  irregular  nucelus,  sometimes 
connected  by  fine  delicate  rays  with  the  periphery. 

(2)  Of  a  variable  amount  of  surrounding  protoplasm,  almost,  if  not 
quite,  filling  a  capsule  (now  and  then  the  protoplasm  exhibits  a  series 
of  peripheral  granules). 

(3)  Of  a  doubly  contoured  capsule  confining  the  whole. 

What  of  its  life  history,  and  especially  its  mode  of  reproduction? 

If  we  turn  to  the  more  thoroughly  known  of  the  microzoa  parasitic 
in  the  lower  animals,  a  distinct  life  history,  often  a  very  complex  one,  is 
to  be  traced  ;  and  a  portion  of  this  may  be  passed  outside  the  body  of 
the  host. 

The  multiplication  of  the  bodies  described  in  carcinoma  is  alleged  to 
take  place  by  binary  division,  and  groups  of  considerable  numbers  may 
be  met  Avith  in  the  epithelial  cells. 

Certain  appearances  characteristic  of  a  protozoic  life  history  have 
been  described,  such  as  falciform  spores  and  spore  cysts. 

As  to  the  former,  the  opinion  of  Metschnikoff  has  yet  to  be  contro- 
verted, viz.,  that  the  appearances  in  question  result  from  nuclear  de- 
generation. Indeed,  bodies  of  similar  forms  may  be  seen  in  degenerating 
tissues  from  sources  altogether  different.  Other  such  particles  within 
the  cell  body  pertain  to  the  nuclei  of  ingested  leucocytes  or  lymphocytes, 
and  yet  smaller  ones  possibly  represent  the  residua  of  chromatin  result- 
ing from  the  irregular  mitoses  so  frequently  observed  in  the  epithelial 
cells  of  carcinoma. 

As  spore  cysts  have  been  described  — 

(1)  Aggregations  of  polynuclear  leucocytes  in  spaces  between  the 
epithelial  cells,  such  as  may  be  produced  in  the  rabbit's  vagina  after 
repeated  application  of  linimentum  iodi. 

(2)  Cell  invaginations,  the  protoplasm  of  which  is  highly  vacuolated 
and  the  cell  membrane  unusually  pronounced ;  and,  as  free  spores,  the 
particles  resulting  from  degenerative  fragmentation  of  the  nucleus  and 
destruction  of  the  cell. 

In  squamous  celled  carcinomata  the  kerafcinising  cells  themselves 
have  been  erroneously  viewed  as  parasites.  The  disproof  of  this  is 
furnished  by  the  readiness  with  which  every  intermediate  phase  may 


SYSTEM  OF  MEDICINE 


be  traced,  between  normal  epithelial  cells  and  those  which  cease  to  take 
any  nuclear  stains. 

As  to  the  particular  body  in  question,  it  closely  approaches  certain 
of  the  results  of  hyaline  degeneration  the  products  of  which  are  equally 
distinguished  by  their  affinity  for  fuchsin,  and  are  met  with,  as  was  shown 
by  ourselves,  in  various  non-cancerous  formations,  diphtheritic  tonsil, 
caseous  lymphatic  glands,  etc.  (14).  One  test  the  body  in  question  cer- 
tainly stands  —  that  of  constancy  ;  it  may  be  demonstrated  in  the  grow- 
ing edge  of  every  carcinoma :  and  nothing  identical  has,  in  our  opinion, 
been  hitherto  produced  in  epithelium  by  artificial  methods  of  irritation. 

The  bodies  seen  in  the  epidermis  raised  by  a  common  blister  stain 
with  differential  dyes  like  nuclear  chromatin  (those  of  carcinoma  stain 
in  general  like  the  nucleolus) ;  they  lie  in  spherical  spaces  in  the  cell 
body ;  and,  what  is  most  important  of  all,  there  is  no  other  structure  in 
the  cell  representing  the  nucleus  ;  they  are,  in  short,  shrunken  nuclei 
lying  in  peri-nuclear  vacuoles,  possibly  compressed  by  the  accumulation 
of  fluid  around. 

As  related  to  the  first  postulate  of  Koch,  reference  may  next  be  made 
to  certain  questions  in  the  chemistry  of  carcinoma.  It  has  been  shown 
that  the  capsule  of  encapsulated  protozoa  consists  at  times  of  chitin  or 
of  cellulose  —  both  of  them  substances  altogether  absent  from  the  tissues 
of  vertebrates.  Is  either  present  in  a  carcinoma  ?  This  question  can 
be  answered  in  the  negative.  The  investigation  was  carried  out  for  us 
by  Gregor  Brodie  at  King's  College,  London,  under  the  direction  of 
Professor  Halliburton,  as  follows :  — 

Method.  — The  tumour  is  cleared  of  surrounding  fat,  but  the  growing 
edge  is  carefully  left ;  it  is  then  minced  on  a  sheet  of  glass,  and  boiled  in 
20  per  cent  solution  of  caustic  soda  for  ten  minutes,  the  tissue  being  in 
this  way  dissolved ;  whilst  hot  the  fluid  is  filtered  through  asbestos,  the 
process  being  hastened  by  means  of  a  vacuum  pump.  A  yellowish 
residue,  indicating  the  presence  of  fats  in  excess,  remains  on  the  surface 
of  the  asbestos.  Should  chitin  or  cellulose  be  present  it  would  also  re- 
main on  and  in  the  asbestos,  seeing  that  it  is  insoluble  in  caustic  soda. 
Boiling  caustic  potass  (5  per  cent)  is  run  through  the  filter,  and  then  20 
per  cent  of  the  same  boiling  solution ;  the  precipitate  on  the  asbestos  is 
next  washed  with  boiling  distilled  water.  Nearly  the  whole  of  the  pre- 
cipitate, or  at  least  of  the  pale  yellow  portion,  disappears  in  this  process. 
The  caustic  potass  is  then  neutralised  by  drawing  through  the  asbestos  10 
per  cent  hydric  sulphate,  first  cold  and  afterwards  boiling,  and  finally 
boiling  distilled  Avater  in  order  to  remove  all  trace  of  the  acid.  The 
presence  of  chitin  or  cellulose  is  now  tested  thus  :  — 

Cellulose  is  soluble  in  concentrated  hydric  sulphate,  chitin  in  concen- 
trated hydric  chloride.  A  small  amount  of  hydric  sulphate  is  poured  on 
the  filter,  and  after  five  minutes  drawn  through.  The  addition  of  dis- 
tilled water  to  the  pale  brown  filtrate  gives  a  precipitate.  The  fluid  is 
then  filtered  through  the  asbestos,  the  precipitate  appearing  on  the  sur- 
face of  the  latter  as  a  pale  yellow  film.     Were  cellulose  in  solution  in 


GENERAL  PATHOLOGY  OF  NEW   GROWTHS  213 

the  clear  filtrate,  it  would  be  demonstrable  by  boiling  the  fluid  in  order 
to  convert  that  substance  into  dextrose  or  graj)e  sugar,  which  is  recognis- 
able by  boiling  with  Fehling's  solution.  No  reaction,  however,  with 
Fehling's  solution  is  obtainable. 

To  remove  any  fatty  acids  remaining,  or  constituting  the  precipitate 
on  the  asbestos,  the  latter  is  washed  with  cold  alcohol,  hot  alcohol,  and 
finally  warm  ether ;  a  film  of  faint  brown  colour  still  remains  on  the 
filter.  The  test  for  chitin  is  next  carried  out.  Chitin  is  insoluble  in 
strong  hydric  sulphate,  but  soluble  in  strong  hydric  chloride. 

Concentrated  hydric  chloride  is  poured  in  small  quantities  on  the 
filter,  and  the  filtrate  tested ;  dilution  of  part  with  water  gives  no  pre- 
cipitate of  chitin ;  the  remainder  is  evaporated  in  a  capsule  over  a  water 
bath ;  the  thinnest  pale  yellow  film  remains  on  the  side  and  bottom  of 
the  vessel.  This  alcohol  at  once  dissolves,  proving  it  to  be  fatty  acid 
remaining  over  from  experimental  error. 

Is  there  albumose  in  a  carcinoma  ? 

We  were  induced  to  look  for  such  a  body  in  consequence  of  its 
discovery  in  cultures  of  pathogenic  bacteria ;  it  seemed  to  us  that  a 
like  substance  derived  from  the  agency  of  a  specific  micro-organism  might 
possibly  exist  in  malignant  growths. 

The  method  adopted  was  as  follows :  — 

The  tumour,  scirrhus  of  the  breast,  is  minced  and  pounded  in  a 
mortar  with  50  per  cent  glycerine  and  distilled  water,  to  which  is  added 
a  little  thymol.  Before  applying  the  test  to  the  extract,  it  is  ascertained 
that  the  reaction  is  not  acid,  and  that  no  trace  of  decomposition  is  present. 
An  equal  bulk  of  trichloracetic  acid  (10  per  cent  solution)  is  added,  and 
the  mixture  boiled  five  minutes  in  a  beaker  to  bring  about  the  precipita- 
tion of  the  globulins  and  albumin ;  it  is  then  filtered.  The  direct  albu- 
mose tests  next  applied  to  the  clear,  faintly  opalescent  filtrate  are  nega^ 
tive  in  result. 

A  drop  of  strong  hydric  nitrate  gives  no  precipitate ;  cupric  sulphate 
solution  gives  no  precipitate ;  caustic  potash  solution  gives,  after  the 
addition  of  the  latter,  not  a  rose  colour  (albumose),  but  a  violet  —  an 
ordinary  proteid  reaction  possibly  due  to  a  trace  of  acid  albumin  not  pre- 
cipitated by  the  trichloracetic  acid  (Brodie).  Two  possible  fallacies  may 
be  here  noticed.  If  putrefaction  be  allowed  to  arise  before  the  applica- 
tion of  the  test  the  ordinary  albumose  resulting  from  that  process  would 
have  been  formed.  There  is,  however,  a  more  subtle  source  of  possible 
error.  The  reaction  of  a  carcinoma  or  sarcoma  immediately  after  removal 
is  alkaline ;  in  a  few  hours  it  becomes  acid :  in  this  the  morbid  tissue 
resembles  those  of  the  body  in  general  —  not  only  muscular,  but  glandular 
also.  In  muscle  a  post-mortem  formation  of  albiimose  is  actually  brought 
about  by  the  acid  reaction  allowing  the  pepsin,  which  circulates  in  small 
quantity  through  the  body,  to  digest  the  proteid.  It  is  quite  possible 
that  a  trace  of  albumose  might  thus  be  formed  after  tissue-death  if  the 
examination  of  the  growth  be  deferred. 

KoclCa  Second  Poatulate.  —  Seeing  that  no  spores  or  other  indispu- 


214  SYSTEM  OF  MEDICINE 

table  evidences  of  a  protozoon  have  been  histologically  demonstrated  in 
malignant  tumours,  the  proof  of  a  parasite  must  depend  upon  its  cultiva- 
tion outside  the  body.  And  it  is  in  this  direction  that  our  own  latest 
work  has  lain  (15).  We  were  induced  to  carry  it  out,  also,  for  the 
theoretical  reason  that  the  want  of  success  attending  the  transplantation 
of  carcinoma  from  man  to  the  lower  animals  might  be  due  to  the 
fact  that  it  was  necessary  for  the  parasite  to  assume  a  phase  outside 
its  host  in  order  to  transmit  the  disease.  Although  at  one  time  we 
employed  fluid  media  in  test-tubes,  very  dilute  broth,  very  dilute  agar, 
milk  (to  all  of  which  6  per  cent  glycerine  Avas  added),  potassium  oxalate 
plasma  (dog),  we  ultimately  abandoned  these  methods  as  not  ensuring 
sufiiciently  natural  aeration. 

We  also  fed  worms  with  pieces  of  mammary  scirrhus  placed  in 
sterilised  sand  and  water,  with  the  idea  that  it  might  be  necessary  for 
the  hypothetical  protozoon  to  pass  through  the  body  of  some  lower  form 
in  order  to  acquire  an  infective  quality  for  man  and  animals.  The 
experiment  failed;  although  the  cancer  was  devoured  the  worms  died, 
doubtless  because  the  sterility  of  the  sand  had  deprived  them  of  all  other 
kinds  of  nourishment. 

Again,  we  buried  mammary  carcinoma  in  garden  soil  and  sub- 
sequently inserted  portions  of  the  tumour  (exhumed  after  six  weeks) 
into  the  abdomen  of  rats,  but  without  obtaining  any  positive  result. 

Our  final  method  of  experiment  consisted  in  the  use  of  sterilised  sand 
and  water  as  a  culture  medium,  and  of  deep  capsules  of  different 
diameters  as  well  as  Petri  dishes,  in  the  place  of  test-tubes.  Portions 
of  the  growing  edge  of  the  tumour  were  cut  with  knives  previously 
sterilised  by  heat,  and  then  transferred  to  the  sand  in  the  neigh- 
bourhood of  a  littoral  which  was  made  by  so  tilting  the  sand  that 
the  water  did  not  completely  submerge  it.  The  capsules  were  afterwards 
stored  in  a  laboratory  between  sterilised  double  dishes,  the  covers  of 
these  being  raised  for  a  short  distance  with  wooden  blocks  soaked  in 
solution  of  corrosive  sublimate.  From  most  of  the  smaller  deep 
capsules  the  covers  were  removed  as  they  were  placed  between  the 
double  dishes ;  the  Petri  capsules  were  kept  covered  throughout. 
Occasionally  a  small  quantity  of  beef  peptone  broth  was  added  to 
the  water.  The  examinations  were  conducted  by  removing  some  of 
the  sand  from  the  littoral  in  the  neighbourhood  of  the  pieces  of 
tumour  with  a  sterilised  glass  rod  to  a  sterilised  slide;  the  sand 
so  removed  is  gently  stroked  with  the  rod,  the  slide  being  so  inclined 
that  sufficient  fluid  leaves  the  sand  to  make  a  microscopic  preparation. 
Many  such  experiments  were  made  both  with  mammary  carcinoma  and 
different  sarcomata ;  most  of  the  latter  were  of  the  melanotic  variety 
from  recently  killed  horses. 

In  all  the  experiments  carried  out  with  carcinoma  we  confined  our- 
selves to  the  typical  scirrhus  of  the  breast  for  the  reason  that,  in  the  case 
of  new  growths  involving  superficial  parts  like  the  lip  or  tongue,  there 
exists  the  possibility  of  infection  with  purely  saprophytic  protozoa ;  some 


GENERAL   PATHOLOGY   OF  NEW   GROWTHS  C15 

of  which  occur  normally  in  such  mucous  canals  as  the  vagina  and 
intestine. 

The  examinations  were  made  at  different  intervals  up  to  periods  of 
five  months.  In  none  of  the  series  were  any  indications  of  jjrotozoic 
life  encountered.  Active  amoebae  were  found  on  four  or  five  occasions 
in  different  Petri  capsules  infected  T,vith  mammary  scirrhus  and  squa- 
mous-celled  carcinoma ;  but  this  observation  was  limited  to  the  earlier 
experiments  in  which  the  sources  of  fallacy  were  not  rigidly  excluded. 
In  all  cases  a  growth  of  bacteria  ensued,  and  the  purpose  of  adding 
broth  to  the  fluid  was  to  favour  this,  in  order  that  pabulum  might  thus 
be  furnished  for  the  growth  of  any  protozoa  present. 

It  need  hardly  be  said  after  this  that  infection  experiments  carried 
out  upon  animals  by  means  of  such  sand,  or  the  grafting  of  portions  of 
tumours  incubated  in  fluid  media,  have  yielded  negative  results  in  our 
hands,  whether  the  sand  were  introduced  into  the  venous  current  in 
dogs,  into  the  peritoneal  cavity  of  rats,  or  rubbed  weekly  for  many 
months  into  the  scarified  skin. 

In  the  various  experiments  so  performed  the  sand  actually  used  was 
teeming  with  amoebae,  which  later  observation  proved  to  be  adventitious 
and  non-pathogenetic.  Similar  experiments  made  with  sand  infected  with 
the  pump-water  from  the  cancerous  village  referred  to  in  the  earlier  part 
of  this  article  were  likewise  negative ;  nor  did  the  feeding  of  white  rats 
with  food  to  which  this  water  was  added  lead  to  any  different  result. 

Treatment.  —  It  would  be  outside  the  purpose  of  the  present  article 
to  deal  with  the  operative  procedures  practised  in  the  surgical  treatment 
of  cancer,  or  to  do  more  than  mention  the  chief  remedies  which  have 
been  tried  from  time  to  time  in  the  treatment  of  malignant  disease.  In 
considering  this  subject  the  occasional  spontaneous  disappearance  of 
certain  tumours  must  be  borne  in  mind.  Such  a  disappearance  has  been 
observed  not  only  in  benign  growths,  like  fibro-adenomata  of  the  breast 
and  uterine  myomata,  but  also  in  sarcomata. 

In  the  museum  of  St.  Bartholomew's  Hospital,  London,  is  the  cast 
of  the  head  of  a  man  twenty -four  years  of  age,  who  about  six  years 
before  admission  was  struck  with  the  fly-wheel  of  an  engine ;  a  few 
months  later  a  tumour  commenced  to  grow  at  the  stricken  spot,  aud 
after  reaching  the  size  of  a  sparrow's  q^,%  disappeared  in  about  the  space 
of  six  months.  Six  or  eight  tumours  which  subsequently  grew  in  dif- 
ferent situations  on  the  head  afterwards  diminished  in  size.  On  his 
admission  there  was  a  large  tumour  near  the  middle  of  the  anterior 
border  of  the  left  parietal  bone,  its  longest  diameter  being  five  inches ; 
and  in  addition  the  six  or  eight  smaller  growths  before  mentioned. 
The  chief  formation  was  excised  in  March  1890,  and  histologically  pre- 
sented the  structure  of  a  fibro-sarcoma.  Mr.  Butlin  has  recorded  the 
partial  disappearance  of  what  Avas  presumed  to  be  a  sarcoma  of  the 
testicle  in  a  boy.  In  this  case  tumours  previously  removed  from  the  fore- 
head and  front  of  the  ear  exhibited  the  structure  of  round-celled  sar- 
coma; both  testicles  subsequently  enlarged,  but  the  right  afterwards 


2i6  SYSTEM  OF  MEDICINE 


underwent  marked  diminution  in  size ;  many  growths  appeared  about 
the  same  time  in  various  other  parts  of  the  body  :  the  administration  of 
mercury  had  not  the  slightest  effect.  It  is  not  impossible  that  the 
above  case  was  one  of  malignant  lymphoma  or  generalised  lymphoma- 
tosis, rather  than  of  true  round-celled  sarcoma;  the  partial  disappear- 
ance of  such  formations  is  a  well-known  clinical  phenomenon,  especially 
during  the  administration  of  arsenic. 

Considerably  more  voluminous  growths  of  a  tissue  that  has  been  by 
some  compared  with  sarcoma,  though  it  has  histologically  the  structure 
of  granulation-tissue  (granuloma  fangoides),  have  been  known  to  un- 
dergo complete  disappearance  quite  independently  of  any  local  treat- 
ment. The  difficulty  occasionally  presented  in  the  differential  diagnosis 
of  malignant  tumours  and  syphilomata  must  also  be  borne  in  mind- 
As  a  matter,  possibly,  of  interest  we  may  state  that,  in  search  of  a 
protective  vaccine,  we  have  tried  the  effects  of  subcutaneous  injection 
of  a  50  per  cent  glycerine  extract  of  both  carcinoma  and  sarcoma,  hope- 
less cases  being  selected  for  treatment. 

The  injections  in  one  case  of  mammary  carcinoma  exceeded  fifty  in 
number,  no  less  than  ten  different  carcinomata  being  employed.  In  one 
instance  of  recurrent  sarcoma  of  the  mamma  the  glycerine  extract  of  four 
different  sarcomata  was  used.  No  local  reaction  ensued,  such  as  is  ob- 
served after  the  injection  of  "tuberculin"  in  cases  of  tuberculosis;  and 
the  procedure  in  no  case  retarded  the  growth  and  multiplication  of  the 
tumours.  The  use  of  fresh  sheep  serum  was  equally  inefficacious  in  car- 
cinoma, i.e.  the  serum  of  an  animal  in  which  malignant  disease  is  so  rare 
that  it  may  be  considered  to  enjoy  a  natural  immunity.  Amongst  other 
methods  may  be  recounted  Fehleisen's  inoculation  of  erysipelas,  the 
interstitial  injection  of  methyl  violet,  the  passage  of  electric  currents, 
and  more  recentlj^  the  injection  of  the  combined  toxins  of  streptococcus 
erysipelatis  and  bacillus  prodigiosus  (Coley).  The  effect  of  the  last-men- 
tioned treatment,  like  that  of  Fehleisen,  is  a  local  and  not  a  general  one. 
The  serum  of  animals  into  the  circulation  of  which  cancer  juice  has 
been  introduced  has  also  been  used  therapeutically.  This  method  we 
based  upon  the  results  obtained  with  serum  antitoxins  in  general,  and 
we  are  at  present  engaged  in  putting  it  to  the  test :  the  same  idea  has 
independently  served  as  a  basis  of  recent  work  abroad. 

Up  to  the  present  the  only  hope  has  lain  in  early  removal  before  the 
infective  elements  of  the  tumour  have  been  widely  transported  into  the 
surrounding  tissues  or  to  distant  parts  of  the  body.  The  most  successful 
operator  is  he  who,  knowing  the  pathology  of  the  disease,  appreciates  the 
value  of  free  and  careful  excision.  The  incisions  must  be  planned  to  pass 
through  parts  believed  to  be  healthy,  no  knife  which  has  been  infected 
with  the  juice  of  the  tumour  must  be  used  for  the  division  of  healthy 
tissues,  lest  the  seeds  of  recurrence  be  sown  along  the  fresh  cut  surfaces, 
and  not  only  must  lymph  glands  be  removed,  but  lymphatic  vessels.  In 
certain  localities  the  operation  for  cancer  conducted  on  these  principles 
may  permanently  rid  the  patient  of  the  disease.     Excision  of  carcinoma  of 


PRINCIPLES   OF  DRUG    THERAPEUTICS  217 

the  lip  may  be  completely  successful ;  so,  in  a  certain  percentage,  is  that 
of  mammary  carcinoma,  whilst  the  free  removal  of  the  rectum  is  followed 
by  better  results  as  regards  respite  from  recurrence  than  that  of  any 
other  part. 

Samuel  G.  Shattock, 
Charles  A.  Bal  lance. 

REFERENCES 

1.  R.  ViRCHOW.  Die  kranlchafte  Geschwulste. — 2.  Charles  Darwin.  Descent  of 
Man,  sec.  ed.,  chap.  xix.  —  3.  Klebs.  Allgemeine  Pathologie,  Bd.  ii.  p.  524. — 4. 
CoHNHEiM.  Vo7-lesungen  ii.  allgem.  Path.  1877. — 5.  Shattock  and  Ballance.  "  Au 
Experimental  Investigation  into  the  Pathology  of  Cancer,"  Proc.  Royal  Society,  vol. 
xlviii.  1890. — 6.  Law  Webb.  Birmingham  Med.  Revieio,  December  1892,  p.  342. — 7. 
Haviland.  Geography  of  Heart  Disease,  Cancer,  and  Phthisis,  1875.  —  8.  Shattock 
and  Ballance.  "Cultivation  Experiments  with  New  Growths  and  Normal  Tissues, 
togetlier  with  Remarks  on  the  Parasitic  Theory  of  Cancer,"  Trans.  Path.  Soc.  vol. 
xxxviii.  1887. — 9.  Noeggerath.  Beitrdge  zur  Struktur  u.  Entwickelung  des  Carci- 
noms,  1892.  — 10.  Soudakewitch.  Annates  ds  I'lnstitut  Pasteur,  March  1892.  — 11. Foa. 
"  Uber  die  Krebsparasiten,"  Centralblatt  fiir  Bakteriologie  u.  Parasitenkunde,  Bd.  xii. 
No.  6,  August  9,  1892.  — 12.  L.  Pfeiffer.  Die  Protozoen  als  Krankheitserreger,  1890. 
— 13.  Armand  Ruffer.  Journal  of  Pathol'igy,  October  1892,  et  s^q.  —  14.  Shattock 
and  Ballance.  British  Med.  Journal,  1891.  — 15.  Shattock  and  Ballance.  "An 
Attempt  to  cultivate  Parasitic  Protozoa  from  Malignant  Tumours,  Vaccinia,  Molluscum 
contagiosum,  and  certain  Normal  Tissues,  together  witli  Infection  Experiments  carried 
out  with  the  Culture  Media,  and  a  Note  on  the  Treatment  of  Cancer,"  Proceedings  Royal 
Society,  vol.  lix.  1895.  — 16.  Butlin.     Trans.  Path.  Soc.  London,  1878. 

S,  G.  S. 
C.  A.  B. 


PEINCIPLES   OF  DRUG  THEEAPEUTICS 

I.    Introductory 

The  work  of  the  great  Italian  anatomists,  Vesalius,  Fallopius,  Eustachius 
and  others  in  the  latter  half  of  the  sixteenth  century,  led  eventually  to 
the  overthrow  of  the  Galenic  system  of  drug  therapeutics  ;  but  the  in- 
fluence of  the  anatomists  in  this  direction  was  by  no  means  immediate. 
The  early  editions  of  the  London  PharmacopcEia,  which  was  first  published 
in  1618,  probably  indicate  fairly  well  the  method  on  which  drugs  were 
used  in  England  at  that  day  for  the  cure  of  disease.  In  that  of  1632 
most  of  the  formulae  are  copied  from  the  works  of  Greek  and  Arabian 
physicians,  —  from  Galen,  Avicenna,  Rhazes,  Haly-abbas  and  Mesne, — 
the  name  of  the  physician  being  given  in  each  case  at  the  head  of  the 
formula.  Some,  however,  are  of  more  modern  date ;  John  of  Arderne 
(1370j  is  responsible  for  two  compounds,  and  from  Fernlius  many'  are 
derived.  We  note  many  substances  and  processes  introduced  by  the 
alchemists  ;  vitrum  antimonii  and  acetate  of  lead,  for  example,  are 
amongst  the  remedies,  and  several  of  the  preparations  are  made  by  dis- 


SYSTEM  OF  MEDICINE 


tillation.  We  also  see  the  influence  of  the  discovery  of  the  New- 
World  on  medicine,  for  guaiacum,  cnbebs,  sarsaparilla  and  sassafras  are 
amongst  the  ofiicial  substances.  There  is  a  great  variety  of  com- 
pounds ;  almost  all  are  very  complex,  many  of  them  containing  30  to  50 
ingredients;  into  the  "Antidotus  Magna  Matthioli  Adversiis  Venena  et 
Festem  "  there  enter  131  ingredients.  There  was  certainly  no  lack  of 
curative  agents ;  in  the  list  of  simples  we  find  160  roots,  30  barks, 
16  woods,  220  herbs,  90  flowers,  96  fruits,  136  seeds,  and  50  gums ; 
besides  juices  and  some  other  special  parts  of  plants.  The  animal 
kingdom  furnished  190  items.  The  fat  of  22  animals,  the  excrement  of 
11,  and  the  urine  of  5,  occupy  places  in  the  official  list  of  remedies ;  man 
is  included  in  each  case.  Sweat  was  an  official  remedy,  so  too  were  the 
ossa  triquetra  of  the  human  cranium.  The  brains  of  the  leopard  and  of 
the  sparrow,  the  lungs  of  the  fox,  and  the  body  of  the  viper  are  found 
among  the  official  animal  substances.  Sixty  syrups  and  180  waters  were 
official. 

The  discovery  of  the  circulation  by  Harvey,  and  the  advances  made 
in  the  knowledge  of  the  structure  and  functions  of  the  body  by  Willis, 
Glisson,  Malpighi,  and  others,  together  Avith  the  advancement  of  chem- 
istry and  physics,  led,  during  the  seventeenth  century,  to  the  formation 
of  new  hypotheses  concerning  disease  and  its  treatment.  Van  Helmont 
taught  that  life  was  connected  with  the  presence  in  man  of  a  kind  of 
personal  spirit  (Archeus),  which  from  its  seat  in  the  epigastrium 
presided  over  the  functions  of  the  body.  This  Archeus  sometimes  went 
wrong,  owing  to  external  or  internal  influences,  hence  diseases  arose. 
Later  we  find  chemical  and  mechanical  theories  of  disease.  By  Sylvius 
and  Willis  acidity  and  alkalinity,  or  fermentation  in  the  fluids  of  the 
body,  were  supposed  to  cause  disease;  whilst  Baglivi  and  other  Italian 
observers,  and  still  later  Archibald  Pitcairn  in  this  country,  laid  chief 
stress  on  the  mechanical  changes  connected  with  the  tissues  and  the  cir- 
culation as  causes  of  disease.  All  the  advocates  of  these  theories  either 
contributed  something  to  the  knowledge  of  the  treatment  of  disease  by 
drugs,  or  by  their  works  instigated  further  inquiry  :  to  Willis  and  Syden- 
ham we  owe  the  greatest  advances. 

Willis  was  one  of  the  first  to  lay  stress  on  the  importance  of  a  knowl- 
edge of  the  structure  of  the  different  organs  as  a  guide  to  the  use  of 
drugs ;  and  in  his  Pharmaceuti'ke  rationalis  (1676)  he  first  gives  an  account 
of  the  minute  structure  of  the  alimentary  canal  audits  various  parts,  and  of 
the  arteries ;  he  then  describes  the  action  of  emetics,  cathartics,  diuretics, 
diaphoretics,  cordials,  hypnotics,  and  opiates.  Further  on  he  deals  with 
the  lungs  and  bronchial  tubes,  and  the  changes  in  respiration  in  diseases 
such  as  phthisis,  haemoptysis,  and  other  lung  ailments,  giving  the  indica- 
tions for  treatment  and  the  remedies  which  in  his  opinion  answered  these 
indications.  He  likewise  points  out  what  he  regards  as  the  rational 
treatment  for  jaundice,  ascites,  tympanites,  and  anasarca.  In  a  third 
portion  of  the  work  he  deals  with  the  causes  and  treatment  of  haemorrhage, 
and  with  blisters,  issues,  etc.    The  practical  outcome  of  the  work  of  Willis 


PRINCIPLES   OF  DRUG    THERAPEUTICS  219 

was  of  less  value  than  the  spirit  of  his  teaching ;  his  pathological  ideas 
about  animal  spirits  and  fermentation  as  causes  of  disease  were  very 
crude ;  he  was  much  influenced  in  his  conclusions  by  old  theories  of  the 
action  of  morbid  materials,  and  the  indications  of  the  qualities  (heat, 
cold,  etc.),  of  drugs ;  above  all,  he  too  readily  supposed  that  the  drugs 
under  which  his  patients  recovered  had  cured  them.  His  prescriptions 
are  complex,  and  contain  not  only  a  large  number  of  iiseless  agents,  but 
such  remedies  as  the  human  skull,  viper's  flesh,  millipedes,  etc.  Yet 
when  he  dealt  with  subjects  controlled  by  anatomical  knowledge,  he 
made  valuable  additions  to  the  existing  therapeutical  means. 

Sydenham  professes  to  recognise  the  value  of  anatomical  knowl- 
edge, but  we  find  little  of  it  in  his  work.  Like  Hippocrates,  he 
sought  to  aid  the  natural  progress  of  those  changes  or  "  commotions  "  in 
the  blood  and  fluids  of  the  body  which  he  regarded  as  the  causes  of  acute 
disease,  and  to  help  nature  in  her  struggle  to  remove  morbid  matters. 
He  advocated  the  removal  of  the  immediate  causes  of  disease,  but  had 
no  belief  in  the  possibility  of  dealing  with  remote  causes.  By  close 
observation  he  attempted  to  determine  definite  lines  for  the  administra- 
tion of  drugs ;  he  also  sought  to  discover  specific  remedies,  such  as  he 
held  cinchona  to  be  for  ague.  He  preferred  vegetable  drugs  to  animal 
or  mineral,  becaiise  the  animal  are  too  like,  and  the  mineral  too  unlike 
the  tissues  of  the  body.  His  prescriptions  were  more  simple  than  those 
of  Willis,  and  they  are  almost  free  from  absurd  constituents.  But  if 
we  examine  the  prescriptions  of  both  Willis  and  Sydenham  we  cannot 
but  see  that,  with  the  exception  of  emetics,  purgatives,  bitters,  and  car- 
minatives, very  few  of  the  drugs  they  used  had  the  powers  which  were 
claimed  for  them ;  and  that  the  art  of  medicine  suffered  no  loss  when  a 
large  proportion  of  the  drugs  in  which  they  had  faith  were  consigned  to 
oblivion.  Under  such  circumstances  we  cannot  be  surprised  that  the 
Pharmacopoeia  of  the  middle  of  the  seventeenth  century  showed  no 
signs  of  improvement.  In  that  of  1677  we  find  the  drugs  and  compounds 
almost  as  numerous  as  in  the  Pharmacopoeia  of  1618 ;  indeed  some  of 
the  remedies  in  the  latter  are  even  more  extraordinary  than  any  in  the 
earlier  Pharmacopoeia.  Not  only  is  human  urine  set  forth  as  a  remedy, 
but  care  is  taken  to  distinguish  Urina  hominis  pueri  impuberis  from 
Urina  hominis  adulti ! 

It  is  interesting  to  note  that  in  this  Pharmacopoeia  we  find  for  the 
first  time  jalap,  serpentary,  digitalis  and  cinchona;  and  that  the  names 
of  Galen  and  the  Arabian  physicians  cease  to  appear  at  the  head  of  the 
formula?  copied  from  their  works. 

At  the  end  of  the  seventeenth  century  the  theories  of  Boerhaave,  Hoff- 
mann, and  Stahl  considerably  influenced  therapeutic  practice.  The  two 
former  looked  on  health  and  disease  as  the  outcome  of  chemical  and' 
physical  conditions  acting  on  tissues  endowed  with  vital  properties, 
which  Hoffmann  thought  due  to  the  presence  of  an  ether-like  fluid 
existing  both  in  the  solids  and  the  blood;  Stahl  attributed  everything 
to  soul  or  spirit.     Though  both  Boerhaave  and  Hoffmann  looked  upon 


SYSTEM   OF  MEDICINE 


the  solids  of  the  body  as  playing  an  important  part  in  disease,  they  did 
not  consider  them  as  alone  concerned.  The  former,  holding  that  acridity 
or  viscosity  of  the  humours  shared  in  the  production  of  disease,  pre- 
scribed medicines  with  the  view  of  rendering  them  less  viscid;  the 
latter,  though  attributing  disease  chiefly  to  excessive  or  defective  con- 
traction of  the  solid  tissues  (spasm  or  atony),  nevertheless  prescribed 
alteratives  for  the  humours,  and  evacuants  for  defective  excretions. 
Stahl,  on  the  other  hand,  was  led  by  his  animistic  views  to  deny  the 
efficacy  of  medicine  almost  entirely :  he  even  threw  doubt  on  the  use  of 
opium  and  cinchona  bark.  Though  all  these  eminent  men,  and  many 
others,  added  something  to  the  general  fund  of  knowledge  concerning 
therapeutics,  the  treatment  of  disease  by  drugs  improved  but  slowly, 
and  was  dominated  by  strange  conceits  and  superstitions. 

Scorpions,  earthworms,  woodlice  and  viper's  flesh,  also  the  excre- 
ment of  the  dog,  goose,  horse  and  pigeon,  appear  in  the  Pharma- 
copoeia of  the  Royal  College  of  Physicians  of  London  of  1721.  The 
formulae  were  somewhat  less  complex  than  in  the  previous  century  ; 
but  one,  *'  Mithradatium,"  contains  49  ingredients  ;  another,  "  Theriaca 
Andromachi,"  63,  including  viper's  flesh  ;  and  one  of  the  Confectiones, 
50,  amongst  which  appear  bezoars,  corals,  pearls,  and  the  flesh,  liver 
and  heart  of  the  viper. 

Amongst  the  drugs  which  appear  for  the  first  time  are  the  follow- 
ing:—  Canella  alba,  tartar  emetic,  secale  cornutum,  stramonium,  gam- 
boge, ipecacuanha  and  senega.  Chemical  knowledge  has  not  reached 
the  physicians,  for  the  minerals  are  still  divided  into  sulphurs,  salts  and 
earths ;  arsenious  acid  being  included  among  the  sulphurs.  Twenty-five 
years  later  the  Pharmacopoeia  of  the  College  of  Physicians  indicates  a 
considerable  change.  The  compounds  are  much  simpler,  and  with 
a  few  exceptions  they  are  not  unlike  those  of  the  present  day  in  the 
number  of  their  ingredients. 

The  Mithradatium,  however,  still  contains  46  ingredients,  and  the 
Theriaca  Andromachi  62.  The  long  list  of  animal  substances  has  dis- 
appeared, but  a  few  extraordinary  materials  are  still  met  with :  crab's 
claws,  the  so-called  "  crab's  eyes,"  viper's  flesh  (in  an  ointment),  bezoars, 
woodlice  and  red  coral  are  still  official.  On  the  other  hand  some  useful 
remedies  seem  to  have  dropped  out.  Nux  vomica,  digitalis,  senega, 
hyoscyamus,  stramonium,  male  fern,  and  secale  cornutum  are  no  longer 
official.  Spirit  of  nitrous  ether  is  official  for  the  first  time.  A  large 
number  of  useful  oils  are  introduced,  and  the  chemistry  is  much  more 
advanced. 

During  the  latter  half  of  the  eighteenth  century  very  great  advances 
were  made  in  all  the  sciences  bearing  on  medicine.  Haller  founded 
Physiology.  Chemistry  had  advanced  greatly.  Barthez,  in  France, 
advanced  a  more  tenable  vitalistic  theory  of  the  nature  of  disease,  and 
Cullen's  Materia  Medica  was  in  every  respect  a  great  advance  on  any 
which  had  preceded  it.  The  London  Pharmacopce.ia,  published  in  1788, 
and  that  of  Edinburgh,  which  appeared  in  1780,  reflected  the  rapid 


PRINCIPLES   OF  DRUG    THERAPEUTICS 


advance  of  knowledge  in  Physiology,  Pathology,  Chemistry  and  Medi- 
cine which  now  occurred.  The  excessively  comjjlicated  formulae,  which 
the  older  Pharmacopoeias  contained,  were  swept  away.  The  numerous 
absurd  animal  substances  present  in  previous  Pharmacopoeias  were  almost 
entirely  omitted.  Digitalis,  senega  and  male  fern  recovered  their  place 
in  the  London  Pharmacopoeia ;  and  cascarilla,  kino,  calumba  and  quassia 
were  introduced. 

The  last  years  of  the  eighteenth  and  the  first  years  of  the  present 
century  were  marked  by  a  fresh  outbreak  of  theories  concerning  the 
cause  and  cure  of  disease  which  had,  for  the  time  being,  a  considerable 
influence  on  the  treatment  of  disease  by  drugs. 

Brown,  a  pupil  of  Cullen,  maintained  that  the  tissues  of  the  body 
possess  excitability ;  that  life  is  the  outcome  of  the  action  of  stimuli, 
such  as  warmth,  food,  etc.,  on  this  excitability,  which  is  uniformly 
diffused  in  all  tissues ;  that  sthenic  diseases  are  due  to  excessive,  and 
asthenic  to  defective  excitement.  All  remedies  are  stimuli,  and  only 
differ  in  their  power.  Strong  stimuli,  such  as  opium,  musk,  ammonia 
and  camphor,  are  useful  in  asthenic  diseases ;  but,  if  given  in  excess, 
they  may,  by  producing  over-excitement,  lead  to  debility :  other  sub- 
stances, such  as  purgatives,  emetics,  etc.,  produce  less  excitement  than 
is  requisite  for  health,  and  are  antisthenic,  or  debilitating.  Brown  held 
that,  for  the  most  part,  diseases  are  asthenic,  and  his  treatment  therefore 
consisted  chiefly  in  the  exhibition  of  stimulants.  He  looked  upon 
sthenic  and  asthenic  conditions  as  affecting  the  entire  economy,  and  took 
little  note  of  local  changes,  holding  that  excitability  is  uniformly  dif- 
fused ;  and  that  it  cannot  be  augmented  in  one  part  only,  for  then  it 
would  be  unevenly  distributed.  This  doctrine  was  largely  accepted,  and 
modifications  of  it  were  promulgated  both  in  Italy  and  in  France. 

Easori  held  views  not  unlike  those  of  Brown.  Broussais  also 
taught  that  life  is  due  to  stimulation ;  that  to  live  is  nothing  else 
than  to  be  excited :  but,  he  considered  that  different  diseases  possess 
different  degrees  of  excitability ;  and  further,  that  as  the  sum  total  of 
excitability  in  the  body  is  always  the  same,  augmentation  in  the  one 
part  occasions  diminution  elsewhere.  He  looked  upon  all  medicines  as 
either  stimulants  or  debilitants,  but  strongly  upheld  the  view  that  all 
so-called  general  diseases  have  a  local  origin.  Fevers,  for  instance,  he 
believed  to  depend  on  gastro-intestinal  inflammation.  He  classified 
medicines  as  debilitants,  direct  stimulants,  and  revulsives ;  and,  like 
Easori,  he  looked  upon  undue  irritation  as  the  cause  of  most  diseases; 
practically,  he  recommended  only  debilitating  agents  in  the  treat- 
ment of  disease.  The  English,  Italian  and  French  systems  had,  during 
the  first  two  or  three  decades  of  the  nineteenth  century,  great  influence 
in  determining  the  use  of  drugs,  and  the  doctrine  of  Broussais  affected 
treatment  until  after  the  middle  of  this  century.  But  with  increasing 
knowledge  of  Chemistry,  Physiology  and  Pharmacology,  belief  in  the 
Brunonian  and  allied  systems  gradually  declined. 

The  last  theory  of  disease  and  its  cure  which  I  shall  notice  is  that  of 


SYSTEM   OF  MEDICINE 


Hahnemann,  who,  at  the  end  of  the  last  century,  made  the  theory  that 
*'  like  cures  like  "  the  central  point  of  a  new  system  of  therapeutics.  Hip- 
pocrates pointed  out  the  occasional  value  of  similars,  that  is,  of  drugs  which 
produce  symptoms  similar  to  those  observed  in  the  disease  for  which  they 
are  given ;  so,  too,  did  Galen,  and  some  later  writers.  But  Hahnemann  was 
the  first  who  raised  the  proposition  that  like  cures  like  into  a  natural  law ; 
and  he  conjoined  with  this  view  a  belief  in  the  power  of  infinitesimal 
doses.  He  formulated  new  theories  to  account  for  disease  and  the  curative 
action  of  his  drugs.  He  held  that  a  spiritual  power  (the  vital  force)  ani- 
mates the  human  body,  and  that  disease  consists  in  a  diversion  of  the 
automatic  vital  force  into  an  abnormal  direction.  Drugs  rightly  selected 
can  produce,  in  his  opinion,  a  disease  like  to,  but  stronger  than  that  for 
which  they  are  given,  and  such  medicinal  diseases  are  more  easily  over- 
come by  the  spiritual  or  vital  force  than  natural  diseases.  In  selecting 
a  drug  for  any  particular  ailment,  it  is  therefore  necessary  to  choose  one 
which  produces  symptoms  like  to  those  which  are  present  in  the  natural 
disease  for  which  it  is  given.  He  said  that  knowledge  of  pathology, 
or  of  the  causation  of  disease,  is  useless.  The  powerful  action  of 
infinitesimal  doses  he  attributed  to  the  fact  that  in  their  preparation 
succussion  and  trituration  were  much  used,  and  these  processes  in  his 
belief  increased  enormously  the  spiritual  or  dynamic  power  of  the  drug. 

The  theories  of  Hahnemann  on  the  nature  of  disease  and  drug 
action  have  long  died  out ;  but  there  are  still  a  few  believers  in  the 
so-called  law  of  "  similars,"  and  in  the  efficacy  of  drugs  given  in 
infinitesimal  doses. 

With  Brown,  Broussais  and  Hahnemann,  another  phase  in  the 
history  of  drug  treatment  closed.  With  them  the  theoretical  systems 
of  treatment,  which  had  succeeded  one  another  since  the  sixteenth  cen- 
tury, came  to  an  end.  Therapeutics  became  rational.  A  tendency  in 
this  direction  had  long  been  manifest;  with  the  increasing  knowledge 
of  Chemistry,  Anatomy  and  Physiology  during  the  seventeenth  and 
eighteenth  centuries,  truer  conceptions  of  the  causes  of  diseases  became 
more  general ;  and  it  came  to  pass  that  drugs  were  increasingly  used  for 
the  removal  of  causes  apart  from  belief  in  any  abstract  generalisations. 
Alkalies  were  given  for  acidity,  even  though  chemical  theories  of  disease 
were  discarded.  The  knowledge  that  the  bronchial  tubes  are  surrounded 
by  muscle  led  to  the  tentative  administration  in  asthma  of  substances 
such  as  opium  and  ether,  without  relation  to  any  theories  ;  and  the  good 
effects  observed  from  evacuants  in  many  ailments  led  to  their  ex- 
tended use,  without  any  definite  regard  to  Sydenham's  theory  of  aid- 
ing nature. 

Morgagni's  great  work  on  Pathological  Anatomy,  published  in  1795, 
threw  a  fiood  of  light  on  the  conditions  of  disease,  and  Bichat  not  only 
pointed  out  the  importance  of  considering  changes  of  tissues,  as  well  as  of 
organs,  but  urged  that  the  true  use  of  medicine  is  to  restore  organs  and 
tissues  to  a  normal  state ;  and,  by  the  discovery  of  the  influence  which 
drugs  have  on  tissues  and  organs  and  the  functions  they  subserve,  the 


PRINCIPLES   OF  DRUG    THERAPEUTICS  223 

way  was  cleared  for  the  next  great  step  in  therapeutic  progress.  The 
advances  of  chemistry  gave  facilities,  previously  wanting,  for  exact  in- 
vestigation of  the  action  of  drugs.  Stoerk,  indeed,  in  17G2,  had  pub- 
lished a  good  account  of  the  action  of  henbane,  aconite,  and  some  other 
drugs  on  the  healthy  organism,  together  with  the  therapeutic  inferences 
he  drew  from  this  action;  we  find,  however,  few  records  of  similar  inves- 
tigations, and  at  the  end  of  the  eighteenth  century  very  little  had  been 
ascertained  as  to  the  exact  manner  in  which  drugs  influence  the  body,  or 
as  to  those  constituents  of  drugs  on  which  their  properties  are  now  known 
to  depend.  The  progress  of  chemistry  had  indeed  led  to  a  search  for 
active  principles  in  vegetable  substances;  but  Cullen  (in  1778)  threw 
doubt  on  the  value  of  any  attempts  to  determine  them.  In  the  early 
part  of  the  nineteenth  century,  however,  chemists  were  enabled  to 
separate  several  important  alkaloids.  Morphia  was  discovered  in  1816, 
quinine  in  1820,  strychnine  in  1818.  These  discoveries  facilitated  those 
investigations  into  the  action  of  drugs  on  the  various  organs  and  tissues 
of  the  body  and  their  functions,  of  which  Magendie  was  the  pioneer,  and 
have  so  largely  influenced  the  therapeutic  theories  and  practices  of 
the  present  day.  Magendie  showed  that  it  was  possible  to  determine  not 
only  the  organ  on  which  a  drug  acts,  but  even  the  part  of  the  organ. 
By  a  series  of  striking  experiments  he  demonstrated  that  strychnine 
produces  its  tetanising  effects  not  by  influencing  the  nerves  or  muscles 
but  by  acting  on  the  reflex  centres  of  the  spinal  cord ;  and  the  methods 
by  which  he  showed  this  have  been  more  or  less  a  model  for  all  who 
have  forwarded  the  work  which  he  so  ably  initiated.  Soon  chemists 
throughout  Europe  were  busy  in  attempting  to  separate  the  active 
principles  from  all  the  well-known  drugs ;  and  physiologists  were  equally 
active  in  trying  to  determine  exactly  the  organs  on  which  these  principles 
act  and  the  manner  in  which  they  affect  them.  Foremost  among  such 
workers  was  Claude  Bernard,  to  whom,  more  than  any  man  in  this  cen- 
tury, we  are  indebted  for  the  progress  made  in  the  comprehension  of  the 
action  of  drugs ;  as,  not  only  by  his  experiments  on  the  physiological 
effects  of  many  drugs,  but  also  by  his  discovery  of  the  part  which 
the  vaso-motor  nerves  and  the  muscular  coat  of  the  arteries  play  in  the 
circulatory  system,  he  prepared  a  way  for  the  further  investigations  on 
the  vascular  system,  which  have  led  to  the  discovery  of  some  of  the 
most  powerful  means  we  possess  for  relieving  suffering  and  saving  life. 
His  successors  have  been  continuously  occupied  in  following  out  the 
researches  which  Magendie  initiated;  and  every  year  we  see  additions 
made  to  physiological  and  pharmacological  knowledge,  which,  immedi- 
ately or  at  some  future  time,  will  enable  us  to  treat  disease  Avith  increasing 
certainty.  When  it  had  been  sufficiently  demonstrated  that  substances 
derived  from  the  mineral,  vegetable  and  animal  kingdoms  have  a  specific 
effect  on  disease,  and  that  this  action  in  the  case  of  animal  and  vegetable 
substances  could  be  traced  to  the  chemical  compounds  they  contain,  the 
method  in  which  the  structure  of  these  compounds  influences  their  effects 
became  a  subject  of  investigation.    Blake  in  1842  came  to  the  conclusion 


224  SYSTEM   OF  MEDICINE 

that  all  salts  having  the  same  base  exert  a  similar  action  when  introduced 
into  the  blood,  and  that  a  close  relation  exists  between  the  chemical 
properties  of  substances  and  their  physiological  results. 

We  have  now  found  that  it  is  possible  in  many  instances  to  form  an 
idea,  from  the  composition  of  a  drug,  of  its  influence  on  the  body; 
that  this  influence  may  be  altered  in  certain  directions  by  modifying  its 
chemical  structure,  and  that  ncAv  substances  may  be  built  up  chemically 
to  fulfil  pharmacological  and  therapeutical  requirements. 

The  advances  of  recent  years  have  been  chiefly  in  the  direction  of 
the  discovery  and  production  of  new  agents  calculated  to  exercise  definite 
pharmacological  actions,  of  determining  their  exact  influence,  as  well  as 
that  of  the  older  drugs,  on  the  various  parts  of  the  body  and  on  the  lower 
forms  of  life,  of  ascertaining  the  minute  changes  which  take  place  in  dis- 
ease in  the  various  organs,  and  of  discovering  the  relation  which  exists  be- 
tween micro-organisms  and  the  production  of  disease  on  the  one  hand  and 
the  products  of  the  micro-organisms  and  the  cure  of  disease  on  the  other. 


II.   Present  Principles  of  Drug  Therapeutics 

We  give  drugs  in  disease  for  two  purposes  :  — 

1.  To  restore  health  directly  by  removing  the  sum  of  the  conditions 
which  constitute  disease.  Here  we  act  empirically,  with  no  definite 
knowledge,  —  often  indeed  with  little  idea  of  the  action  of  our  drugs,  but 
on  the  ground  that  in  our  hands  or  in  those  of  others  they  have  restored 
health  in  like  cases. 

2.  To  influence  one  or  more  of  the  several  tissues  and  organs  which 
are  in  an  abnormal  state,  so  as  to  restore  them  to  or  towards  the  normal ; 
with  the  hope  that  if  we  succeed  in  our  purpose  recovery  will  take 
place.  This  purpose  we  effect  by  means  of  the  influence  which  the 
chemical  properties  of  drugs  exert  on  the  structure  and  functions  of  the 
several  tissues  and  organs.  Minute  information,  therefore,  of  the  nature 
of  the  drugs  and  their  action  is  essential  for  their  proper  employment. 

Nature  of  Drugs. — Drugs  were  formerly  looked  upon  as  simple  sub- 
stances having,  amongst  other  attributes,  the  power  of  curing  disease, 
indeed  the  popular  idea  concerning  them  has  not  advanced  beyond  this 
view ;  but  physicians  now  refer  their  influence  to  the  textural  and 
functional  changes  they  are  capable  of  effecting  in  definite  portions  of 
the  body  by  virtue  of  their  total  composition,  or  that  of  certain  chemical 
substances  they  contain.  Not  only  do  the  elements  of  which  a  drug  is 
constituted  affect  its  action,  but  the  way  in  which  these  elements  are 
grouped  and  combined  is  of  importance. 

The  effect  which  several  of  the  elements  exert  in  their  compounds 
have  been  traced  by  Brunton,  Einger,  Harnack,  Binz  and  others.  It  has 
been  shown  that  chlorine  and  bromine,  potash,  lime,  and  many  other 
metals,  always  tend  to  act  on  certain  tissues  in  a  definite  manner, 
unless  their  influence  be  neutralised  by  other  elements  with  which  they 


PRINCIPLES    OF  DRUG    THERAPEUTICS  225 

are  in  combination.  It  has  been  shown  also  that  small  groups  of  ele- 
ments may  play  a  similar  part  in  more  complex  compounds,  that  the 
action  of  ^H^  and  ISTOg,  for  example,  can  be  as  distinctly  traced  in  the 
compounds  in  which  they  occur  as  that  of  chlorine  or  potassium  or  cal- 
cium. A  compound  containing  the  group  NHg  stimulates  the  medulla ; 
a  drug  containing  the  group  NOg  acts  on  the  vessels  and  dilates  them. 

On  the  other  hand,  in  many  of  the  organic  compounds  we  are  quite 
unable  to  trace  the  effects  of  the  several  elements ;  and  it  is  rather  the 
manner  of  grouping  of  the  elements  which  seems  to  confer  on  the  com- 
pounds their  pharmacological  and  other  properties.  Two  compounds 
may  contain  exactly  the  same  elements  and  the  same  number  of  atoms 
of  each,  yet  if  these  atoms  be  differently  arranged  the  compounds  may 
differ  entirely  in  pharmacological  and  other  properties.  Methyl  nitrite, 
and  nitro-methane  have  the  same  formula  (CH3  NOo),  but  the  oxygen  and 
nitrogen  atoms  in  the  two  substances  are  joined  together  in  a,  different 
way.  The  result  is  they  act  quite  differently :  the  nitrite  dilates  the 
vessels ;  nitro-methane  has  no  such  action. 

In  the  more  complex  organic  compounds  the  addition  or  removal  of 
one  of  these  small  groups  of  elements  often  greatly  alters  the  pharmaco- 
logical effect.  Fraser  and  Crum-Brown  showed  many  years  ago  that 
by  replacing  an  atom  of  hydrogen  in  conine  by  one  of  methyl  (CHg) 
a  great  change  in  properties  was  effected.  Conine  paralyses  the  nerve 
endings  alone,  the  methyl  compound  depresses  the  spinal  cord.  It  is 
not  always  possible  to  anticipate  the  influence  Avhich  the  addition  or 
subtraction  of  one  or  more  of  these  groups  will  have  on  complex  com- 
pounds which,  like  the  alkaloids,  are  made  up  of  a  very  large  number 
of  simpler  groups.  The  result  doubtless  depends  on  the  place  which 
the  added  group  takes  amongst  the  other  groups,  or  the  effect  produced 
by  the  subtraction  on  the  arrangement  of  the  other  groups.  Though 
the  character  and  arrangement  of  the  groups  in  a  compound  do  not 
certainly  indicate  the  action,  yet  they  often  give  a  good  clue  to  it ; 
they  point  to  the  manner  in  which  the  compound  breaks  up  when 
taken  into  the  system,  and  suggest  the  new  combinations  which  may 
be  formed.  Again,  they  often  indicate  modifications  and  additions  by 
which  new  compounds  may  be  produced  for  the  fulfilment  of  needs. 
Thus,  for  example,  by  adding  the  group  NHo,  H.CO  to  the  group  C.CI3, 
COH  (chloral)  we  get  a  compound  chloralamide  (C.CI3,  CHO,  HCO, 
NHg)  which  has  the  soporific  properties  of  chloral,  but  does  not  so 
deleteriously  affect  the  cardiac  and  respiratory  system.  By  the  substi- 
tution in  sulphonal  of  a  molecule  of  ethyl  (CoH^)  for  a  molecule  of 
methyl,  trional  is  formed,  which  appears  to  have  in  some  cases  a  better 
effect  than  sulphonal.  Many  of  the  modern  remedies  are  the  outcome 
of  a  knowledge  of  the  influence  exerted  by  various  groups,  and  by  the 
manner  of  arrangement  of  such  groups  in  a  compound. 

In  the  laboratory  we  can  easily  so  modify  the  composition  of  medic- 
inal agents  as  to  transform  them  into  compounds  having  very  different 
pharmacological  effects. 

VOL.    I  Q 


226  SYSTEM   OF  MEDICINE 

If  morphia  (C17,  Hig,  NO2  (OH)  )  be  boiled  under  pressure  with  water 
acidulated  with  hydrochloric  acid,  it  loses  a  molecule  of  H,0,  and  is 
converted  into  apomorphia  (Ci7,  H17,  NO^).  If  it  be  heated  with  soda 
and  methyl  iodide,  codeia  (C17,  Hjjj,  NO^,  OCH3)  is  formed.  Pilocarpine, 
when  heated  with  dilute  hydrochloric  acid,  is  converted  into  jaborine,  a 
compound  allied  chemically  to  pilocarpine,  but  resembling  atropine  in 
its  pharmacological  effects. 

The  changes  which  can  thus  be  effected  in  a  drug  outside  the  body 
may  also  be  produced  within  the  body  ;  moreover  these  changes  may 
vary  with  the  conditions  of  the  body.  It  is  important,  therefore,  to 
determine  the  changes  which  can  occur  in  chemical  compounds  under 
varying  circumstances. 

In  drugs  derived  from  the  mineral  kingdom  the  grouping  of  the 
elements  is  simple;  the  influence  of  the  drug  often  depends  almost 
entirely  on  one  of  the  elements  present  —  as,  for  example,  in  the  com- 
pounds of  iron  and  mercury  —  and  we  can  easily  comprehend  all  the 
possible  alterations  which  such  drugs  may  undergo  in  the  system. 

In  the  case  of  organic  compounds  belonging  to  the  fatty  and  aromatic 
series,  again,  we  may  sometimes  trace  out  the  nature  of  the  decompo- 
sition which  goes  on  in  the  body,  and  estimate  the  effect  of  any  new 
compounds  which  may  be  formed ;  but  when  we  administer  very  complex 
substances,  like  the  alkaloids,  it  is  often  impossible  in  the  present  state 
of  knowledge  to  determine  what  changes,  if  any,  take  place ;  we  cannot 
know,  therefore,  the  nature  of  the  effects  which  may  be  produced. 

Still  more  difficult  is  it  to  determine  definitely  the  action  of  crude 
vegetable  drugs,  the  effects  of  which  are  due  to  the  alkaloids,  glucosides, 
oils,  etc.,  which  they  contain.  In  many  instances  more  than  one  of  these 
active  principles  are  present,  and  not  unfrequently  we  find  these  closely 
related  chemically,  being  probably  derived  one  from  another  in  the 
chemical  processes  going  on  in  the  plant. 

The  number  of  active  principles  in  a  plant  is  largely  influenced,  by 
the  circumstances  connected  with  its  growth,  such  as  temperature,  nature 
of  soil,  and  so  forth.  Stenhouse  found  that  broom  grown  in  the  sun 
contains  four  times  as  much  alkaloid  as  that  grown  in  the  shade.  Not 
only  so,  but  the  relative  amounts  of  the  various  active  principles  will 
vary  somewhat  as  the  conditions  under  which  the  plant  is  grown  are 
favourable  to  the  occurrence  of  chemical  changes,  or  the  reverse. 

From  all  these  causes  the  effects  of  crude  vegetable  drugs,  and  there- 
fore of  the  galenical  preparations  obtained  from  them,  are  apt  to  vary ; 
and  this  variation  is  at  times  increased  by  differences  in  the  method  of 
preparation.  Hence  arises,  perhaps,  the  divergence  of  opinions  so  often 
noted  with  regard  to  the  therapeutic  powers  of  certain  drugs.  The  process 
of  ''  standardisation  "  which  has  been  already  adopted  in  two  instances 
in  the  British  Pharmacopoeia,  and  is  likely  to  be  extended,  will  to  a  certain 
extent  obviate  this  source  of  error ;  for  the  standardised  preparations  will 
contain  a  uniform  amount  of  the  alkaloidal  principles  contained  in  a  plant. 
But  if  the  relative  quantities  of  these  principles  vary  under  different  con- 


PRINCIPLES    OF  DRUG    THERAPEUTICS  227 


ditions  of  growth,  the  effects  of  preparations  apparently  identical  will 
still  be  liable  to  corresponding  variation ;  this  may  occur  especially 
where  drugs  contain  substances  easily  modified,  as  in  the  case  of  atropine 
and  hyoscyamine.  Ladenberg  has  given  reasons  for  believing  that  the 
latter  is  changed  into  the  former  even  by  the  process  of  extracting  the 
alkaloid.     Examples  of  such  readiness  to  change,  however,  must  be  rare. 

ISTotwithstanding  all  these  possible  sources  of  error  the  action  of 
drugs  on  the  system  is  moderately  constant;  but  not  until  we  are  much 
better  acquainted  than  we  now  are  with  the  chemical  nature  of  drugs 
shall  we  be  able  to  explain  the  very  diverse  therapeutic  results  which 
are  recorded. 

The  Nature  of  Pharmacological  Action.  —  By  the  word  "  pharmaco- 
logical action"  is  meant  the  action  of  remedial  agents  on  tissues  and 
the  function  they  subserve  in  health  and  disease.^ 

The  ultimate  nature  of  the  influence  which  drugs  exercise  on 
organised  material  cannot  be  absolutely  determined ;  but,  as  Schmiede- 
berg  has  said,  it  must  be  chemical  —  using  the  word  chemical  in  a  broad 
sense. 

When  a  pharmacological  agent  comes  in  contact  with  a  tissue  its  ef- 
fects may  be  purely  chemical ;  it  may  act  in  virtue  of  its  acid  or  alkaline 
properties,  or  by  leading  to  decomposition  of  a  purely  chemical  nature. 
It  may  also  effect  changes  in  the  tissues  by  coagulating  the  albuminous  or 
gelatinous  materials  contained  in  them ;  but,  beyond  this,  it  may  alter 
their  functions  and  vitality,  without,  so  far  as  we  can  tell,  producing 
chemical  change  in  the  strict  sense  of  the  term.  When,  for  example,  we 
pass  through  the  muscle  of  a  frog  a  very  dilute  solution  of  barium 
chloride,  or  expose  it  to  a  similar  solution,  the  function  of  the  muscle 
is  distinctly  modified,  as  shown  by  its  increased  contraction  to  stimuli, 
and  by  the  prolonged  duration  of  the  contraction.  By  acting  on  the 
muscle  of  the  heart  or  the  vessel  walls,  their  functions  and  vitality 
may  also  be  altered ;  the  systole  of  the  heart  is  strengthened  and  pro- 
longed, and  the  vessel  walls  are  contracted.  But  if,  after  producing 
these  effects  on  voluntary  muscle,  heart  or  vessel,  we  take  means  to  wash 
the  tissues  through  with  a  nutrient  fluid  containing  no  poison,  the  mus- 
cles and  organs  will  resume  their  normal  functions.  We  can,  moreover, 
antagonise  the  effect  of  chloride  of  barium  by  means  of  a  weak  solution 
of  potash,  or  by  a  solution  containing  NO2,  combined  with  a  compara- 
tively inactive  base  (sodium).  In  the  latter  case,  however,  NO2,  though 
neutralising  the  modification  effected  by  barium  on  the  function  of  the 
muscle,  joins  with  it  in  depressing  vitality,  and  the  muscle  quickly 

1  The  word  pharmacolo{2:y  was  formerly  applied  to  the  consideration  of  medicines 
generally,  including  their  physical  characteristics  and  mode  of  preparation  ;  and  in  this 
sense  it  is  still  often  used  in  other  countries.  In  England  it  signifies  that  department  of 
therapeutics  which  concerns  the  effect  of  remedies  as  distinguished  from  their  therapeu- 
tic application.  It  is  well  that  the  term  "  pharmacology  "  should  be  taken  as  including 
the  action  of  drugs  on  morbid  as  well  as  on  healthy  tissues ;  otherwise  it  would  be 
synonymous  with  physiological  action,  and  we  should  have  no  term  applicable  to  the 
investigations  of  the  action  of  drugs  on  morbid  tissues. 


228  SYSTEM   OF  MEDICINE 

dies.  A  minute  quantity  of  calcium  chloride,  on  the  other  hand,  whilst 
affecting  the  contractility  of  muscle,  tends  to  prolong  vitality.  Now 
in  these  cases  there  is  no  evidence  that  any  chemical  change  takes 
place ;  the  influence  is  apparently  molecular  rather  than  chemical,  for  if 
positive  chemical  change  took  place  it  is  not  probable  that  the  effects 
could  be  so  easily  abolished,  either  by  the  removal  of  the  barium,  or  by 
the  addition  of  substances  between  which  and  the  barium  chloride  no 
chemical  change  takes  place.  The  exact  process  by  which  the  molecule 
of  the  drug  acts  ou  the  ultimate  elements  of  the  muscle  fibre  in  order 
to  produce  change  in  function  is  beyond  our  knowledge.  It  seems  prob- 
able that  the  influence  of  chemical  compounds  on  the  muscular,  nervous, 
and  all  other  tissues  of  the  body,  is  similar  to  that  which  occurs  in  the 
skeletal  muscles  or  heart  removed  from  the  body.  The  functions  of  the 
tissues  are  altered  by  the  influence  which  the  molecules  of  the  chemical 
compounds  exert  upon  them,  and  their  vitality  raised  or  depressed.  It 
is  in  this  way  that  strychnine  and  physostigmine  respectively  stimulate 
and  depress  the  spinal  cord,  that  curare  paralyses  the  nerve  endings,  that 
atropine  paralyses  the  vagus  endings  and  centre,  and  that  the  tissues 
engaged  in  secretion  or  excretion  are  stimulated  or  depressed.  Most  sub- 
stances at  first  increase  and  then  decrease  the  functional  activity  of 
muscle;  in  some  the  stimulating,  in  others  the  depressing  effect  is  more 
marked:  in  some  substances,  indeed,  no  primary  stimulating  effect  is 
observed.  The  same  is  the  case  with  regard  to  the  action  of  drugs  on 
the  other  tissues  within  the  body.  Remedial  agents  for  the  most  part 
first  stimulate  and  then  depress  the  functional  activity  of  the  parts  they 
influence ;  but  the  stimulation  may  be  more  marked  than  the  depressing 
effect,  or  vice  versa ;  or  it  may  be  entirely  absent. 

The  effect  in  all  cases  may  be  looked  upon  as  ''molecular,"  that  is,  it 
may  be  produced  without  ascertainable  chemical  or  structural  change. 
If  the  supply  of  the  chemical  compound  in  the  blood  cease,  it  is  sooner 
or  later  washed  out  of  the  tissue  by  the  circulating  fluid,  and  the  normal 
function  is  restored.  In  experiments  on  muscle  tissue  it  can  be  shown 
that  some  substances,  such  as  the  nitrites  which  powerfully  alter  func- 
tional activity  and  vitality,  can  be  easily  washed  out,  and  the  muscle 
thus  restored  to  its  normal  condition.  Other  substances,  such  as  barium, 
are  washed  out  with  difficulty.  It  is  probable  that  there  is  a  similar 
difference  in  the  influence  of  drugs  on  all  tissues,  and  that  this  in  part 
accounts  for  the  well-known  difference  in  the  duration  of  the  action  of 
medicines.  The  removal  of  a  drug  from  the  tissues  which  it  has  tem- 
porarily influenced,  unless  the  effect  have  been  very  strong,  is  followed 
by  a  return  to  the  normal  state  ;  but  it  seems  probable  that  under  some 
conditions  the  continued  interference  with  the  function  of  a  part  is 
followed  by  nutritional  changes  of  a  permanent  character.  It  is  from 
this  cause  probably  that  alcohol  in  time  leads  to  those  changes  in  muscle 
and  nerve  which  are  characteristic  of  its  prolonged  imbibition. 

In  order  that  drugs  taken  by  the  mouth  may  act  on  various  parts  of 
the  body,  such  as  the  spinal  cord,  brain  and  nerve  endings,  it  is  evident 


PRINCIPLES   OF  DRUG    THERAPEUTICS  229 

they  must  be  absorbed  and  carried  by  the  blood  to  these  several  parts. 
The  absorption  of  active  principles  no  one  now  questions,  though  in 
earlier  days  it  was  denied.  Cullen  held  that  medicines  act  almost 
entirely  by  the  influence  they  exert  on  the  mucous  membrane  of  the 
stomach  and  intestines ;  and  in  the  first  decades  of  the  present  century 
the  necessity  for  the  absorption  of  a  drug  antecedent  to  its  action  was 
doubted  by  many.  Drugs  carried  by  the  blood  do  not  affect  the  tissues 
equally :  one  exercises  its  influence  on  the  tissues  of  the  cord,  another 
on  those  of  the  cerebrum,  a  third  on  the  respiratory  centre,  and  so  on. 
To  explain  this  we  must  assume  that  tissues  have  a  selective  affinity, 
and  that,  as  the  blood  circulates  through  them,  each  retains  or  submits 
to  the  material  which  is  in  functional  relation  to  itself. 

Perhaps  the  most  difficult  part  of  pharmacological  action  to  determine 
is  the  influence  of  remedial  agents  on  the  blood  and  nutritional  proc- 
esses. There  can  be  no  doubt  that  some  agents  markedly  affect  the 
haemoglobin  in  the  corpuscles,  as  shown  by  the  cyanosis  they  produce ; 
others,  like  chlorate  of  potash,  are  under  certain  conditions  capable  of 
causing  dissolution  of  corpuscles,  and  there  can  be  little  doubt  that  the 
alkalinity  of  the  plasma  may  be  increased  or  decreased.  But  over  and 
above  these  effects  it  would  seem  as  if  some  substances,  such  as  alcohol  and 
arsenic,  are  capable  of  modifying  the  metabolic  changes  —  delaying  or 
accelerating  them ;  but  whether  such  results  are  due  to  a  primary  alter- 
ation in  the  blood,  or  to  a  direct  influence  of  the  alcoholic  molecule  on 
the  tissues,  is  not  known. 

Besides  influencing  the  functions  of  tissues  in  the  manner  which  has 
been  distinguished  as  molecular,  drugs  may  produce  direct  structural 
changes  in  tissues.  Apart  from  all  chemical  action,  they  may  excite 
irritation  and  inflammation  such  as  that  which  is  produced  by  mechanical 
agencies.  In  this  way  they  may  produce  important  effects  not  only  on  the 
tissues  with  which  they  come  in  contact,  but  also  on  parts  remote  from 
them.  By  the  irritation  produced  in  the  nerve  endings  in  the  tissue  a 
centre  with  which  these  nerves  are  connected  may  be  altered,  and  other 
tissues  supplied  by  this  centre  may  have  their  function  and  vitality 
increased  or  decreased.  The  vomiting  produced  by  emetics,  and  the 
nutritional  changes  which  occasionally  seem  to  follow  external  applica- 
tions, may  be  thus  explained. 

The  influence  of  pharmacological  agents  under  the  abnormal  condi- 
tions present  in  disease  is  by  no  means  always  the  same  as  in  health; 
the  difference  is,  however,  usually  quantitative  rather  than  qualitative. 
A  weak  walled  heart,  for  example,  is  much  more  easily  influenced  by 
digitalis  than  a  healthy  one.  The  functions  of  the  kidney  can  never  be 
affected  in  health  as  at  times  they  may  be  in  certain  diseases.  Anti- 
pyretics exert,  on  those  parts  upon  which  they  act,  a  different  effect  in  a 
febrile  as  compared  with  a  normal  condition.  Lastly,  mercury  and  iodide 
of  potassium  have  special  action  on  certain  forms  of  diseased  tissue 
which  we  do  not  see  in  health.  This  is  probably  due  to  the  fact  that  in 
the  diseased  conditions  they  act  upon  new  tissue  of  a  less  stable  character 


230  SYSTEM   OF  MEDICINE 


than  normal  tissue ;  or  it  may  be  that  new  compounds  are  formed  with 
the  mercury  or  iodide  which  are  easily  broken  up  and  destroyed. 

As  already  pointed  out,  the  pharmacological  action  of  a  drug  is  apt 
to  be  influenced  by  changes  which  the  chemical  processes  of  the  body 
effect  in  the  drug  itself.  Such  changes  may  occur  in  the  gastro-intestinal 
canal,  in  the  blood,  in  the  tissues,  or  at  the  moment  of  excretion.  Hence 
the  chemical  composition  of  a  drug  is  not  unfrequently  the  key  to  its 
pharmacological  action. 

Principles  on  which  Drugs  are  Selected.  —  Rational  TlierapeuUcs.  — 
Wlien  a  case  of  disease  presents  itself  for  treatment  the  first  step  is  to 
determine  whether  any  drug  be  known  which  has  cured  an  exactly 
similar  case.  This  can  only  be  done,  of  course,  when  full  knowledge  of 
the  clinical  features  and  pathology  of  the  case  has  been  obtained.  If  no 
such  drug  is  known  one  of  two  plans  is  adopted:  we  may  select  a 
remedy  on  the  ground  of  analogy,  because  it  has  done  good  in  an  instance 
so  like  the  present  one  that  it  may  reasonably  be  expected  to  be  again  of 
service.  If  experience  and  analogy  fail  recourse  must  be  had  to  such 
pharmacological  knowledge  as  we  may  possess ;  that  is,  we  may  select  a 
drug  capable,  directly  or  indirectly,  of  causing  the  return  of  one  of  the 
abnormal  tissues  and  organs  to  a  normal  state. 

Whether  a  drug  be  selected  in  the  first  place  on  analogical  or 
on  pharmacological  grounds  will  largely  depend  on  the  bent  of  the 
observer.  Some  see  analogies  quickly,  others  more  readily  resort  to 
reasoning.  The  same  treatment  may  result  from  either  attitude  of 
mind. 

The  chief  point  in  which  the  modern  method  of  selecting  a  drug 
differs  from  that  formerly  employed  is,  that  when  empirical  knowledge 
does  not  appear  available  we  employ  methods  of  reasoning  founded  more 
directly  on  the  pathology  of  the  disease  and  on  drug  action,  instead  of  on 
metaphysical  or  fanciful  theories  as  to  the  nature  of  disease  and  of 
remedies.  Nevertheless,  it  must  be  pointed  out  that  in  the  application 
of  pharmacological  knowledge  to  the  cure  of  disease  we  still  use  hypothe- 
ses ;  and  on  the  correctness  of  these  our  results  must  depend.  The  patho- 
logical changes  in  every  ailment  are  more  or  less  complex  and  wide-spread  ; 
the  immediate  influence  of  remedial  agents  is  more  limited  :  hence  when 
we  desire  to  restore  health  by  urging  the  tissues  and  organs  towards  the 
normal  state  we  have  to  make  choice  of  the  pathological  condition  which 
shall  first  be  dealt  with ;  and  this  we  do  in  accordance  with  certain  im- 
perfect inductions  to  which  experience  has  led  us.  We  assume  in  each 
case  either  (1)  that  in  diseased  conditions  there  is  naturally  a  return  to 
health,  or  (2)  that  if  the  apparent  cause  of  the  ailment  be  removed  cure 
will  follow,  or  (3)  that  by  the  restoration  of  tissues  and  organs,  which 
are  the  special  seat  of  pathological  changes,  to  their  normal  textural  and 
functional  state,  or  to  a  state  approaching  the  normal,  we  promote  cure ; 
and  further,  that  when  organs  are  caused  by  drugs  to  resume  their  nor- 
mal function,  their  improved  condition  may  continue  even  when  the 
drug  is  withdrawn. 


PRINCIPLES   OF  DRUG    THERAPEUTICS  231 

The  first  assumption  is  one  on  which  Hippocrates  and  Sydenham 
relied,  and  it  lies  at  the  root  of  much  of  our  therapeutic  reasoning.  Expe- 
rience proves  to  us  that  many  diseases  tend  to  terminate  in  recovery ;  but 
that,  nevertheless,  pathological  changes  at  times  occur  in  their  course 
which,  unless  prevented  by  suitable  remedies,  will  terminate  life.  Yet 
we  often  fail  to  save  life  by  dealing  with  sudden  causes  of  danger.  The 
removal  of  the  apparent  cause,  or  of  the  more  marked  pathological  condi- 
tions in  a  disease,  does  not  always  lead  to  a  favourable  termination.  Each 
of  these  generalisations,  however,  holds  good  in  a  large  number  of  cases ; 
and  in  selecting  a  drug  apart  from  the  teachings  of  experience  we  found 
our  judgment  on  our  pathological  and  clinical  knowledge;  we  decide 
under  which  of  these  generalisations  the  case  before  us  falls,  and  then 
with  the  aid  of  pharmacological  knowledge  we  select  a  drug  to  fulfil  one 
of  the  following  indications  —  a  drug  which  will  (a)  so  influence  some 
organ  or  organs  as  to  avert  the  tendency  to  death,  (&)  remove  the  appar- 
ent cause  of  the  ailment,  (c)  restore  as  far  as  possible  the  tissues  and 
organs,  which  are  the  special  seat  of  pathological  .changes,  to  a  normal 
state.  In  addition  to  these  indications  we  are  manifestly  called  upon 
to  (d)  relieve  pain  and  suffering. 

Our  success  will  depend  on  the  correctness  of  our  judgment  as  to 
whether  the  case  really  comes  under  the  generalisation  we  employ,  and 
on  the  correctness  of  our  pharmacological  knowledge. 

It  is  apparent  that  in  one  sense  indication  c  includes  a  and  6,  In 
averting  death  or  removing  the  apparent  cause,  however,  we  do  not 
necessarily  deal  with  the  special  seat  of  pathological  change.  We  always 
meet  indication  a  at  once,  and  then  indication  h  if  we  can. 

Experience  and  Analogy.  —  The  cases  in  which  experience  founded 
on  simple  observation  can  be  trusted  in  the  selection  of  a  drug  are  few. 
The  same  collocation  of  symptoms  and  conditions  are  rarely  repeated; 
yet,  unless  they  are,  when  we  select  a  drug  on  the  ground  that  it  has 
before  done  good,  we  act  on  analogy  rather  than  on  actual  experience. 
In  times  past  the  judgments  formed  on  the  ground  of  experience  of  the 
action  of  medicines  were  very  fallacious  ;  to  this  the  enormous  number 
of  medicines  then  used  and  now  discarded  are  witnesses.  Yet  the  dis- 
covery of  mercury,  quinine,  arsenic,  and  many  other  remedies,  is  an 
evidence  of  the  value  of  simple  observation.  Want  of  knowledge  of  the 
natural  history  of  disease,  of  pathology  and  of  pharmacology,  is  the  cause 
of  the  errors  which  are  made  when  experience  is  trusted  alone. 

Belief  in  a  drug  of  no  value  is  easily  engendered  if  the  natural  course 
of  disease  be  unknown;  defect  of  pathological  knowledge  and  observa- 
tion leads  rather  to  the  misapplication  of  useful  remedies.  Quinine 
rarely  fails  in  ague ;  but  in  a  counterfeit  of  ague,  say  in  the  fever  caused 
by  suppuration  in  the  liver  due  to  gall  stones,  it  is  useless. 

Pharmacological  knowledge  corrects  many  of  the  errors  to  which 
simple  experience  is  apt  to  lead ;  the  want  of  it  permits  their  continu- 
ance. If  a  drug  have  no  active  properties  it  is  surely  devoid  of  medicinal 
effect  unless  it  be  a  food ;  for  medicinal  action  is  the  outcome  of  the 


232  SYSTEM   OF  MEDICINE 

effects  of  active  principles  on  tissues.  It  is  always  possible  that  in  any- 
particular  drug  the  active  medicinal  agent  may  have  escaped  notice ;  but 
in  the  present  state  of  chemical  science  it  is  not  likely  that  undiscovered 
principles  reside  in  such  substances  as  sarsaparilla  and  hemidesmus :  yet 
these  drugs  are  given  on  the  testimony  of  experience,  —  a  testimony  no 
stronger  than  that  which  has  supported  scores  of  other  agents  eventually 
discarded.  If  the  indications  given  by  the  pharmacological  examination 
of  a  drug  are  opposed  to  experience  in  its  favour,  the  latter  must  almost 
certainly  be  at  fault. 

Experience  and  analogy,  then,  should  only  be  trusted  within  narrow 
limits  ;  but  when  we  can  combine  the  indications  of  experience  with  those 
of  pharmacology  we  strengthen  both.  The  influence,  for  example,  of 
antimony  in  eczema,  especially  when  combined  with  magnesium  sulphate, 
has  often  been  vouched  for  on  the  ground  of  experience ;  but  not  more 
strongly  than  has  been  the  case  with  scores  of  useless  agents.  It  can  be 
shown,  however,  that  antimony  does,  in  the  frog,  influence  the  epithelium 
very  markedly,  as  does  arsenic ;  and  this,  without  proving  its  remedial 
value,  distinctly  adds  to  the  probability  that  those  observers  are  right 
who  hold  antimony  to  be  useful  in  some  forms  of  eczema. 

The  value  of  the  antitoxins  and  of  thyroid  extract  is  vouched  for  by 
many  careful  observers.  Pharmacological  knowledge  is  certainly  not 
opposed  to  the  probability  of  their  usefulness ;  it  rather  supports  it.  On 
the  other  hand,  it  has  so  far  given  no  support  to  a  number  of  new  animal 
substances  brought  forward  recently,  many  of  them  on  analogical  grounds 
founded  on  some  error  in  observation.  To  the  use  of  analogy  in  drug 
therapeutics  we  owe  great  advances,  especially  in  early  times  —  it  has 
been  a  great  inciter  to  experiment,  and  is  so  still.  Guided  by  due  knowl- 
edge of  the  course  of  disease  and  of  pathology  it  leads  to  increased  knowl- 
edge ;  but  as  used  in  times  past  it  has  burdened  our  Materia  Medica 
with  much  rubbish,  as  recoveries  following  the  use  of  substances  suggested 
by  analogy  have  been  looked  upon  as  cures.  It  was  by  false  analogy 
that  mercury  came  so  much  into  use  in  inflammations.  When  mercury 
was  found  to  influence  so  markedly  the  swellings  and  thickening  occur- 
ring in  syphilis,  it  was  used  by  analogy  in  all  the  forms  of  inflammatory 
disease  which  cause  swellings  and  thickenings.  As  many  of  these  nat- 
urally siibsided  thereafter,  mercury  was  thus  credited  with  a  curative 
power  in  inflammation.  It  Avould  be  going  too  far  to  say  mercury  has 
no  influence  in  inflammatory  chaiiges.  There  are  probably  conditions  in 
which  it  is  of  service,  but  the  facts  that  it  is  now  so  little  used,  and  that 
no  apparent  evil  has  followed  its  abandonment,  indicate  that  the  views 
formerly  held,  and  apparently  grounded  on  experience,  were,  to  a  large 
extent,  erroneous;  and  that  the  employment  of  analogy  may,  in  this 
instance,  have  been  productive  of  evil. 

(a)  Method  of  averting  the  Tendency  to  Death.  —  We  find  not  unfre- 
quently  in  the  progress  of  acute  diseases,  and  sometimes  under  other 
circumstances,  that  death  seems  to  be  impending  by  the  failure  in  func- 
tion of  one  organ  when  the  condition  of  the  others  is  compatible  with 


PRINCIPLES   OF  DRUG    THERAPEUTICS  233 

continued  life ;  and  this  even  when  in  the  organ  affected  there  is  no 
evidence  of  fatal  structural  change. 

The  cardiac  and  respiratory  systems  are  most  commonly  those  in 
which  such  failure  takes  place.  Suddenly  or  gradually,  during  the 
course  of  many  diseases,  the  condition  of  the  pulse  points  to  failing  heart 
action  which  threatens  life ;  or  again  the  blood  changes  essential  to  the 
continuance  of  life  are  imperilled  by  failing  powers  of  the  respiratory 
centre,  or  by  paroxysmal  obstruction  to  the  entrance  of  air  into  the  lung. 
These  things  may  happen  even  though  the  heart  and  lungs  are  not  the 
seat  of  any  considerable  pathological  changes. 

In  case  of  heart  failure  we  may  fulfil  the  indication  of  averting  the 
tendency  to  death  by  giving  drugs  which  (a)  strengthen  the  power  of 
the  heart  or  (^)  decrease  the  work  it  has  to  do. 

(a)  In  selecting  drugs  to  strengthen  the  heart  the  whole  of  their 
pharmacological  properties  must  be  borne  in  mind.  Digitalis  is  one  of 
the  most  effective  agents  we  have  for  increasing  the  power  of  the  heart's 
action,  but  it  contracts  the  vessels  and  is  long  in  acting.  By  contracting 
the  vessels  it  is  capable  of  doing  harm  in  certain  cases  of  heart  failure, 
especially  in  goaty  people  with  tendency  to  high  arterial  pressure;  because 
of  the  slowness  of  its  action  (especially  when  taken  by  the  mouth)  it  is 
often  given  in  vain  in  cases  where  the  heart's  failure  is  urgent.  On  the 
other  hand,  where  the  heart's  failure  is  gradual  and  the  arterial  pressure 
low,  digitalis  is  called  for.  Strophanthus  does  not  contract  the  vessels, 
and  seems  to  act  more  quickly ;  whether  it  acts  as  powerfully  as  digitalis 
is  a  point  on  which  we  are  not  agreed.  Strychnine,  as  a  heart  stimulant, 
acts  more  rapidly  than  digitalis  ;  when  given  subcutaneously  its  effects 
can  often  be  noted  in  a  few  minutes;  and,  though  perhaps  thej^  do  not 
last  so  long  as  those  of  digitalis  or  strophanthus,  they  are  more  perm.a- 
nent  than  those  of  the  volatile  cardiac  stimulants.  Strychnine,  moreover, 
has  the  advantage  of  being  a  respiratory  as  well  as  a  cardiac  stimulant : 
ammonia  shares  this  advantage  with  strychnine,  but  it  is  more  evanes- 
cent in  its  influence  on  the  heart,  although  perhaps  more  immediate  in 
its  effects.  The  injection  of  ether  subcutaneously  is  the  most  powerful 
means  we  have  of  immediately  stimulating  a  failing  heart,  but  its  action  is 
probably  even  more  transitory  than  that  of' ammonia;  though,  owing  to 
the  fact  that  it  can  be  injected  subcutaneously,  it  is  more  frequently  em- 
ployed in  urgent  depression  of  the  heart's  power.  The  cardiac  stimula- 
tion produced  by  smelling  ammonia  is  of.  course  of  a  reflex  nature. 
Although  ammonia  has  undoubtedly  a  stimulating  effect  on  the  heart, 
increasing  both  its  force  and  frequency,  it  is  not  always  easy  to  determine 
its  utility  in  this  direction.  It  is  possible  the  condition  of  the  stomach 
at  the  moment  influences  its  cardiac  effects  to  some  extent.  So  far  as  it 
is  converted  into  chloride  it  can  have  little  action  on  the  heart,  although 
the  chloride  may  stimulate  the  respiratory  centre. 

(/?)  Of  drugs  which  act  by  dilating  the  vessels,' and  thus  relieving  the 
heart  in  its  work,  there  is  one — amyl-nitrite  —  which  dilates  the  vessels  in 
about  ten  seconds,  and  is  therefore  applicable  in  the  most  urgent  cases. 


234  SYSTEM  OF  MEDICINE 

As  its  influence  on  tlie  circulation,  however,  ceases  in  two  or  tliree  min- 
utes, this  drug,  though  of  great  value  in  immediate  exigencies,  must  not 
be  relied  on  for  continuous  action. 

Nitrite  of  sodium  and  nitro-glycerine  exert  a  distinct  influence  in  from 
two  to  four  minutes,  but  their  effects  continue  for  two  or  three  hours ; 
they  are  therefore  serviceable  in  cases  where  we  want  to  relieve  the 
heart's  action  for  a  considerable  period,  though  useless  where  instant 
effect  is  required. 

Vessel  dilators  are  of  special  use  in  warding  off  evil  where  cardiac 
failure  is  not  accompanied  by  vascular  dilatation.  In  certain  forms  of 
cardiac  degeneration  it  would  appear  as  if  periodic  waves  of  increasing 
arterial  contraction  become  a  grave  source  of  danger,  and  these  may  be 
well  met  by  the  quickly  or  by  the  more  slowly  acting  vessel  dilators 
according  to  circumstances. 

It  is  possible  in  some  cases  to  combine  a  cardiac  stimulant  with  a 
vessel  dilator ;  indeed  the  vessel  dilators  may  have  at  first  a  slight 
stimulating  effect  on  the  heart,  even  if,  in  large  doses,  they  eventually 
depress  it,  which,  however,  is  not  definitely  proved.  The  combination 
of  a  nitrite  with  ether  is  thus  often  distinctly  advantageous  in  the  relief 
of  cardiac  failure. 

Any  lethal  tendencies  of  drugs  used  in  cases  where  life  is  in  the 
balance  must  always  be  borne  in  mind.  It  can  be  shown  by  experiments 
on  animals  that  a  slight  excess  of  digitalis  over  the  amount  required  to 
stimulate  the  heart  may  cause  an  immediate  and  permanent  cessation  of 
the  beat;  and  there  is  reason  to  believe  that  in  some  forms  of  cardiac 
degeneration  digitalis  is  capable  of  stopping  the  heart's  action  suddenly. 
On  the  other  hand,  in  certain  other  ailments,  such  as  pneumonia  and 
delirium  tremens,  it  would  appear  that  the  heart  can  bear  large  quantities 
of  digitalis  without  injury.  Unlike  digitalis,  strychnine  seems  to  have  no 
lethal  effect  on  the  heart  even  when  given  in  large  medicinal  doses ;  and 
we  rarely  see  indications  of  the  physiological  effects  of  strychnine  on  the 
nervous  system  following  their  use.  The  powerful  effects  of  the  nitrites 
on  the  circulation  make  us  cautious  in  the  use  of  these  agents,  the  more  so 
since,  as  before  said,  they  are  capable  of  depressing  the  contractile  power 
of  the  heart :  it  is  worthy  of  note,  however,  that,  considering  the  extent 
to  which  they  have  been  used,  grave  evil  has  very  rarely  been  attributed 
to  them ;  this  may  be  due  to  the  fact  that  the  molecular  influence  they 
exert  on  tissue  is  not  so  permanent  as  in  the  case  of  many  other  drugs : 
It  has  been  shown  that  they  can  readily  be  washed  out  of  muscle  tissue, 
which  then  resumes  its  normal  function. 

In  cases  Avhere  life  is  immediately  threatened  by  defective  blood 
changes  due  to  failure  of  the  respiratory  centre,  or  to  paroxysmal  obstruc- 
tion to  the  entrance  of  air  into  the  lung,  we  may  in  the  first  place 
administer  substances  which  have  a  directly  stimulant  action  on  the 
respiratory  centre ;  of  these  perhaps  the  most  useful  are  ammonia  and 
strychnine. 

Belladonna  has  also  a  powerful  effect  on  the  centre;  it  has  an  influence, 


PRINCIPLES   OF  DRUG    THERAPEUTICS  235 

too,  in  relaxing  undue  contraction  of  the  muscles  of  the  bronchial  tubes 
if  it  occur.  In  using  it,  however,  we  must  bear  in  mind  its  wide  influ- 
ence over  many  other  systems  of  the  body. 

In  paroxysmal  obstruction  to  the  entrance  of  air  into  the  lung  the 
nitrite  will  often  be  found  of  value ;  one  or  two  drops  of  liquor  trinitrini, 
or  a  drachm  of  a  3  per  cent  solution  of  nitrite  of  ethyl,  or  two  grains  of 
sodium  nitrite,  will  very  often  remove  perilous  dyspnoea  by  relieving  the 
spasm  which  interferes  with  the  entrance  of  air  into  the  bronchi. 

Even  when  we  cannot  remove  the  causes  which  lead  to  defective 
aeration  of  the  blood,  we  may  sometimes  temporarily  neutralise  their  ill 
effects  by  the  inhalation  of  oxygen.  It  is  quite  true  that  in  most  cases 
where  oxygen  is  used  no  permanent  good  is  effected;  but  it  is  very 
commonly  employed  where  the  causes  which  lead  to  defective  aeration 
are  continuous  :  as  a  means  of  removing  temporary  cyanotic  conditions 
oxygen  is  distinctly  useful. 

The  reduction  of  hyperpyrexia  occurring  in  the  course  of  acute  dis- 
eases is  another  instance  of  the  use  of  drugs  in  warding  off  a  tendency 
to  death ;  but  here  drugs  are  probably  of  less  value  than  other  means. 
If  drugs  are  employed  quinine  is  by  far  the  best  remedy  for  this  purpose, 
but  less  than  10  grains  is  generally  useless.  The  employment  of  anti- 
pyrine,  antifebrin,  or  phenacetin  is  very  questionable  practice. 

(&)  Removal  of  the  apparent  Cause  of  the  Ailment.  —  In  the  removal 
of  remote  causes  of  disease  drug  treatment  takes  but  little  part.  A 
foreign  body  in  the  stomach  or  intestines  may  be  the  cause  of  the 
pathological  conditions  leading  to  colic,  vomiting  or  diarrhoea;  and 
we  employ  pharmacological  knowledge  in  the  selection  of  emetics  or 
purgatives  for  their  removal. 

Micro-organisms,  too,  may  be  looked  upon  as  the  cause  of  a  large 
number  of  ailments.  Proof  is  yet  wanting  that  we  can  destroy  micro- 
organisms in  the  blood  and  tissues  by  so-called  germicidal  substances 
such  as  perchloride  of  mercury,  the  sulphites,  carbolic  acid,  etc. ;  even 
on  external  surfaces  and  on  mucous  membranes,  as  in  ringworm  and 
diphtheria,  these  substances  often  fail  to  destroy  them,  though  they  are 
capable  of  chec"king  their  growth. 

Most  of  the  other  conditions  usually  called  "  causes  "  of  ailments  are 
really  abnormal  conditions  of  tissues  and  organs  giving  rise  to  groups  of 
symptoms.  In  the  series  of  antecedents  which  constitute  collectively  the 
true  cause  of  an  ailment,  we  often  stop  in  an  arbitrary  manner  at  one  of 
them  and  call  it  the  cause  of  the  collocation  of  phenomena  by  which  the 
disease  is  signified.  Practically  by  the  word  cause  is  usually  meant  the 
most  remote  of  the  antecedents  which  it  is  in  our  power  to  influence  by 
drugs ;  it  is  by  no  means  always  the  most  manifest. 

In  considering  whether  it  be  possible  to  remove  an  apparent  cause  we 
have  first  to  decide  whether  it  is  really  in  action,  next  whether  it  goes  far 
enough  back  in  the  chain  of  antecedents,  and,  lastly,  how  far  drugs  can 
influence  it.  A  gumma  may  have  been  the  direct  cause  of  a  hemiplegia ; 
we  may  remove  the  cell  deposit  by  mercury  or  iodide,  but  yet  no  im- 


236  SYSTEM   OF  MEDICINE 

provement  may  take  place,  for  further  structural  changes  have  occurred. 
The  gumma  may  not  still  be  the  cause  of  the  loss  of  power,  although  at 
first  it  was.  Again,  cerebral  symptoms  may  be  due  to  changes  in  the 
vessel  walls  and  high  arterial  tension  —  the  latter  being  the  outcome  of 
the  products  of  imperfect  metabolism,  which  in  their  turn  may  have 
originated  in  imperfect  digestion.  To  treat  the  high  tension  will  not 
suffice ;  it  does  not  go  far  enough  back  in  the  order  of  events  :  we  must 
treat  the  imperfect  metabolism  or  the  indigestion.  Lastly,  the  limit  of 
the  action  of  drugs  comes  to  be  considered  :  in  the  case  of  gout,  syphilis, 
and  a  few  other  ailments,  we  can  definitely  affect  structural  change  by 
drugs ;  in  most  cases,  however,  our  power  to  remove  a  cause  by  drugs 
ceases  as  soon  as  it  consists  of  definite  statical  tissue  change. 

The  indication  to  remove  the  cause  might  of  course  be  included  in  the 
next  one  relating  to  the  removal  or  diminution  of  the  special  pathologi- 
cal changes  present  ;  yet  practically  in  selecting  a  drug  we  have  always 
first  in  our  mind  this  question  of  cause,  and  it  often  leads  to  the  selec- 
tion of  an  apparently  subordinate  lesion  for  treatment.  In  nothing  is 
the  judgment  more  exercised  than  in  determining  whether  we  shall  deal 
with  the  remoter  or  with  the  more  immediate  or  evident  causes  of  the 
case  before  us.  After  all,  however,  the  removal  of  a  remote  cause,  like 
the  removal  of  the  immediate  factors  threatening  death,  is  only  an 
instance  of  the  general  statement  that  when  empirical  treatment  fails 
or  is  not  possible,  we  try  to  cure  by  restoring  individual  organs  as  far 
as  possible  to  a  normal  condition. 

(c)  Restoration  of  Tissues  and  Organs  ivhich  are  the  Seat  of  Special 
Pathological  Changes.  —  The  influence  of  drugs  in  restoring  organs  to 
their  normal  state  depends,  of  course,  on  the  tissue  changes  they  are  ca- 
pable of  effecting  —  using  the  word  tissue  changes  in  its  widest  sense  to 
indicate  changes  which  we  cannot  physically  determine,  as  well  as  those 
we  can.  This  tissue  change,  again,  is  the  outcome  of  the  action  of  ele- 
ments or  groups  of  elements  in  a  drug  on  one  or  more  areas  of  the  body. 

The  general  methods  adopted  when  the  blood  is  in  an  abnormal  state 
may  be  mentioned  first.  In  some  cases  we  have  evidence  that  the  normal 
constituents  of  this  fluid  are  defective ;  in  others  we  have  reason  to 
believe  that  substances  not  ordinarily  contained  in  it  are  present ;  or  that 
some  of  the  normal  constituents  may  be  present  in  excess.  In  the  first 
place  we  may  attempt  directly  to  make  up  the  deficiency.  We  do  this 
when  we  give  iron  in  ansemia  ;  for  recent  evidence  does  not  tend  to  sup- 
port the  views  of  Schmiedeberg,  and  some  other  observers,  who  have 
asserted  that  in  the  use  of  iron  nothing  is  added  to  the  blood,  and  that 
its  effects  are  due  to  changes  brought  about  by  it  in  the  intestines. 
Another  example  of  adding  a  constituent  wanting  in  the  blood  is  seen  in 
the  administration  of  the  thyroid  gland ;  and  bone  marrow  acts  like  iron, 
if  indeed  it  have  any  effect  at  all.  To  remove  abnormal  substances 
present  in  the  blood  various  means  are  adopted.  If  we  have  reason 
to  suppose  that  the  products  of  imperfect  metabolism  are  present 
we  may  attempt  to  promote  their  excretion  by  the  kidneys  or  bowels. 


PRINCIPLES   OF  DRUG    THERAPEUTICS  237 


It  is  possible,  though  by  no  means  proved,  that  such  products  are 
excreted  by  the  bowels;  it  seems  likely  that  saline  diuretics  may 
also' help  to  remove  them.  Another,  and  often  a  more  effective  plan 
is  to  prevent  absorption  of  the  contents  of  the  intestine  in  the  upper 
part  of  the  intestinal  canal  by  means  of  saline  purgatives,  such  as  sul- 
phate of  soda  and  sulphate  of  magnesia;  a  third  is  to  give  drugs  which 
are  supposed  to  facilitate  the  barning  up  of  the  intermediate  products 
of  metabolism.  Alkalies,  for  example,  are  sometimes  used  for  this 
purpose. 

There  seems  reason  to  think  it  possible  in  certain  cases  directly  to 
antagonise  and  destroy  the  effects  of  some  toxic  matters  which  cause 
disease.  This  at  least  seems  the  way  in  which  the  newly-discovered 
antitoxins  act.  It  is  supposed,  for  example,  that  the  diphtheria  and 
tetanus  antitoxins  act  directly  on  the  toxins,  annulling  their  noxious 
influence.  May  it  not  be,  too,  that  quinine,  and  likewise  mercury,  re- 
spectively antagonise  the  poison  of  the  plasmodium  in  ague  and  the 
unknown  toxic  agent  which  exists  in  the  blood  in  syphilis  ? 

The  chief  effects  of  disease  on  other  tissues  and  their  functions 
which  may  be  influenced  by  drugs  are  connected  with  —  (a)  Inflammation 
and  its  results.  (/S)  Other  morbid  processes  which  lead  to  cell  growths, 
(y)  Increased  or  defective  fvmction  with  or  without  ascertained  physical 
changes. 

Though  inflammation  may  be,  on  the  whole,  a  protective  process — the 
reaction  against  some  injurious  material  as  Metschnikoff  thinks  —  yet, 
as  he  also  points  out,  its  local  effect  on  tissues  essential  to  life  may  be 
destructive  \yide  art.  Inflammation] ;  drugs  are  therefore  used  to  mitigate 
or  limit  it.  External  inflammations  may  be  dealt  with  by  local  stimulants 
or  local  sedatives.  In  conjunctivitis,  for  example,  very  dilute  solutions  of 
zinc  sulphate  are  applied  to  the  inflamed  surface,  and  manifestly  tend  to 
subdue  the  process.  They  are  supposed  to  act  by  contracting  the  dilated 
vessels.  It  would  seem  at  times  as  if  substances,  such  as  atropine  and 
morphine  which  depress  the  functions  of  the  sensitive  nerve  endings  in 
tissues,  have  a  beneficial  effect  in  relieving  external  inflammation.  In- 
flammatory processes  in  the  gastro-intestinal  canal  may  be  afl'ected  in  a 
similar  manner.  It  seems  probable  that  minute  doses  of  irritants,  such 
as  ipecacuanha  and  iodine,  may  sometimes  act  in  the  stomach  and  intes- 
tines as  very  dilute  solutions  of  sulphate  of  zinc  act  on  an  inflamed  con- 
junctiva. 

Furthermore,  in  the  stomach  and  intestine  we  may  affect  inflam- 
matory tissue  favourably  by  altering  its  surroundings,  by  removing 
irritating  material  from  the  surface  of  the  inflamed  membrane,  and  per- 
haps by  supplying  an  unirritating  covering  in  the  shape  of  bismuth. 
This  supposition,  however,  to  account  for  the  good  effects  which  bismuth 
undoubtedly  produces  in  irritated  conditions  of  the  stomach  and  intestine 
is  very  doubtful.  It  is  at  least  as  probable  that  an  extremely  small 
amount  of  the  bismuth,  in  contact  with  the  mucous  membrane,  becomes 
decomposed,  so  that  some  soluble  bismuth  is  formed,  which,  being  at  issue 


2^8  SYSTEM   OF  MEDICINE 


irritant,  acts  as  tlie  zinc  sulphate  does  on  the  conjunctiva.  All  inflam- 
mation of  parts  which  can  be  reached  directly  by  local  applications  are 
amenable  to  similar  treatment.  We  can  act,  for  example,  on  the  inflamed 
mucous  membrane  of  the  bladder  by  sedatives,  or  by  slightly  stimulating 
and  germicidal  substances  which  are  taken  into  the  mouth,  carried  by 
the  blood  to  the  kidney,  and  there  excreted,  as,  for  example,  buchu  and 
copaiba.  It  is  quite  possible,  too,  we  may  be  able  to  influence  the  lining 
membrane  of  the  tubes  of  an  inflamed  kidney,  but  definite  proof  that  we 
can  do  so  with  advantage  has  not  yet  been  given.  It  must  be  borne  in 
mind  that  the  whole  surface  of  the  gastro-intestinal  mucous  membrane, 
from  the  fauces  downwards,  acts  to  some  extent  as  an  excreting  surface ; 
so  that  we  may  influence  inflammatory  processes  therein  by  the  excretion 
of  substances  previously  absorbed.  There  is  some  reason  to  believe,  for 
example,  that  the  advantages  of  chlorate  of  potash  in  inflammation  of 
the  fauces  are  connected  with  its  excretion  by  the  mucous  membrane, 
and  are  not  entirely  due  to  its  local  influence  at  the  time  it  is  swallowed: 

What  power  have  we  of  effecting  inflammation  of  organs  which  cannot 
be  reached  directly,  or  through  the  processes  of  excretion  ?  It  was  for- 
merly held  that  in  antimony,  aconite,  and  calomel,  we  have  substances 
which  directly  limit  the  inflammatory  processes  in  tissues ;  but  no  proof 
of  this  has  ever  been  brought  forward,  and  belief  in  it  is  waning.  It  is 
probable  that  we  have  some  power  to  act  indirectly  on  inflammatory  proc- 
esses in  the  internal  organs.  We  can  increase  secretion  in  the  neigh- 
bourhood of  an  inflamed  part,  and  we  can  alter  the  general  tension  of  the 
vascular  system.  We  can  also  modify  the  local  vascular  condition  to 
a  slight  extent  by  dilating  vessels  in  pai'ts  adjacent  by  means  of  phar- 
macological agents.  In  two  other  ways,  also,  it  is  possible  by  drugs 
indirectly  to  influence  inflammatory  processes  in  parts  subjacent  to 
cutaneous  surfaces.  There  is  evidence  that  cutaneous  irritation  has 
a  distinct  effect  on  the  vascular  supply  and  the  nutrition  in  adjacent 
parts,  and  clinically  it  appears  in  some  cases  to  limit  inflammation.  The 
other  method  is  to  give  drugs  which  exercise  a  sedative  influence  on 
the  mechanical  conditions  affecting  the  part  inflamed.  It  is  thus  that 
opium  is  used  in  peritonitis. 

The  products  of  ordinary  inflammation  which  interfere  with  the 
functions  of  tissues  may  possibly,  when  consisting  of  cell  growths,  be 
broken  up  and  absorbed  under  the  influence  of  mercury  and  iodide 
of  potassium,  as  the  products  of  syphilitic  inflammation  certainly  are. 
We  have  as  yet  no  strong  proof  of  this,  though  analogy  has  led  to  an 
extensive  use  of  both  substances  for  the  removal  of  the  various  forms 
of  inflammation  ;  and  the  disappearance  of  deposit  has  so  frequently 
followed  the  use  of  these  drugs  that  we  can  hardly  doubt  that  some  use- 
ful effect  is  produced.  There  is  reason  to  believe  also  that  we  can  cause 
the  absorption  of  inflammatory  deposits  by  stimulating  the  nerve  endings 
in  adjacent  areas.  As  a  rule,  for  this  purpose,  preparations  containing 
mercury  or  iodine  are  employed,  often  with  friction.  It  is  a  moot  point 
whether  the  dissipation  of  inflammatory  deposits  which  certainly  appears 


PRINCIPLES   OF  DRUG    THERAPEUTICS  239 

to  take  place  under  these  applications  is  due  directly  to  the  absorption 
of  these  substances,  or  indirectly  to  their  stimulating  action  on  the  cuta- 
neous surface.  Though  mercury  will  pass  through  the  skin,  we  have  no 
proof  that  either  iodide  of  potassium  or  iodide  of  lead  do  so :  neverthe- 
less they  are  manifestly  of  service  at  times.  On  the  other  hand,  the 
irritation  they  cause  is  so  slight  that  we  can  hardly  attribute  to  this 
agency  the  absorptive  influence  these  applications  seem  to  possess. 

Concerning  the  removal  of  other  cell  growths  which  interfere  with 
the  functions  of  tissues  we  have  but  little  information.  In  all  ailments 
which  have  any  resemblance  to  the  granulation  tissues  of  syphilitic 
deposits  we  use  mercury  and  iodine,  and  not  unf requently  we  see  absorp- 
tion take  place  ;  but  we  do  not  at  present  know  the  natural  history  of 
such  ailments  sufficiently  well  to  feel  assured  that  the  disappearance  is 
due  to  the  drug.  Arsenic  can  be  shown  to  have  a  very  decided  effect 
on  the  nutrition  of  the  skin,  and  it  sometimes  distinctly  influences  inflam- 
matory deposits  therein.  It  is  supposed  also  to  exert  some  influence  on 
sarcomatous  and  cancerous  tissues,  but  here  again  more  exact  observa- 
tion is  required. 

Drugs  such  as  chloral,  belladonna,  physostigma,  and  nux  vomica, 
act  on  the  tissues  of  certain  parts  of  the  brain  and  spinal  cord,  and 
thereby  increase  or  decrease  the  functions  of  those  parts.  We  can 
depress  the  functions  of  the  motor  nerve  endings  with  conine,  and  the 
sensory  nerve  endings  with  aconite.  We  can  paralyse  the  involuntary 
muscle  fibres  directly  with  the  nitrites,  or. indirectly  by  chloral  hydrate, 
which  depresses  the  functions  of  the  vaso-motor  centre.  We  can 
stimulate  or  depress  the  functions  of  the  cardiac  muscle.  The  tissues 
of  the  various  glands  may  likewise  be  stimulated  or  depressed.  We  can 
improve  the  nutrition,  and  therefore  the  function  of  almost  all  the  tissues, 
by  iron,  cod  liver  oil  and  lime  ;  and  indirectly  we  can  produce  the  same 
effect  by  the  gastric  tonics  and  digestives  which  promote  the  taking  and 
absorption  of  food. 

Our  knowledge  of  the  method  in  which  drugs  influence  tissues  in 
health  and  disease  is  largely,  of  course,  the  outcome  of  observations  made 
on  the  effects  of  drugs  on  the  functions  which  they  -modify ;  we  must 
discriminate,  however,  between  the  action  of  drugs  on  an  organ  as  a 
whole,  and  the  changes  in  function  which  arise  from  drug  influence 
on  one  of  its  tissues  or  on  one  of  its  parts.  In  restoring  the  function 
of  an  organ  we  have  then  to  consider  the  influence  of  the  drug 
on  the  various  tissues  and  parts  of  which  it  is  composed.  In  dealing 
with  the  cerebral  functions,  for  example,  the  effect  of  the  remedy 
on  vessels  as  well  as  on  cerebral  tissues  has  to  be  remembered;  and 
in  the  restoration  of  the  cardiac  functions  the  effect  of  agents  on 
various  portions  of  the  nervous  system  as  well  as  on  the  muscle  should 
be  V)orne  in  mind.  The  influence,  too,  of  changes  in  one  organ  on  the 
functions  of  another  are  very  considerable,  and  it  is  often  by  acting  on  a 
healthy  organ  by  stimulating  or  depressing  its  functions  that  we  are  able 
to  restore  another  from  a  pathological  to  the  normal  condition. 


240  SYSTEM  OF  MEDICINE 

In  a  case  of  cerebral  hgemorrliage,  for  example,  iu  which  the  brain  is 
the  main  seat  of  pathological  change,  we  knoAV  of  no  drugs  which  by 
directly  influencing  its  tissues  will  bring  about  its  return  to  a  normal 
state.  We  are  able,  however,  to  act  upon  it  indirectly  by  purgatives 
which  tend  to  lower  blood  pressure,  and  after  a  while  by  giving  drugs 
which  improve  the  general  nutrition.  In  valvular  affections  of  the  heart 
we  cannot  remove  the  chief  pathological  condition,  but  by  acting  on  the 
cardiac  muscle  and  its  ganglia  Ave  can  so  strengthen  and  moderate  the 
beat  as  practically  to  restore  its  normal  function. 

In  phthisis  we  have  hardly  any  power  to  influence  lung  tissue  directly : 
but,  by  substances  such  as  cod  liver  oil  and  lime  which  improve  the  gen- 
eral nutrition  of  the  body,  we  can  indirectly,  perhaps  indeed  to  some  ex- 
tent directly,  help  to  restore  the  lung  tissue  and  function.  In  bronchitis 
we  can  act  directly  on  the  tissue  of  the  mucous  membrane,  and  pro- 
mote its  normal  secretions;  but  in  pneumonia  we  probably  cannot 
influence  the  affected  tissues  directly,  although  we  employ  salines 
with  a  vague  idea  that  we  may  do  so.  Here  we  are  limited  in  our 
action  to  sustaining  the  functions  of  other  parts,  in  which  the  patho- 
logical change  is  much  less  marked,  until  such  time  as  resolution  may 
take  place.  It  is  possible,  indeed,  that  expectorants  sometimes  influence 
the  lung  changes  favourably  by  promoting  secretion  from  the  bronchial 
mucous  membrane  adjacent  to  the  inflamed  tissue  ;  but  it  is  unlikely 
that  they  act  on  this  tissue  itself.  In  pleurisy  we  are  quite  as  helpless 
so  far  as  direct  drug  treatment  is  concerned ;  we  know  no  drug  which  has 
any  direct  effect  in  reducing  pleural  inflammation,  and  we  are  limited  for 
the  most  part  to  the  exhibition  of  agents  for  the  relief  of  pain.  Yet  even 
here,  when  the  acute  stage  has  passed,  we  may  promote  the  restoration 
of  the  pleura  to  a  normal  state  by  iron  and  nutrients. 

Though  we  have  no  more  power  over  peritoneal  inflammation  than 
we  have  over  that  occurring  in  the  lungs  or  pleura  we  are  able  in  peri- 
tonitis to  give  some  aid  by  limiting  the  movements  of  the  inflamed  part. 
Opium  probably  influences  the  nerves  supplying  the  intestinal  muscles, 
and  thus  decreases  peristaltic  action.  It  also  fulfils  the  next  indication, 
the  relief  of  pain.  ■  Here  again,  as  in  many  other  instances,  in  the  efforts 
we  make  to  restore  parts  pathologically  affected  we  act  on  other  and  more 
or  less  normal  structures.  We  have  no  reason  to  believe  that  the  chief 
effect  of  opium,  either  in  relieving  pain  or  in  checking  peristalsis,  is  due 
to  any  large  extent  to  its  action  on  the  nerve  endings  in  the  affected  part. 

In  a  few  cases  we  attempt  to  restore  the  normal  functions  of  an  organ 
by  the  addition  of  certain  materials  which  are  lacking  in  its  secretion. 
Thus,  for  example,  in  dyspepsia  we  administer  pepsin  ;  or  we  may  aid 
duodenal  digestion  by  a  remedy  derived  from  the  pancreas  ;  or  we  may 
give  bile  where  we  think  this  secretion  defective.  In  all  these  cases, 
however,  our  immediate  objects  are  in  tlie  first  place  to  relieve  discom- 
fort, and  in  the  second  to  restore  the  normal  functions  of  the  gastro- 
intestinal tract  which  are  interfered  with  by  the  abnormal  state  of  their 
contents  due  to  the  absence  of  pepsin,  trypsin,  and  bile. 


PRINCIPLES   OF  DRUG    THERAPEUTICS  241 

Sometimes  we  appear  to  apply  pharmacological  substances  to  influ- 
ence a  symptom  rather  than  a  pathological  state,  as  when  we  use  an 
antipyretic  in  fever.  Here,  however,  we  are  really  attempting  to  act  on. 
the  pathological  conditions  causing  higli  temperature ;  but  not  knowing 
what  these  are,  we  have  to  use  a  remedy  in  ignorance  of  the  exact 
nature  of  its  action. 

In  administering  drugs  to  restore  tissues  and  organs  to  a  normal 
state  we  usually  act  on  the  supposition  that  an  organ  thus  restored  will 
maintain  its  improved  condition  even  when  the  drug  is  withdrawn. 
When  digitalis,  for  example,  is  given  in  cardiac  dilatation  and  irregular 
action  it  is  assumed,  and  for  the  most  part  rightly  so,  that  if  we  can 
restore  or  partially  restore  the  heart  to  a  normal  state  it  will  so  remain 
when  the  medicine  is  withheld.  We  do  the  same  in  bronchitis  when 
we  administer  expectorants ;  in  fact  we  apply  a  generalisation  in  this 
matter,  as  in  many  others,  founded  on  a  weak  induction  which  must  be 
referred  to  one  or  more  inductions  of  wider  scope.  The  reason  that  a 
tissue  or  organ  restored  to  its  normal  state  by  a  drug  does  not  revert  to 
its  abnormal  condition  on  the  loss  of  the  drug,  depends  partly  upon  the 
fact  that  every  altered  condition  of  an  organ  reacts  on  the  surrounding 
tissues  and  organs ;  and  partly  on  the  tendency  to  revert  towards  the 
normal  when  perturbations  have  ceased  to  act. 

(f?)  Relief  of  Pain  and  Suffering.  —  This  indication  has  to  be  followed 
not  only  from  considerations  of  humanity,  but  because  pain  and  suffer- 
ing, by  their  influence  on  nutritional  processes,  tend  directly  to  prevent 
the  return  of  tissues  and  organs  to  their  normal  state.  The  relief  of 
pain  may  be  accomplished  by  drugs  which  depress  the  functions  of  the 
sensory  nerve  endings,  or  act  on  certain  parts  of  the  central  nervous 
system.  The  nerve  endings  may  be  affected  through  the  circulation  or 
directly.  It  is  probable  that  most  of  those  substances  which  depress 
the  tissues  of  the  central  nervous  system,  those  especially  which  are  in 
relation  to  its  higher  functions,  have  also  some  influence  on  the  nerve 
endings,  though  by  no  means  in  like  proportion.  On  the  other  hand 
substances,  such  as  cocaine,  which  very  distinctly  paralyse  the  sensory 
nerve  endings,  have  comparatively  little  effect  in  preventing  the  percep- 
tion of  pain  in  the  cerebrum.  The  influence  of  substances  which  act 
directly  on  nerve  endings  is  practically  much  affected  by  the  relations 
between  themselves  and  the  epidermis.  The  epidermic  covering  is 
probably  a  complete  bar  to  the  action  of  cocaine  on  the  nerve  endings ; 
proof  has  not  yet  been  given  that,  even  by  combining  it  with  substances 
such  as  chloroform  and  lanolin  which  are  said  to  aid  the  passages  of 
drugs  through  the  epidermis  or  its  ducts,  any  effective  influence  is 
exerted  on  the  tissues  beneath.  The  epidermis  likewise  almost  entirely 
resists  the  passage  of  morphia:  hence  opiate  applications  are  far  less 
frequently  of  benefit  than  is  popularly  supposed.  On  the  other  hand 
atropia,  although  not  a  powerful  depressant  of  the  functions  of  the 
nerve  endings,  passes  readily  through  the  epidermis ;  so  too  does  aconi- 
tine,  which  has,  however,  in  addition  to  its  anaesthetic  effects  on  the 

VOL.    I  R 


242  SYSTEM   OF  MEDICINE 

nerve  endings,  an  irritant  effect  on  other  tissues.  Conium,  like  cocaine, 
has  no  action  when  applied  to  a  surface  covered  with  epidermis. 

The  exact  part  influenced  by  analgesics  acting  on  the  central  nervous 
system  is  not  known. 

Substances  which  depress  the  higher  cerebral  functions  such  as 
anaesthetics,  chloral,  bromide  of  potassium,  are  undoubtedly  analgesics ; 
but  opium,  which  stands  first  and  foremost  of  all  drugs  in  the  relief  of 
pain,  may  act  as  an  analgesic  without  exerting  the  slightest  recognisable 
influence  on  the  higher  centres.  We  have  no  evidence  that  its  influence 
is  largely  due  to  its  local  action  on  the  nerve  endings;  morphia  will 
indeed  relieve  pain  applied  locally,  but  this  may  be  due  to  its  absorp- 
tion into  the  blood.  It  certainly  has  no  such  depressing  effects  on  the 
nerve  endings  as  cocaine;  if  injected  subcutaneously  the  place  of  injec- 
tion is  a  matter  of  indifference.  Possibly  it  influences  the  gray  matter 
in  the  cord  along  which  painful  sensations  are  conveyed,  and  the  con- 
tinuation of  the  gray  matter  into  the  brain;  or  it  may  affect  the  centre 
for  the  reception  of  pain. 

The  exact  point,  then,  on  which  morphia  exerts  its  effect  in  produc- 
ing analgesia  is  still  unknown.  Such  too  is  the  case  with  the  newer 
analgesics  —  antipyrine,  antif ebrin,  and  phenacetin.  They  likewise  in- 
fluence painful  sensations  in  a  manner  for  which  neither  their  local 
action  nor  their  influence  on  the  cerebrum  can  account. 

In  choosing  an  analgesic  the  pharmacological  influences  of  the  drug, 
other  than  those  which  effect  the  relief  of  pain,  are  not  to  be  forgotten ; 
these  secondary  actions  often  limit  their  use. 

Not  only  must  we  relieve  pain  where  possible,  but  all  forms  of  suf- 
fering also ;  and  next  to  pain  insomnia  is  perhaps  the  most  distressing 
of  these  forms.  There  is  reason  to  believe  the  presence  of  certain  ele- 
ments and  radicals  in  drugs  gives  them  a  power  of  depressing  the  tissues 
of  the  higher  centres  of  the  brain,  and  thus  causing  sleep.  Almost  all 
soporifics  are  derived  from  the  fatty  series,  and  many  of  them  contain  the 
elements  chlorine  and  bromine.  It  seems  probable  that  these  elements, 
and  also  the  fatty  radicals,  directly  depress  the  function  of  the  nerve  cells 
in  the  cortex.  The  structure  of  hypnotics  which  do  not  belong  to  the 
fatty  series,  of  which  opium  is  the  only  one  of  importance,  is  not  suf- 
ficiently known  to  enable  us  to  ascertain  to  which  of  its  constituent 
groups  of  molecules  its  effects  are  due.  As  in  the  case  of  analgesics  the 
use  of  soporifics  is  limited  by  the  extent  of  their  other  pharmacological 
effects ;  chloral  depresses  the  cardiac  and  respiratory  centres,  the  former 
to  a  dangerous  extent  when  administered  in  large  doses.  In  the  newer 
compound  chloralamide  this  effect  is  in  part  avoided  by  the  presence  of 
a  molecule  of  formamide,  which  contains  a  group  N.Hj  capable  of  stimu- 
lating the  centres  in  the  medulla.  It  still  remains  to  be  seen  whether 
this  is  sufficient  to  neutralise  entirely  the  depressing  action  of  chloral. 

Paraldehyde  produces  few  special  effects  other  than  those  procuring 
sleep,  but  its  taste  and  the  odour  it  gives  to  the  breath  are  very  objection- 
able ;  it  is  moreover  much  less  certain  in  its  effects  than  chloral.     Sul- 


PRINCIPLES   OF  DRUG    THERAPEUTICS  243 

phonal  is  also  less  certain  than  chloral ;  it  is  devoid  of  the  unpleasant- 
ness of  paraldehyde,  but  it  seems  at  times  to  disturb  muscular  co-ordina-. 
tion,  and  it  is  said  to  lead  to  the  presence  of  haematoporphorin  in  the  urine. 


III.  Principles  of  Administkation 

In  the  administration  of  drugs  the  chief  point  for  consideration  is 
the  method  by  which  they  can  best  be  brought,  in  the  requisite  quantity, 
in  contact  with  the  tissues  to  be  influenced. 

Methods. — Drugs  may  be  introduced  into  the  body  in  many  ways, 
which  may  thus  be  shortly  enumerated. 

1.  By  the  Skin.  —  The  skin  presents  two  pathways  for  the  absorption 
of  drugs,  viz.,  through  the  epidermis  or  through  the  cutaneous  glands. 
Whether  drugs  actually  penetrate  the  epidermis  is  very  doubtful,  and  it 
is  found  that  the  more  effectual  ways  of  securing  absorption  through 
the  skin  are  those  which  appear  most  apt  to  carry  the  drug  into  the 
interior  of  the  cutaneous  glands,  such  as  the  inunction  of  a  mercurial 
ointment,  the  exposure  of  the  skin  to  the  hot  moist  vapour  of  a  calomel 
fumigation,  or  the  solution  of  the  drug  in  chloroform  as  a  liniment.  By 
this  mode  of  administration  we  avoid  any  disturbing  influence  of  the 
drug  on  the  digestive  organs,  and  young  children  can  thus  easily  be  put 
under  treatment.  The  disadvantages  consist  in  uncertainty  as  to  the 
quantity  of  drug  absorbed,  and  in  the  unpleasantness  of  greasy  and 
sometimes  dirty  applications  to  a  large  surface  of  skin. 

The  following  means  are  usually  adopted  for  securing  cutaneous 
absorption :  — 

Fumigations  .....  1 

Inunction  of  ointments  or  liniments  .  .  !- Effectual. 

Endermic  applications  to  surfaces  denuded  of  epidermis   J 
Plasters  continually  applied  .  ^ 

Baths  .  .  .  .  1-  Of  doubtful  value. 

Medicated  poultices  and  fomentations      J 

2.  By  the  Alimentary  Canal. 

(a)  By  the  stomach.     The  disadvantages  of  stomach  administrations 


(a)  The  drugs  may  be  variously  changed  and  decomposed  by  the 
digestive  juice. 

(/5)  They  may  disturb  the  digestive  functions. 

(y)  There  is  often  delay  in  action,  the  rate  of  absorption  being  influ- 
enced by  the  solubility  of  the  drug  and  the  condition  of  the 
stomach  mucous  membrane  ;  hence  certain  substances,  such  as 
sulx)honal,  are  very  uncertain  in  the  time  of  their  action. 

(V)  By  the  rectum  in  the  form  of  enema  and  suppository.      Absorp- 
tion is  slow  from  the  rectum  in  the  case  of  most  drugs,  and  the  dose 


^44 


SYSTEM   OF  MEDICINE 


needed  is  larger  than  when  given  by  the  stomach.      Strychnine  and 
tobacco  are  exceptions  to  this  rule. 

3.  By  the  Respiratory  Mucous  Membrane.  —  This  is  probably  the  most 
rapid  means  of  entrance  for  drugs,  owing  to  the  large  absorbent  surface 
of  the  lung,  and  to  the  fact  that  the  blood  into  which  the  drug  has 
passed  goes  directly  to  the  heart.  Hence  the  extremely  rapid  action  of 
amyl-nitrite.  This  method  of  administration  is  limited,  for  the  most 
part,  in  its  application  to  drugs  volatile  at  the  temperatures  of  the  body, 
but  injections  into  the  trachea  have  been  made ;  atomisation  and  in- 
sufflation of  powders  are  commonly  employed  in  local  medication  of  the 
respiratory  mucous  membrane. 

4.  By  the  Genital  Mucous  Memhrane. — Absorption  through  this  chan- 
nel is  slow  and  uncertain.  Usually  the  injections,  pessaries,  bougies, 
etc.,  used  in  this  form  of  medication  are  employed  for  their  local  effect 
only. 

5.  By  Hypodermic  Injection.  — This  has  the  advantage  of  directly  in- 
troducing the  drug  into  the  lymph  stream  without  any  decomposition. 
The  influence  is  rapid,  and  the  dose  of  the  drug  can  be  accurately 
graduated.  The  use  is  limited  to  drugs  which  are  not  irritating,  and, 
for  the  most  part,  to  those  of  which  the  dose  is  small. 

6.  By  Intravenous  Injection.  —  This  is  practically  only  used  for  the 
introduction  of  large  quantities  of  saline  fluid,  though  ammonia  has  thus 
been  given. 

7.  By  Intraserous  Injection.  —  This  has  been  employed  in  exceptional 
cases,  but,  so  far  as  drug  treatment  is  concerned,  is  of  no  value.  The 
rapidity,  however,  with  which  absorption  from  serous  cavities  takes  place 
is  of  importance  in  other  relations. 

Dosage.  —  The  dose  of  a  drug  is  not  a  fixed  quantity,  but  must  be 
determined  according  to  the  purpose  for  which  the  drug  is  used,  and  the 
conditions  under  which  it  is  used.  The  conditions  which  chiefly  influence 
dosage  are  age,  sex,  size  and  weight,  and  disease. 

j^ge_  —  The  usual  rule  is  to  take  the  adult  dose  as  1  year,  and  make 
a  fraction,  which  has  the  age  of  the  child  for  a  numerator,  and  this  age 
plus  12  for  a  denominator :  this  gives  the  fraction  of  the  adult  dose  which 
is  suitable  for  the  child.  Thus,  for  a  child  of  six  the  dose  would  be  ~r^ 
or  one-third  of  the  adult  doses.  This  is,  of  course,  a  mere  approxima- 
tion ;  moreover,  each  drug  has  to  be  considered  separately  in  this  respect. 
Children,  for  example,  bear  much  larger  relative  doses  of  belladonna  and 
arsenic  than  adults ;  but  of  opium,  on  the  other  hand,  smaller  doses. 

Sex.  —  Women  differ  considerably  from  men  in  their  reaction  to 
medicine ;  the  dose  for  a  woman  is  usually  considered  to  be  four-fifths 
of  that  for  a  man. 

Size  and  Weight  seem  to  have  less  influence  than  would  be  generally 
supposed.  It  is  only  in  exceptional  cases  —  that  is,  where  the  size  and 
weight  are  very  small  —  that  these  factors  need  be  taken  into  con- 
sideration. 


PRINCIPLES   OF  DRUG    THERAPEUTICS  245 

The  Present  Disease.  —  This  lias  often  an  important  bearing  on  the 
dose.  Any  ailment  which  interferes  with  the  functional  activity  of 
eliminating  organs  may  seriously  modify  drug  action.  Hence,  in  kidney 
diseases,  for  example,  opium  has  at  times  an  exaggerated  action. 

As  the  dose  of  a  drug  has  to  be  adapted  to  the  changes  in  the  tissues 
and  organs  it  is  meant  to  affect,  and  as  the  tissues  of  similar  kind  in 
different  individuals  are  not  influenced  by  the  same  amount  of  a  drug, 
the  dose  which  will  effect  its  purpose  has  often  to  be  arrived  at  by 
experiment  —  that  is  to  sa}",  by  gradually  raising  it  until  a  definite 
result  is  obtained. 

Circumstances  modifying  the  Influence  of  Drugs.  —  Idiosyncrasy.  — 
One  or  more  of  the  tissues  may  be  unduly  susceptible  or  insusceptible 
to  the  action  of  a  drug.  It  is  well  known  that  the  smallest  quantity  of 
calomel  will  salivate  some  persons,  and  a  very  minute  dose  of  quinine 
will  cause  a  rash  in  others.  The  explanation  of  this  is  quite  unknown, 
but  even  the  simplest  tissues  vary  in  their  reaction  to  drugs  ;  the  excised 
muscles  of  one  frog,  for  example,  may  differ  considerably  in  their  ordi- 
nary reactions  from  those  of  a  series  of  other  frogs  without  any  other 
ascertainable  differences  in  the  experiment.  [  Vide  art.  "  Temperament."] 

Toleration. — When,  on  taking  a  drug  continuously,  the  first  effects 
decrease  until  they  are  no  longer  noticed,  toleration  is  said  to  be  estab- 
lished. In  some  cases  this  may  be  due  to  conditions  causing  increased 
elimination,  or  to  the  initiation  of  new  chemical  changes  by  which  the 
drug  becomes  altered  and  even  rendered  inert.  It  may,  however,  also 
be  due  to  some  modification  in  the  reacting  tissue,  caused  by  the  con- 
tinuous contact  of  the  drug.  It  would  appear  as  if  toleration  can  be 
established  more  readily  with  some  drugs  than  others ;  with  opium,  for 
example,  it  is  easily  established.  For  arsenic  the  toleration  is  not  so 
readily  established,  unless  indeed  we  accept  the  stories  of  the  Styrian 
peasants.  For  chloral  hydrate  tolerance  seems  to  become  only  partially 
established ;  patients  can  become  habituated  to  larger  doses,  yet  at  times 
toleration  seems  temporarily  to  disappear,  and  a  large  habitual  dose  may 
at  last  have  a  fatal  effect. 

TJie  duration  of  action  of  a  drug  is  likewise  dependent  on  the  rapidity 
of  its  excretion  and  its  adhesion  to  the  tissues.  The  difference  between 
drugs  in  this  matter  is  enormous.  Such  substances  as  ammonia,  ether, 
the  nitrites  and  alcohol,  produce  their  effects  on  the  tissues  quickly,  and 
their  effect  as  quickly  passes  away.  An  ordinary  dose  of  ammonia  or 
ether  acts  within  a  second  or  two ;  its  effects  do  not  last  more  than  half 
an  hour  or  an  hour.  Two  grains  of  nitrite  of  sodium  begins  to  act  in 
two  or  three  minutes,  and  its  influence  cannot  be  detected  after  three 
hours.  Digitalis,  on  the  other  hand,  does  not  show  any  signs  of  affect- 
ing the  system  for  a  long  time,  but  its  effect  is  long  continued.  It  is 
manifest  that  this  difference  in  the  duration  of  the  action  of  medicines 
should  be  considered  in  our  combinations  of  them.  It  seems  probable, 
for  example,  that  if  ammonia  and  digitalis  are  given  in  combination  the 
ammonia  will  have  ceased  to  act  before  the  digitalis  begins. 


246  SYSTEM  OF  MEDICINE 

Cumulative  Action.  —  Some  drugs  are  quickly  excreted,  others  are 
stored  up  in  the  body,  and  may  not  exert  their  characteristic  effect 
until  a  certain  amount  has  accumulated.  This  is  the  case  with  digi- 
talis, for  example.  When  this  drug  is  taken  in  small  doses,  its  special 
effects  are  not  seen,  as  a  rule,  for  two  or  three  days.  Cumulative  action 
of  a  drug  is  usually  due  in  part  to  difficulty  of  excretion,  but  also  to  the 
stronger  adhesion  of  its  molecules  to  the  tissues.  Digitalis,  as  a  matter 
of  experiment,  is  washed  out  of  tissues  with  much  greater  difficulty  than 
many  other  substances.  The  reverse  is  the  case  with  curare,  which  is  so 
slowly  absorbed  from  the  stomach  and  so  quickly  removed  from  the  tis- 
sues and  excreted  that,  if  the  drug  be  taken  by  the  mouth,  a  sufficient 
quantity  does  not  abide  in  them  to  produce  its  characteristic  effect. 
Hence  it  must  be  given  subcutaneously. 

Sources  of  Fallacy  in  Therapeutics.  —  Some  of  the  fallacies  arising 
from  defective  observation  and  other  causes  have  already  been  pointed 
out  incidentally. 

One  is  the  assumption  of  pharmacological  knowledge  which  does  not 
exist.  Some  knowledge  of  the  action  of  drugs  on  various  parts  of  the 
body  has  been  obtained,  but  concerning  the  effects  of  a  large  number 
definite  information  is  wanting.  Unfortunately,  when  knowledge  is 
wanting,  suppositions  founded  not  on  experiment  but  on  fancy  or  on 
imperfect  observation  usually  take  their  place.  The  reputed  action  of 
many  drugs  as  cholagogues,  diaphoretics,  diuretics,  etc.,  is  founded  on 
the  most  slender  basis ;  yet  it  is  constantly  alleged  as  if  it  were  founded 
on  real  knowledge.  Of  the  alleged  diaphoretic  action  of  such  substances 
as  sassafras,  and  serpentary,  nothing  certain  is  ascertained.  Again,  under 
what  conditions  the  so-called  "  expectorants  "  produce  their  effects  we  do 
not  know,  and  so  forth ;  indeed  the  action  of  most  drugs  on  the  tissues 
and  organs  is  guessed  at  rather  than  known.  Yet  in  therapeutic  reason- 
ing these  hazy  apprehensions  are  usually  accepted  as  a  basis  for  treatment. 

A  second  source  of  fallacy  is  the  persistence  of  old  and  baseless 
theories.  The  opinions  of  Hippocrates  and  of  Sydenham ;  tho^e  of  Willis, 
concerning  the  aiding  of  nature  with  regard  to  fermentation ;  of  Boer- 
haave,  on  obstruction  of  the  vessels;  of  Brown  on  asthenia,  still  colour 
our  therapeutic  reasoning,  and  lingering  like  the  nomenclature  of  their 
inventors,  like  it  they  influence  thought. 

Limits  of  the  Utility  of  Drugs. — Drugs  only  act  beneficially  when 
they  can  exercise  such  influence  on  the  morbid  changes  in  tissues  and 
organs  as  to  restore  the  parts  to  a  state  compatible  with  systemic  life. 
But  in  a  large  proportion  of  cases  such  restoration  is  impossible.  Ijnfor- 
tunately  for  the  reputation  of  drugs  it  is  considered  necessary  to  give 
them  in  all  cases,  even  where  it  is  manifest  that  the  case  is  beyond  the 
limits  of  drug  treatment.  The  prevalent  want  of  belief  in  drugs  is  largely 
due  to  the  fact  that  they  are  expected  to  achieve  the  impossible. 

D.  J.  Leech. 


CLIMATE  IN   THE    TREATMENT   OE  DISEASE  247 


BIBLIOGRAPHY 

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Thomson,  John.  Life  of  William  Cullen,  voL  i.  Edin.  1859.  —  7.  Brown,  John. 
Elements  of  Medicine,  with  a  Biograpliical  Preface  by  Thomas  Beddoes.  Lond.  1795. 
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Magendie.  Journal  de  physiologie  experimentale.  Paris,  1821. — 11.  Bernard,  Cl. 
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T.  K.  Tr^ie  Art  of  Healing.  Lond.  1866.  — 13.  Headland.  "Advance  in  the 
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Disease.  Lond.  1858. — 17.  Brunton.  Pharmacology  and  Therapeutics;  or,  Medicine 
Past  and  Present.  Lond.  1880. — 18.  Schmiedeberg.  Elemeiits  of  Pharmacology 
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setzung  und  pharmakodynamischen  Wirkung.  Jena,  1886. — 23.  Boehm.  "  Einige 
Beobachtungen  iiber  die  Nervenendwirkuug  des  Curarin,"  Arch.  f.  exp.  Path.  u. 
Pharm.  B.  xxxv.  H.  1. 

D.  J.  L. 


CLIMATE   IN   THE   TREATMENT   OF   DISEASE 

The  Climate  of  a  region  or  site  is  the  combined  effect  of  the 
atmosyjhere  and  of  the  nature  of  the  surface  in  their  relation  to  man. 
Of  these  the  atmosphere,  which  is  the  product  of  many  more  or  less 
varying  agents,  is  the  chief.  The  most  important  qualities  of  the  atmos- 
phere are  :  — 

1.  The  chemical  composition.  2.  The  organic  and  inorganic  substances  floating 
in  it.  3.  The  temperature  and  its  variations.  4.  The  degree  of  humidity.  5.  The 
diathermancy.  6.  The  transparency  and  the  quality  of  light.  7.  The  density  and 
pressure.  8.  The  electrical  conditions.  9.  The  circulation  of  the  air  —  the  direc- 
tions and  the  force  of  the  winds. 

The  climatic  character  of  a  locality  depends  chiefly :  — 

1.  On  the  distance  from  the  equator.  2.  The  elevation  above  the  sea.  3.  The 
relation  of  its  position  to  adjacent  seas  or  large  inland  lakes,  or  deserts,  or  marshes. 
4.  The  predominating  winds.  5.  The  nature  of  the  soil :  whether  rock  or  dry  por- 
ous ground,  such  as  sand,  allowing  rapid  percolation  of  moisture,  and  enclosing 
between  the  solid  particles  a  large  amount  of  air;  or  stiff,  more  or  less  impermeable 
ground,  such  as  clay,  peat,  or  marsh.  6.  Configuration  of  surface :  the  amount  of 
shelter,  the  position  on  a  slope,  terrace,  or  plateau,  or  in  a  valley  ;  the  aspect  towards 
the  sun,  and  possible  amount  of  sunshine.     7.  The  mode  of  the  cultivation  of  soil. 


248  SYSTEM   OF  MEDICINE 

whether  arable  fields  or  pastures  ;  the  planting  and  clearing  of  forests  ;  the  density 
of  population  ;  the  establishment  of  manufactures ;  the  amount  of  drainage  of  the 
rural  and  the  urban  districts. 

This  article  will  be  divided  into  three  sections,  as  follows:  — 

First  Section  :  Remarks  on  some  of  the  principal  elements  of  climate. 

Second  Section :  Principal  climatic  regions  and  health  resorts. 

Third  Section :  Use  of  climate  in  the  treatment  and  prevention  of 
disease,  with  a  snb-section  on  the  use  of  "  home  "  from  a  hygienic  and 
therapeutic  point  of  view. 

First  Section.  —  Remarks  on  some  of  the  Principal  Elements  of 

Climate 

1.  Compositioji  of  the  Air.  —  At  one  time  it  was  generally  maintained 
that  the  composition  of  the  air  was  the  same  in  all  parts  of  the  earth 
—  at  the  tops  of  the  mountains,  on  the  sea,  in  rural  and  in  town  districts ; 
but  the  researches  of  Tyndall,  Frankland,  R.  Angus  Smith,  and  others 
have  shown  that  there  are  slight  differences  from  the  usually  assumed 
composition,  viz.  — 

Oxygen  .  .  20-96 

Nitrogen  .  .  79-00 

Carbonic  acid      .  .  0-04 

in  100-00  volumes  of  air. 

Although  the  differences  in  the  proportion  of  oxygen  rarely  exceed 
y^g-  volume,  such  a  plus  or  minus  is  of  great  importance  if  we  consider 
the  large  quantity  of  air  which  we  inhale,  and  if  we  may  assume  that 
any  deficit  is  generally  associated  with  the  presence  or  the  increase  of 
more  or  less  injurious  substances. 

R.  Angus  Smith  found  even  in  the  same  town  considerable  differences 
in  the  proportion  of  oxygen,  e.g.  in  a  northern  suburb  of  London 
(Belsize  Park)  21-01  per  cent,  in  the  middle  of  Hyde  Park  21-005,  in 
the  Eastern  district  20-86,  in  the  tunnel  of  the  Metropolitan  Railway 
20-70.  In  an  open  yard  before  a  house  more  oxygen  was  found  than 
within  the  rooms  of  the  house.  At  the  same  spot  he  found  differences 
under  the  influence  of  weather  —  more  oxygen  during  and  after  rain 
than  in  dry  and  foggy  weather. 

Carbonic  acid  was  first  found  by  De  Saussure  as  a  regular  constituent 
of  the  air  in  the  proportion  of  3-6  to  6  parts  in  10,000 ;  but  its  percentage 
varies  considerably.  Thus  Angus  Smith  found  in  crowded  law  courts 
as  much  as  20,  and  in  theatres  even  32  in  10,000  ;  and  Pettenkofer  found 
20  to  58  in  10,000  in  crowded  schools  at  Munich.  It  is  probable  that  air 
rich  in  carbonic  acid  is  also  rich  in  other  impurities  and  in  bacteria. 

The  air  contains  other  gaseous  substances,  such  as  ozone,  antozone, 
ammonia,  on  which  we  cannot  enter  here;  and  the  vapour  of  water, 
which  we  shall  discuss  under  humidity. 

Very  important  are  the  solid  substances  floating  in  the  air,  the  nature 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  249 

of  which  varies  considerably  at  different  localities  and  under  different 
conditions.  They  are  partly  inorganic,  such  as  salty  particles,  silica, 
chalk,  iron,  etc. ;  partly  organic,  such  as  pollen,  algse,  bacteria,  fragments 
of  hair,  vegetable  fibre,  and  insects.  Some  of  these  substances  are  inno- 
cent, or  nearly  so ;  others  are  injurious.  Ehrenberg,  Schwann  and  others 
directed  attention  to  this  matter  long  ago ;  but  to  Pasteur  and  Tyndall 
our  debt  is  greatest.  Pasteur  has  shown  the  absence  of  organic  impurity 
on  glaciers,  and  its  presence  in  large  quantities  in  villages  not  far  distant. 

The  recognition  by  Lister  of  the  influence  of  these  suspended  matters 
on  wounds,  and  the  adoption  of  successful  means  to  exclude  them,  mark 
an  epoch  in  the  history  of  Medicine ;  and  their  presence  in  the  air  of 
different  localities  deserves  attention  in  the  appreciation  of  climates. 
On  this  depends  the  septic  or  aseptic  character  of  the  atmosphere ;  and 
the  predominant  feature  of  the  localities  most  beneficial  in  the  treat- 
ment of  tubercular  phthisis  is  the  aseptic  character  of  the  atmosphere. 

2.  Temperature  is  a  most  powerful  modifier  of  climates.  We  dis- 
tinguish between  radiant  or  sun  heat,  and  shade  or  air  heat.  The  rays 
of  the  sun  have  great  power  of  heating  the  human  body  and  other  solid 
substances  on  which  they  fall,  but  heat  only  slightly  the  air  through 
which  they  pass.  The  air  would,  in  fact,  allow  the  heat  to  pass  through 
it  entirely — -it  would  be,  to  use  a  scientific  term,  quite  diathermic  — 
were  it  not  for  the  watery  vapour  it  contains.  On  the  amount  of  this 
vapour  depends  the  degree  of  the  diathermancy  of  the  air,  which  is  a 
very  important  factor  of  different  climates.  The  more  vapour  the  air 
contains  the  less  powerful  is  the  direct  or  radiant  sun  heat. 

The  shade  temperature  is  due  mainly  to  the  warmth  imparted  to  the 
air  from  the  ground — v/ater  as  well  as  land — previously  warmed  by  the 
sun's  rays.  The  shade  temperature  may,  however,  be  greatly  infiuenced 
by  currents  of  air  from  distant  regions,  viz.,  warm  or  cold  winds. 

Melloni  and  Tyndall  discovered  that  the  water  vapour  is  much  less 
diathermic  to  the  invisible  waves  of  heat  radiated  back  from  the  earth 
than  to  the  direct  luminous  rays  of  the  sun.  To  this  is  due  the  pro- 
tecting influence  of  the  vapour  on  the  ground,  especially  during  the 
night —  without  it  the  greater  part  of  the  heat  absorbed  during  the  day 
would  be  rapidly  radiated  into  space,  which  indeed  does  occur  when  the 
air  is  very  dry  and  the  sky  cloudless. 

The  nature  of  the  surface  of  the  ground  exercises  great  influence 
on  the  amount  of  heat  which  is  absorbed  and  reflected.  We  can  only 
briefly  allude  to  Frankland's  instructive  experiments  on  this  subject. 
The  nearer  the  colour  of  the  ground  approaches  to  white  (snow,  chalk 
cliffs,  white  walls,  etc.)  the  more  the  direct  sun  heat  is  reflected  by  it, 
the  less  heat  is  absorbed;  the  darker  the  ground  (grass,  green  leaves)  the 
less  heat  is  reflected,  the  more  is  absorbed.  The  ground  which  absorbs 
more  heat  from  the  direct  rays  of  the  sun  can  give  out  more  heat  dur- 
ing the  night  and  vice  versa.  The  influence  thus  exercised  on  the  cli- 
mate of  a  place  is  evident,  and  the  white  snow  fields  of  the  Alps  in 
winter  form  a  well-known  illustration. 


250 


SYSTEM   OF  MEDICINE 


We  cannot  enter  on  the  distribution  of  temperature  in  tlie  atmos- 
phere on  the  surface  of  the  earth,  or  on  the  great  differences  existing 
between  the  distances  from  the  equator  and  the  isothermal  lines  (with 
the  same  annual  temperatures),  and  the  isochimenal  lines  (with  the 
same  winter  temperatures),  and  the  isotheral  lines  (with  the  same 
summer  temperatures).  We  must  refer  to  Humboldt,  Dove,  Carpenter, 
Haughton,  Scott,  and  others,  for  accounts  of  the  warming  influences 
of  the  equatorial  currents  of  the  sea,  and  of  the  chilling  action  of  the 
Arctic  and  Antarctic  streams.  This  and  other  factors  of  climate  are 
very  clearly  described  in  the  Lumleian  lectures  on  "Aero-therapeutics" 
(1894)  by  Dr.  C.  T.  Williams. 

The  temperature  of  the  sea-coasts,  however,  is  influenced  not  only 
by  great  sea  currents ;  the  nearness  of  oceans  acts  powerfully  on  the 
temperature  of  large  tracts  of  continents  —  the  range  of  temperature, 
as  a  rule,  increasing  from  the  coasts  towards  the  interior.  The  Pacific, 
the  Atlantic  and  other  oceans  diminish  the  annual  range  of  tempera- 
ture on  adjacent  shores  to  20°  F.  and  less ;  while  in  the  interior  of  large 
continents  —  as  in  the  centre  and  north  of  Asia  —  the  range  may  be 
60°,  80°,  and  even  100°  F. 

Mountains  and  high  elevations  above  the  sea  act  likewise  to  some 
degree  as  equalisers  of  temperature  by  lowering  the  annual  range.  In 
addition  to  this  high  mountain  ranges  act  as  shelters  to  the  leeward 
regions ;  they  condense  the  moisture  on  the  side  towards  the  sea,  and 
render  the  air  currents  on  the  leeward  side  drier.  We  see  this,  for 
instance,  by  comparing  the  dry  climates  of  Tibet  and  Cashmere  with 
those  of  the  windward  side  of  the  Himalayas,  and  those  of  the  eastern 
side  of  the  Kocky  Mountains  with  those  to  the  west  of  them. 

Our  knowledge  of  the  influence  of  different  degrees  of  temperatiire  on 
the  human  body  is  still  imperfect.  Experiments  have  shown  that  cold 
acts  as  a  stimulant  and  increases  the  amount  of  carbonic  acid  exhaled ;  but 
Pflliger  has  found  a  similar  increase  from  heat,  and  Marcet  came  to  the 
same  result  from  his  observations  on  the  island  of  Teneriffe :  we  must 
infer,  then,  that  heat,  up  to  a  certain  limit,  acts  likewise  as  a  stimulant. 
Our  general  views  on  the  influence  of  temperature  are  based  partly  on 
the  effects  of  different  seasons  on  the  health  of  individuals ;  partly  on 
the  effects  of  moving  during  winter  to  warmer  climates,  and  vice  versa ; 
partly  on  the  consideration  of  the  physical  and  mental  constitution  of 
peoples  dwelling  in  different  regions:  but  the  coexistence  of  other 
climatic  factors  —  such  as  moisture,  light,  rarefaction,  or  condensation  of 
air  —  render  inferences  difficult,  a  difiiculty  further  increased  by  differ- 
ences in  the  manner  of  life. 

It  is  necessary  to  distingxiish  between  radiated  or  sun  heat  and 
shade  heat.  We  do  not  yet  know  how  great  a  degree  of  sun  heat  can  be 
borne.  It  is  certain  that  sunstroke  is  very  rare  in  great  sun  heat  in  the 
pure  and  comparatively  dry  air  of  high  elevations ;  and  this  seems  also 
to  be  the  case  on  the  ocean.  High  shade  temperature  is,  however, 
much  less  easily  borne,  and  persons  who  can  do  hard  work  in  a  sun  heat 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  251 

of  120°  become  rapidly  exhausted  in  a  shade  heat  of  90°.  Here  again 
we  must  bear  in  mind  that  we  cannot  distinguish  the  effects  of  tempera- 
ture from  those  of  moisture,  electrical  condition,  and  movement  of  air. 
Different  individuals  bear  heat  very  differently ;  and  many  Europeans 
living  in  hot  climates  injure  themselves  by  continuing  to  take  the  same 
kind  and  amount  of  food  and  stimulants  as  they  do  at  home  (Ranald 
Martin,  Parkes,  Fayrer,  and  others).  However,  as  Parkes  says,  great 
heat  in  shade  exerts  ''  a  depressing  influence,  lessening  the  great  func- 
tions of  digestion,  respiration,  sanguification,  and,  directly  or  indirectly, 
the  formation  and  destruction  of  tissues."^ 

At  climatic  health  resorts,  however,  we  have  not  to  deal  with  high, 
but  with  moderate  degrees  of  heat,  such  as  we  find  in  summer  in  temperate, 
and  in  winter  in  hot  climates,  namely,  between  55°  and  70°  F.  In  such 
temperatures  the  organism  loses  less,  heat  than  at  lower  degrees.  In 
strong  persons,  after  long  exposure  to  such  temperatures,  we  often  find 
a  certain  degree  of  lassitude,  diminution  of  appetite,  and  impairment 
of  the  functions  of  digestion,  respiration,  circulation,  and  metabolism. 
Weak  persons,  on  the  other  hand,  often  exhibit  greater  energy  of 
all  the  functions  of  the  mind  and  body,  gain  in  weight,  and  are  less 
liable  to  disease.  Hence  the  value  of  such  climates  to  permanently 
delicate  persons,  or  to  those  temporarily  weakened  by  disease,  and  to  the 
elderly. 

The  effects  of  low  temperature  are  likewise  rarely  observed  alone; 
but  it  is  certain  that  the  body  loses  more  heat  and  has  to  supply  this 
loss.  Increase  of  appetite,  improvement  of  digestion,  circulation,  sangui- 
fication, and  metabolism  are  in  vigorous  persons  generally  the  results  of 
moderate  degrees  of  cold.  The  opposite  is  often  the  case  with  delicate 
persons,  and  especially  so  when  cold  is  combined  with  damp  and  wind. 
It  is  especially  amongst  old  persons  that  the  combination  of  cold  with 
damp  and  high  winds  and  absence  of  sun  acts  injuriously.  The  reports 
of  the  Registrar-General  give  ample  proof  of  this.  Thus  in  the  last 
quarter  of  1878,  including  two  very  cold  months,  the  mortality  of  people 
above  sixty  was  24  per  cent  higher  than  in  1877,  when  the  same  period 
was  characterised  by  mild  weather.  The  rate  of  increase  amongst  people 
below  sixty  was  only  8  per  cent.  However,  by  dryness  of  the  air,  light, 
sunshine,  and  absence  of  wind,  moderate  degrees  of  cold  are  rendered 
beneficial  even  to  many  delicate  persons. 

The  fact  that  cold  is  disagreeable  to  many  persons  induces  them  to 
regard  it  as  injurious.  That  this,  however,  is  not  the  case,  is  proved  by 
the  fact  that  the  mortality  decreases  as  we  proceed  from  the  tropics 
towards  the  pole.     We  quote  Michel  Levy's  table  in  his  Hygiene :  — 

From    0  to  20  degrees  latitude,  1  death  in  25     inhabitants. 
,,      20  „  40       „  ,,  1      ,,      ,,  35-5 

„      40  „  60       „  „  1      „      „  4.3.2 

„      60  „  80       „  „         1      ,,      „  55 

1  Manual  of  Practical  Hygiene,  1878,  p.  436. 


252  SYSTEM   OF  MEDICINE 

It  was  formerly  assumed  that  great  equability  of  temperature  is  a 
necessary  element  of  a  climate  useful  in  the  treatment  of  chest  complaints 
and  vice  versa;  but  this  again  is  not  correct.  There  may  be  great  dif- 
ferences between  sim  heat  and  shade  temperature,  and  still  greater  dif- 
ferences between  day -and  night  temperatures  —  as  in  Alpine  climates 
in  winter^ — and  yet  such  climates  exercise  the  most  beneficial  effects, 
provided  the  invalid  can  take  sufficient  shelter. 

3.  The  humidity  of  the  air  is  almost  as  important  a  factor  of  climate 
as  the  temperature.  Watery  vapour  is  always  contained  in  the  air,  but 
its  amount  is  constantly  changing  by  the  ceaseless  processes  of  evapora 
tion  and  condensation.  The  degree  of  absolute  humidity  varies  with  the 
seasons,  and  at  different  hours  of  the  day ;  it  is  generally  greater  with 
higher  temperatures  and  vice  versa.  The  variations  of  relative  humidity 
follow  to  some  degree  an  opposite  course :  the  relative  humidity  is,  in 
general,  lower  in  summer  than  in  winter,  and  lower  during  the  warmer 
parts  of  the  day  than  during  the  colder ;  lowest,  in  fact,  during  the  first 
hours  of  the  afternoon  and  highest  about  sunrise.  The  variations  are 
greater  in  summer  than  in  winter,  greater  in  inland  than  in  marine 
climates ;  they  are  influenced  by  predominant  winds. 

Saturation  of  the  air  leads  to  mists  and  clouds,  and  the  periods  and 
frequency  of  their  occurrence  are  of  great  importance  in  the  appreciation 
of  climates.  Mists  are  more  rare  at  considerable  elevations  above  the 
sea:  clouds  are  more  frequent  at  certain  medium  elevations,  changing 
with  the  seasons. 

The  rainfall  varies  considerably  in  different  regions,  from  0  in  the 
desert  of  Sahara,  and  at  some  parts  of  the  coast  of  Peru,  to  several 
hundred  inches  on  the  south-east  slopes  of  the  Himalayas,  which  are 
exposed  to  the  moisture-laden  monsoons.  The  amount  of  rain  is  not 
proportionate  to  the  moisture  of  the  air,  for  a  region  may  be  rainless,  as 
Lima  on  the  coast  of  Peru,  in  spite  of  a  very  humid  atmosphere ;  and 
localities  with  considerable  rainfall,  like  Genoa,  may  have  tolerable  dry- 
ness of  soil  and  air.  The  number  of  rainy  days  does  not  correspond  to 
the  amount  of  rainfall.  It  may  even  be  said,  with  some  exceptions,  that 
the  number  of  rainy  days  increases  with  the  distance  from  the  equator, 
while  the  amount  of  rainfall  decreases.  The  number  of  rainy  days,  the 
season  when  it  rains  oftenest,  and  the  hours  of  the  day  on  which  the 
rain  falls,  are  important  matters  to  the  invalid. 

It  is  generally  assumed  that  considerable  rainfall  is  an  injurious 
condition,  but  this  is  not  always  correct.  Provided  time  enough  be  left 
for  the  invalid  to  take  exercise  and  sit  in  the  open  air,  rain  is  to  some 
degree  usefiil,  as  it  has  a  purifying  influence  on  the  atmosphere.  We 
must  remember  that  Angus  Smith  found  an  increased  amount  of  oxygen 
during  and  after  rain,  and  cool  and  rainy  summers  in  England  mostly 
show  smaller  mortality  than  hot  and  dry  ones.  The  notion  that  S7iow 
is  injurious  is  even  more  incorrect.  It  is  true  that  frequent  melting  of 
snow  is  apt  to  produce  catarrh,  but  if  the  snow  remain  on  the  ground 
without  melting  for  periods  of  several  months,  it  is  to  many  invalids  a 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  253 


source  of  benefit,  for  (a)  it  keeps  the  air  free  from  the  impurities  rising 
from  the  soil,  and  from  dust ;  (6)  it  increases  the  amount  of  radiant  or 
sun  heat  by  reflection ;  (c)  it  diminishes  local  currents  of  air  by  prevent- 
ing the  heating  of  the  ground. 

We  have  spoken  of  the  moisture  of  the  atmosphere  as  a  great  regu- 
lator of  the  distribution  of  warmth  on  the  surface  of  the  globe,  and 
that  it  is  as  essential  to  man  as  to  vegetation ;  but  it  is  difficult  to  define 
accurately  the  effects  on  man  of  different  degrees  of  moisture,  because 
the  factor  of  moisture  cannot  be  separated  from  other  factors,  especially 
temperature,  light,  atmospheric  pressure,  wind.  In  dry  air  the  evapora- 
tion from  the  skin  and  from  the  lungs  is  promoted,  and  this  effect  is 
increased  if,  at  the  same  time,  the  sunshine  be  powerful,  as  in  elevated 
regions.  In  moist  air  both  are  diminished.  In  moist  and  warm  air  the 
appetite  and  the  vital  energies  become  diminished,  and  there  is  often  a 
tendency  to  diarrhoea  and  to  affections  of  the  abdominal  organs.  The 
development  of  low  organisms  is  favoured  in  such  climates,  and  this 
probably  is  the  reason  why  in  some  such,  as  at  Lima,  tuberculosis  is 
frequent  and  runs  a  most  rapid  course.  In  moist  and  cold  air  the  evap- 
oration from  the  skin  is  checked,  the  surface  loses  much  warmth,  and 
rheumatic  and  catarrhal  complaints  are  common.  Climates  with  a  moder- 
ate amount  of  moisture  are  more  equable  by  day  and  night,  and  in  sun 
and  shade ;  the  evaporation  also  is  slight ;  in  dry  climates,  as  we  have 
already  said,  the  opposite  holds  good.  Climates  with  much  moisture, 
especially  with  low  temperatures,  often  have  a  very  dull  sky,  which  may 
shut  out  the  light  and  heat  of  the  sun  for  many  days  and  weeks ;  such 
climates  are  not  exhilarating,  but  with  proper  hygienic  management 
may  allow  perfect  maintenance  of  health  and  vigour. 

4.  Our  knowledge  of  the  effects  of  slight  changes  in  the  atmospheric 
pressure  is  not  well  defined ;  the  effects  of  the  great  diminution  of  press- 
ure at  high  elevations  will  be  discussed  under  Alj^ine  climates. 

6.  Light  is  of  primary  importance.  As  we  all  know,  light  is  neces- 
sary for  the  development  of  chlorophyll  in  plants ;  and  we  meet  per- 
sons frequently  who  after  some  dull  days  with  absence  of  sun  become 
depressed,  disinclined  to  work,  and  dyspeptic,  and  who  regain  their 
energy  with  the  return  of  the  sun.  We  also  often  see  home-sickness 
in  natives  of  foreign  and  more  sunriy  countries  after  some  sunless  weeks 
in  London,  which  disappears  after  a  few  weeks  of  sunny  weather ;  but 
though  we  may  suppose  that  absence  of  sunshine  is  the  principal  cause 
of  such  mental  and  bodily  distiwbance,  it  is  difficult  to  say  how  much 
is  due  to  concomitant  circumstances,  such  as  excessive  moisture  and 
to  low  temperature.  W.  F.  Edwards  showed  long  ago  that  light  is 
necessary  for  the  development  of  the  perfect  form  of  the  Batrachia. 
Moleschott,  Pfluger,  von  Platen,  Tubini,  and  others  have  found  in- 
creased absorption  of  oxygen  and  excretion  of  carbonic  acid  under 
the  influence  of  light  in  Batrachia  and  in  some  warm-blooded  animals. 
H.  Quincke's  experiments  prove  that  the  oxidation  of  animal  cells  (of 
blood  and  pus)  is  increased  under  the  influence  of  light.     Many  of  the 


254  SYSTEM   OF  MEDICINE 

effects  of  light  on  the  animal  organism  are,  no  doubt,  due  to  its  action 
on  the  centripetal  nerves,  and  especially  on  those  of  the  retina;  but 
the  result  of  Quincke's  researches,  and  also  of  those  of  other  observers, 
show  that  light  acts  also  directly  on  the  cells  and  tissues  without  the 
influence  of  nerve  centres. 

The  human  body  is  influenced  indirectly  by  the  action  of  light  on 
certain  microbic  parasites.  Downes  and  Blunt,  Arloing  and  Roux,  had 
already  shown  that  sunlight  can  kill  bacteria,  when  Koch  stated  to  the 
International  Medical  Congress  at  Berlin  (1890)  that  it  kills  the  tubercle 
bacillus  within  a  very  short,  time  —  varying  from  a  few  minutes  to  a  few 
hours ;  and  that  even  diffuse  daylight  does  so,  but  requires  from  five  to 
seven  days.  According  to  P.  A.  Komelevsky,  solar  light  destroys  the 
vitality  of  the  Staphylococcus  pyogenes  aureus  and  albus,  etc.,  in  about 
six  hours.  He  found  that  all  portions  of  the  spectrum  powerfully  affect 
the  microbes,  excepting  the  red  and  infra-red  rays.  Professor  Marshall 
Ward  showed  by  experiments  that  the  blue  rays  of  the  spectrum  have 
the  greatest  power  in  destroying  bacteria ;  while  the  red,  orange,  yellow, 
and  ultra-violet  rays  do  not  affect  them ;  our  present  experience  seems 
to  him,  however,  not  conclusive  with  regard  to  all  varieties  of  microbes. 
Dr.  Arthur  Ransome  communicated  to  the  Royal  Society  in  1890  ex- 
periments on  the  action  of  soil,  air,  and  light  on  the  tubercle  bacillus; 
and  again  Drs.  Ransome  and  Delepine  infer  "  (1)  that  finely-divided 
tuberculous  matter  —  such  as  pure  cultures  of  the  bacillus,  or  tuber- 
culous dust,'  in  daylight  and  in  free  currents  of  air  —  is  rapidly 
deprived  of  virulence ;  (2)  that  even  in  the  dark,  although  the  action 
is  retarded,  fresh  air  has  still  some  disinfecting  influence ;  and  (3)  that 
in  the  absence  of  air,  or  in  confined  air,  the  bacillus  retains  its  power 
for  long  periods  of  time."  These  experiences  seem  of  great  importance 
in  the  explanation  of  the  aseptic  nature  of  the  air  in  the  high  Alps,  on 
the  Riviera,  in  the  desert,  etc.  It  may  further  be  mentioned  that 
Buchner  has  shown  that  direct  as  well  as  diffused  sunlight  very  rapidly 
kills  bacteria  suspended  in  water. 

There  is  yet  a  third  kind  of  influence  of  light  on  the  human  body, 
namely,  on  the  skin.  John  of  Gaddesden,  a  court  physician  in  the  reigns 
of  the  Edwards  ("  Rosa  Anglica"),  in  treating  a  royal  prince,  a  son  of 
Edward  I.,  for  small-pox,  prevented  scars  by  having  the  bed-curtains 
and  all  surroundings  made  of  red  colour.  The  same  treatment  has  been 
pursued  by  N.  Pinsen^  and  Svensden,^  with  the  result  of  preventing  the' 
suppurative  stage  and  the  pitting.  This,  if  confirmed,  may  be  explained 
by  the  exclusion  of  the  chemical  rays  by  the  red  curtains.  On  the  irritat- 
ing influence  of  these  rays  interesting  experiments  have  been  made  by 
Drs.  Bowles,  Unna,  Hammer,  Pinsen,  and  others.  Dr.  Bowles  in  his  re- 
searches in  the  Alps  on  the  effects  of  sunlight  on  the  human  body,  was 
led  to  the  conclusion  that  it  is  not  heat,  but  those  rays  of  shorter  vibra- 
tion at  the  violet  end  of  the  spectrum,  which  give  rise  to  the  phenomena 

1  Hospitalstidende,  1893. 

2  Pen  ledste  Koppeepidemi  i  Bergen,  Medeeinsk  Revue,  October  1893. 


CLIMATE  m   THE    TREATMENT   OF  DISEASE  255 

of  sunburn,  and  that  rays  reflected  from  snow  are  far  more  potent  than 
rays  direct  from  the  sun,  or  those  reflected  from  rocks.  He  found  that 
various  colours  applied  to  the  skin  prevented  the  harmful  rays  from 
reaching  the  delicate  nerves  and  vessels  beneath  the  epidermis,  and 
quotes  a  singular  case  of  an  Indian  officer,  who,  having  had  repeated 
attacks  of  sunstroke,  thinks  that  he  has  prevented  the  recurrence  of  the 
attacks  by  wearing  an  orange  coloured  lining  to  his  clothes. 

6.  Of  Winds — a  large  subj  ect  —  we  can  only  speak  briefly.  They  are 
necessary  as  purifiers  of  the  air,  though  they  may  under  special  circum- 
stances carry  malarial  and  other  poisons.  They  often  produce  great  and 
sudden  changes  in  temperature,  moisture,  light,  and  atmospheric  press- 
ure ;  and  bring  with  them,  so  to  speak,  the  climates  of  distant  regions. 
Before  selecting  a  health  resort  the  winds  prevailing  at  different  seasons, 
at  different  parts  of  the  day,  and  their  character,  must  be  ascertained. 

7.  Mountain  chains  act  as  barriers  to  cold  and  to  hot  winds,  and  thus 
cause  in  the  former  case  higher  annual  temperatures  in  the  leeward 
localities,  in  the  latter  case  lower.  Their  effects  vary  with  their  height, 
extension,  abruptness,  quality,  and  amount  of  vegetation;  and  with 
presence  or  absence  of  snow  and  glaciers.  They  exercise  also  a  great 
influence  on  the  equality  of  the  atmosphere  carried  by  the  wind ;  they 
deprive,  for  instance,  the  moisture-laden,  warm  winds  of  a  great  part  of 
their  moisture,  so  that  the  climates  to  leeward  of  the  chain  are  rendered 
drier  and  less  equable. 

8.  Buchan  (12  and  13)  gives  interesting  facts  on  the  effe*ct  of  drainage 
on  the  temperature  of  the  soil.  The  mean  temperature  of  arable  land  is 
raised  0-80°  F.  by  drainage  ;  cold  penetrates  undrained  more  quickly  than 
drained  land ;  the  temperature  of  drained  land  is  more  equable  than  that 
of  undrained ;  in  summer  the  temperature  of  drained  land  is  occasionally 
raised  1-8°  to  3°  F.  above  that  of  undrained  land.  These  facts  may 
throw  some  light  on  the  discoveries  of  Bowditch  and  Buchanan  with 
regard  to  the  diminution  of  phthisis  mortality  by  drainage. 

9.  The  presence  or  absence  of  vegetation  exercises  a  marked  influence 
in  all  climates.  Bare  surfaces  differ  according  to  the  conducting  power 
of  the  ground.  The  covering  of  the  surface  by  vegetation  prevents 
more  or  less  completely  the  direct  fall  of  the  sun's  rays  on  the  ground 
itself,  and  thus  prevents  it  from  being  heated  to  the  same  degree  as  bare 
rock  or  dry  sand ;  and  the  plants  themselves  are  never  heated  quite  so 
much  as  bare  ground  on  account  of  the  constant  process  of  evaporation. 
We  have  found  the  temperature  above  grass-land,  and  likewise  clover, 
more  than  twenty  degrees  lower  than  above  bare  ground  under  great 
sun  heat.  The  character  of  the  vegetable  covering,  however,  makes  a 
considerable  difference. 

The  influence  of  forests  has  been  carefully  studied  by  Buchan  and 
Ebermayer  (2o).  They  foimd  the  temperature  of  the  ground  on  which 
a  forest  stands  to  be  several  degrees  lower  than  that  of  the  neighbour- 
hood. The  difference  is  greater  in  summer  than  in  winter,  but  the  air 
within  the  forest  has  a  lower  annual  mean.     In  summer  the  cooling 


2s6 


SYSTEM   OF  MEDICINE 


influence  is  specially  marked  during  sunshine.  The  changes  of  temperar- 
ture  in  forests  are  narroT^er  and  less  sudden ;  the  days  are  cooler,  the 
nights  warmer ;  the  climate  more  equable.  Trees  acquire  their  max- 
imum temperature  in  summer  at  about  9  p.m.,  while  that  of  the  air 
occurs  between  2  and  3  p.m.  ''Hence  trees  may  be  regarded  as  reser- 
voirs in  which  the  heat  of  the  day  is  closed  up  against  the  cold  of  the 
night."  The  relative  humidity  in  forests  is  higher ;  in  July  about  10°, 
in  January  about  3-7° ;  forests  lead  also  to  increased  rainfall ;  the  air 
in  forests  being  cooler  and  more  saturated,  the  vapour  of  a  moist  wind 
on  reaching  a  forest  is  condensed  into  mist  and  rain.  There  is  less 
movement  of  air  in  forests,  and  they  protect  the  adjacent  land  on  the 
leeward  side  from  winds  and  cold  currents. 


Second  Section.  —  Principal  Climatic  Regions  and  Health  Resorts 

There  are  insurmountable  diihculties  in  the  classification  of  climates ; 
the  same  degrees  of  latitude,  for  example,  containing  the  most  different 
climates.  Many  French  writers,  especially  Levy,  Rochard,  Fonssangrives 
and  Lacassagne  take  the  mean  annual  temjyerature  with  various  modihca- 
tions ;  but  the  mean  annual  temperature  is  an  imperfect  guide  in  the 
treatment  of  disease,  for  localities  with  the  same  annual  mean  often  differ 
very  widely  in  range  at  the  same  season  or  at  different  seasons.  Thus 
Torquay,  Paris,  and  Odessa  have  approximate  annual  means,  but  the 
following  table  shows  how  different  are  their  seasonal  ranges :  — 


Annual  Temperature. 

Winter. 

Springr. 

Summer. 

Autumn. 

Torquay  about  52°  Fahr. 
Paris  about  51-5°      ,, 
Odessa  about  50-4°    „ 

44-0° 

38-4° 
27-5^ 

50-1° 
60-40 

45-8° 

61 -3° 
64-5° 
70-0° 

53-1° 
52-0° 
50-7° 

Thus  the  difference  between  summer  and  winter  is  for  Torquay  only 
17°,  for  Paris  26°,  for  Odessa  42-5°. 

A  division  according  to  the  temperature  of  the  seasons  would  be 
more  useful,  but  places  with  the  same  winter  temperatures  may  differ 
widely  as  to  equability,  sunshine,  and  humidity. 

Several  authors,  English  and  foreign,  adopt  relative  humidity  as  the 
main  principle  of  classification  (Vivenot,  Walshe,  Pohden,  P.  Niemeyer, 
Thomas),  and  this  arrangement  has  its  advantages ;  but  other  climatic 
factors  may  vary  widely  where  the  relative  humidity  is  almost  the  same. 

All  such  classifications  appear  to  us  so  constrained  that  we  should 
prefer  to  describe  the  several  '"icalities  alphabetically;  but  this  would 
lead  to  much  repetition  and  requ.  -e  more  space. 

We  therefore  propose  to  follow,  with  some  modifications,  the  plan 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  257 

which  has  been  adopted  in  previous  treatises  on  this  subject,'  although 
we  acknowledge  its  imperfections. 

The  sea  exercises  so  powerful  an  influence  on  the  climate  of  the 
localities  adjacent  to  it  that  we  will  consider  these  under  one  great  head 
—  Marine  Climates  (in  distinction  from  Inland  Climates). 

A.  Marine  Climates.  —  As  fully  marine  climates  can  only  be  enjoyed 
on  the  ocean  itself,  we  will  begin  with  a  short  account  of  the  ocean  and 
such  sea-voyages  as  are  best  adapted  to  invalids,  and  then  consider  the 
climates  of  small  islands  and  the  sea-coasts. 

I.  Tlie  Ocean  and  Sea-Voyages.  —  The  climate  of  the  ocean  is  char- 
acterised by  warmth,  equability,  and  considerable  atmospheric  moisture. 
Its  physiological  effects  are  sedative  to  the  nervous  system,  while  at  the 
same  time  appetite  and  digestion  are  much  improved.  The  aseptic 
character  of  the  air,  moreover,  acts  beneficially  both  upon  the  air  pas- 
sages and  the  system  at  large.  The  advantages  which  it  offers  are 
absolute  repose  and  facilities  for  an  open-air  life.  Its  drawbacks  are 
the  coniined  sleeping  space,  the  discomforts  of  cabin  life  in  bad  weather, 
and  in  some  cases  the  monotonous  character  of  the  food. 

The  voyages  most  suitable  to  the  invalid  are  practically  four :  — 
(1)  the  steamship  voyage  to  the  Cape  of  Good  Hope ;  (2)  the  sailing 
voyage  to  Australia;  (3)  the  steamship  voyage  to  Australia;  (4)  the 
steamship  voyage  to  New  Zealand  round  the  Cape. 

The  voyage  to  the  Cape  occupies  about  twenty  days,  and  is  thus  too 
short  for  much  benefit  in  serious  cases ;  but  it  has  great  value  as  a 
remedy  for  overwork  or  tardy  convalescence.  The  heat  in  the  tropics  is 
rarely  injurious,  and  there  is  no  sudden  transition  to  cold. 

The  voyage  to  Australia  on  a  sailing  ship  gives  the  full  benefit  of  the 
marine  climate.  Two  or  three  clipper  ships,  with  special  accommodation 
for  invalids,  sail  in  September  or  October.  The  outward  voyage  takes 
ninety  to  a  hundred  days.  The  log  of  one  of  these  ships  shows  the 
highest  temperature  to  have  been  85°  F.,  the  lowest  49°  F.,  while  the 
difference  between  one  day  and  another  never  amounted  to  more  than 
7°F.  (109).  Except  in  a  long  calm  in  the  equatorial  belt  the  heat  is  not 
severely  felt.  To  obtain  the  benefit  of  the  change  the  patient  should 
be  moderate  in  his  diet  and  take  sufficient  daily  exercise.  With  such 
precautions  selected  cases  will  derive  the  greatest  benefit  from  the  life. 
The  drawbacks  to  the  voyage  are  the  monotony  of  the  life  and  the 
lack  of  fresh  food.  The  return  voyage  might  be  made  in  a  sailing 
ship  round  the  Cape,  or  by  steamer.  A  return  by  Cape  Horn  is  always 
unsuitable.  The  steamship  voyage  offers  more  frequent  places  of  call, 
and  more  frequent  supply  of  fresh  meat  and  vegetables.  On  the  other 
hand  greater  heat  is  experienced  (in  the  Red  Sea),  and  the  greater  speed 
of  the  vessel  makes  the  changes  of  climate  more  sudden.  The  transition 
from  the  Suez  Canal  to  the  Mediterranean  is  a  considerable  danger  on  the 

'  "  Klimato-Thcrapie  "  in  Ziemssen's  Ilandhuch  der  allf/emeinen  Therapie,  vol.  ii. 
part  1,  1880,  English  translation  by  Dr.  Port :  Smith,  Elder  and  Co.,  1885.  Aiid  in  "  Cli- 
mate and  Health  Resorts  "  in  the  Book  0/  Ilmlth.    Cassol  and  Co.,  London,  1883. 

VOL.    I  S 


258 


SYSTEM   OF  MEDICINE 


return  journey.  In  modern  sMps  the  smoke  from  tlie  engines  is  no  longer 
a  real  drawback.  The  times  of  departure  and  return  must  be  carefully 
chosen  in  order  to  avoid  the  hot  months  in  the  Red  Sea  and  the  mon- 
soon in  the  Indian  Ocean ;  it  is  wiser  to  return  by  San  Francisco  than 
to  pass  through  the  Red  Sea  in  the  hot  months. 

In  the  steamship  voyage  to  New  Zealand  the  weather  encountered 
is  very  similar  to  that  met  with  in  the  sailing  voyage,  but  is  shorter, 
and  the  food  more  varied. 

We  may  add  that  in  exceptional  cases  of  hardy  invalids  summer 
voyages  with  whalers  to  the  northern  seas  have  been  tried  with  fairly 
good  results. 

In  the  summer  months  yachting  around  the  coasts  of  England, 
Sweden,  Norway,  and  the  north  of  France  offers  a  good  chance  for  en- 
joying the  advantages  of  marine  climates  without  much  risk. 

A  combination  of  yachting  with  residence  on  land  may  occasionally 
be  carried  out  with  great  advantage  in  the  Mediterranean  during  the 
colder  months. 

II.  Coast  Climates,  including  small  Islands.  —  These  climates,  greatly 
though  they  differ  amongst  themselves,  have  some  points  in  common : 
(1)  The  air  is  comparatively  free  from  organic  dust ;  (2)  it  contains  a 
larger  amount  of  moisture  owing  to  the  constant  evaporation  from  the 
surface  of  the  sea,  and  the  amount  of  moisture  does  not  vary  much; 

(3)  there  is  a  constant  renewal  of  the  atmosphere  by  the  air  currents ; 

(4)  there  is  greater  equability  of  temperature,  not  only  between  differ- 
ent seasons,  but  also  between  the  different  parts  of  day  and  night, 
when  compared  with  inland  climates. 

A  striking  instance  of  this  equability  of  a  climate  almost  entirely 
marine  is  given  by  A.  Buchan  (in  his  suggestive  article  on  "  Climate  "  in 
the  Encyclopcexlia  Britannica)  in  the  island  of  Monach,  situated  about 
seven  miles  westward  from  the  Hebrides,  between  57°  and  58°  N.  "  in 
the  full  sweep  of  the  westerly  winds  of  the  Atlantic  which  there  prevail. 
The  mean  January  temperature  is  43-4°,  being  1-8°  higher  than  the 
mean  of  January  at  Ventnor,  Isle  of  Wight  (nearly  seven  degrees  farther 
south),  0-8°  higher  than  that  of  Jersey  and  Guernsey."  On  the  other 
hand,  the  mean  temperature  of  July  is  55-0°  at  Monach  and  62-4°  at 
Ventnor.  Monach  has  therefore  warmer  winters  and  cooler  summers 
than  an  ordinary  coast  climate  farther  south. 

The  effects  of  the  sea-side,  although  varying  considerably  according 
to  constitutions  and  localities,  may  be  said  to  improve  the  appetite,  the 
mental  and  bodily  energy,  the  condition  of  the  skin,  the  sleep,  and 
metabolism  of  tissues.  Such  changes  are  very  useful  in  many  cases  of 
weakness  without  actual  disease,  during  convalescence  from  disease,  in 
climacteric  conditions,  and  in  people  who  are  said  to  be  "  run  down  '•  from 
work  or  social  exertions  and  worry.  These  climates  are  invaluable  in 
the  physical  training  of  children  disposed  to  scrofulous  diseases  and  allied 
conditions.  They  require,  however,  a  certain  degree  of  resistance,  and,  in 
many  persons,  special  attention  to  the  action  of  the  bowels.     They  are 


CLIMATE   IN    THE    TREATMENT   OF   DISEASE  259 

mostly  unsuitable  for  chronic  affections  of  the  heart  with  great  dilata- 
tion, for  some  kinds  of  asthma,  and  for  skin  diseases.  Although  the 
numerous  varieties  in  the  climatic  conditions  of  different  marine  regions 
render  subdivision  necessary,  yet  different  localities  in  the  same  region 
and  very  near  to  one  another  may  present  varieties  of  climatic  elements, 
such  as  aspect,  elevation,  degree  of  shelter,  and  so  forth. 

As  the  degree  of  humidity  of  the  air  exercises  great  influence  on  the 
equability  of  climates  and  on  the  functions  of  the  body,  we  will  adopt  it 
with  C.  T.  Williams,  Thomas,  and  others,  as  the  principle  of  the  greater 
subdivisions,  and  use  the  differences  of  temperature  for  the  formation 
of   sub-classes. 

If  we  adopt  as  subdivisions :  1.  Humid  marine  climates ;  2.  Marine 
climates  with  moderate  or  slight  humidity,  we  must  confess  that  no 
thorough  lines  of  demarcation  can  be  drawn,  and  that  some  of  the 
localities   placed  in  sub.  1  might  claim  a  place  in  sub.  2. 

1.  Humid  Marine  Climates.  —  There  are  great  differences  in  this  sub- 
division according  to  the  temperature.  We  are,  however,  principally 
concerned  with  the  warmer  climates,  of  which  Madeira  may  be  taken  as 
a  type.  The  opinions  on  the  climato-therapeutic  value  of  Madeira  have 
varied  considerably.  In  former  years  it  was  considered  by  many  authors 
as  the  best  climate  for  consumption,  while  at  present  many  regard  it  as 
the  worst.  We  will  endeavour  to  give  a  short  description,  and  refer  for 
further  information  to  the  works  of  Renton,  Clark,  Mittermaier,  Lund, 
Grabham,  Goldschmidt,  Langerhans,  and  others.  The  Madeira  Islands 
are  situated  between  32°  and  34°  N.  and  between  16°  and  17°  W.  The 
climate  of  Funchal,  the  principal  town,  is  remarkably  equable ;  the  mean 
moisture  varies  between  70°  and  74°,  but  is  subject  to  variations  from 
air  currents.  The  number  of  rainy  days  is  mostly  above  fifty.  The 
mean  annual  temperature  is  65°  F.  —  winter  about  61°,  spring  62°, 
summer  69-5°,  autumn  67°.  Lowest  night  temperature  rarely  below 
43°;  highest  day  rarely  above  86°.  Mean  differences  between  night 
and  day  about  9°,  from  one  day  to  another  about  14°.  Funchal  is  not 
exempt  from  winds,  but  the  air  is  usually  calm  from  7  to  9  a.m.,  at 
which  hour  sea-breezes  blow  till  3  p.m.  ;  land  winds  set  in  later  at 
night.  The  air  is  free  from  dust  and  rich  in  ozone ;  the  character  of  the 
climate  is  sedative,  to  some  people  relaxing.  It  has  great  power  to  allay 
coughs  in  chronic  catarrh  with  irritability  of  the  mucous  membrane ; 
but  many  people  after  some  weeks  feel  depressed,  lose  appetite,  and 
have  a  tendency  to  diarrhoea.  A  disadvantage  of  Funchal  is  the  steep- 
ness of  the  hillside  on  which  it  lies,  and  the  consequent  difficulty  of 
getting  above  the  houses  on  foot. 

As  to  the  effect  on  tubercular  consumption,  the  result  of  the  experi- 
ment made  by  the  authorities  of  the  Brompton  Hospital  on  twenty 
selected  cases  of  consumption  has  not  been  satisfactory,  and  we  know 
ourselves  of  a  rather  large  proportion  of  unfavourable  cases ;  but,  on  the 
other  hand,  we  have  seen  better  effects  than  at  most  other  places  in 
elderly  persons  with  much  loss  of  lung  and  emphysema,  in  complica- 


26o  SYSTEM   OF  MEDICINE 

tions  with  albuminuria,  and  in  weak  and  irritable  people  with  rapid 
pulse  (the  erethic  type).  The  beauty  of  the  vegetation,  the  scenery,  and 
the  easy  life  of  Madeira  exercise  on  some  persons  so  great  a  cliarm  that 
it  is  impossible  to  dissuade  them  from  going  thither,  even  if  they  are 
told  that  they  could  do  better  elsewhere.  More  than  once,  especially 
in  former  years,  patients  would  tell  us  they  would  rather  die  in  the 
enjoyment  of  the  sub-tropical  beauty  of  Funchal  than  light  for  life 
in  the  "ice-bound  Alps,"  or  at  the  "dusty  Riviera,"  or  in  "sunless 
England."  And  such  mental  conditions  have  a  claim  on  our  sympathy. 
This  climate  is  more  generally  beneficial  in  cases  of  chronic  bronchial 
and  laryngeal  catarrh,  and  in  emphysema  with  scanty  expectoration  than 
in  pulmonary  tuberculosis ;  but  in  cases  with  copious  discharges  from 
the  mucous  membranes,  atonic  dyspepsia,  and  tendency  to  diarrhoea, 
Madeira  and  allied  climates  are  to  be  avoided. 

Similar  remarks  may  be  applied  to  the  Azores,  which  are  little  used 
as  climatic  resorts. 

The  Canaries,  with  Teneriffe  and  the  Grand  Canary,  have  in  common 
with  Madeira  the  equability  of  the  climate,  but  have  a  slightly  higher 
temperature  and  are  decidedly  drier,  so  that  they  might  claim  a  place  in 
the  subdivision  of  moderate  humidity.  They  are  mentioned  here  princi- 
pally on  account  of  their  situation  near  Madeira.  The  heat  of  the  day 
is  tempered  and  the  coolness  of  the  night  is  diminished  on  Teneriffe  by  a 
layer  of  mist  between  3000  and  5000  feet  above  the  sea-level.  On  the  Peak, 
above  this  layer  of  mist,  Dr.  Marcet  found  the  climatic  conditions  very  dif- 
ferent, viz.,  hot  days,  cold  nights,  and  great  dryness  of  air.  The  Canaries 
have  a  greater  claim  as  health  resorts  than  Madeira,  and  offer  good  accom- 
modation, but  are  much  wanting  in  means  of  amusement  (53,  35,  60). 

Of  Mogador,  on  the  north-west  coast  of  Africa,  we  owe  a  written 
account,  based  on  personal  experience,  to  the  late  Dr.  Leared,  who 
describes  it  as  one  of  the  most  equable  climates.  Mean  annual  tem- 
perature 67°  F.,  mean  winter  61°,  mean  summer  72°,  mean  hottest 
month  80°,  mean  coolest  59°,  relative  humidity  78°.  Number  of  rainy 
days  44,  of  clear  days  270.  It  is  under  the  influence  of  the  Atlantic ; 
is  sheltered  from  the  desert  winds  by  the  Atlas  chain.  Accommodation 
is  as  yet  limited. 

Cadiz,  on  the  island  of  Leon,  on  the  south-west  coast  of  Spain,  may 
be  placed  in  this  group.  It  partakes  of  the  character  of  the  Atlantic  as 
well  as  of  the  Mediterranean,  has  about  one  hundred  rainy  days  in  the 
year,  and  an  average  relative  humidity  of  76°;  the  mean  winter  and 
spring  temperatures  are  about  59°  F. ;  the  average  daily  range  is  only 
10-5°  F.  AVe  have  seen  some  satisfactory  results  from  this  resort  in 
early  cases  of  consumption  in  weakly  and  irritable  persons,  but  the 
hotels  are  situated  in  the  midst  of  the  town,  and  are  scarcely  suitable  to 
invalids.  Only  persons,  therefore,  who  have  to  earn  their  livelihood  at 
the  place  ought  to  be  sent  there.  San  Lucar,  in  the  same  region,  with 
a  similar  but  somewhat  drier  climate,  is  recommended  by  Spanish  phy- 
sicians at  the  commencement  of  tubercular  phthisis. 


CLIMA  TE  IN  THE    TREA  TMENT   OF  DISEASE  261 

In  the  southern  hemisphere,  where  the  sea  predominates  more  than  in 
the  northern,  there  are  several  islands  with  moist  and  warm  climates, 
which  under  especial  circumstances  may  be  used  as  health  resorts, 
especially  Tahiti,  in  the  Society  Islands,  the  Tristan  cfAcunha  group,  the 
Feejee  (Fidji,  Fiji,  or  Viti),  the  Friendly  or  Tonga  Islands;  but  the  ac- 
commodation and  hygienic  conditions  are  as  yet  defective. 

The  groups  of  islands  situated  to  the  east  of  Central  America,  and 
comprised  under  the  collective  name  of  the  West  Indies  (from  10°  to  27° 
K.L.)  find  a  place  among  the  warm  and  humid  marine  climates.  They 
possess  rather  uniform  high  temperatures,  varying  in  the  different  islands 
between  about  68°  F.  and  83°  F.  Their  action  is  rather  sedative  and 
relaxing.  Diseases  of  the  digestive  organs  are  prevalent ;  and  only  in 
exceptional  cases  can  they  be  recommended  to  invalids  suffering  from 
irritable  catarrhs  of  the  respiratory  mucous  membranes.  Dr.  C.  T. 
Williams  (105)  reports  a  favourable  result  in  a  consumptive  young 
physician  at  Jamaica;  E.  H.  Bakewell  {Practitioner,  1878)  has  a  rather 
high  opinion  of  Barbados ;  and  we  have  ourselves  seen  some  fairly  satis- 
factory results  in  emphysema  with  chronic  pulmonary  catarrh,  and  in  two 
cases  of  phthisis  —  one  at  Jamaica,  the  other  at  Barbados ;  but  unfavour- 
able results  have  prevailed  in  our  experience,  especially  through  failure 
of  the  digestive  system  with  loss  of  appetite  and  chronic  diarrhoea,  so 
that  we  can  scarcely  recommend  these  localities  excepting  in  cases  where 
the  choice  of  climate  is  limited  by  other  circumstances. 

The  climate  of  the  peninsula  of  Florida,  extending  from  24°  to  31°  N., 
resembles  that  of  the  West  Indies,  but  is  less  relaxing.  In  July,  August, 
and  September  fevers  are  prevalent,  but  they  are  rare  during  the  re- 
mainder of  the  year.  Florida  enjoys  some  reputation  in  North  America 
as  a  mild  winter  resort  for  delicate  persons  suffering  from  emphysema, 
chronic  bronchial  catarrh,  and  early  phthisis.  The  adjacent  coasts  of 
Georgia  and  South  Carolina  have  somewhat  similar  climates,  but  they 
are  more  under  the  influence  of  the  continent,  and  have  lower  average 
temperature  and  humidity. 

Humid  and  cool  marine  climates  are  rarely  used  in  climatic  treatment, 
but  they  are  very  interesting  on  account  of  their  great  equability  of  tem- 
perature. The  best  known  localities  belonging  to  Europe  are  the  Hebrides, 
the  Orkneys,  the  Shetland  Islands,  the  Faroe  Islands  and  Iceland ;  and 
in  the  southern  hemisphere  the  Auckland  and  Falkland  Islands. 

2.  Marine  Climates  with  Moderate  or  Slight  Humidity.  —  Amongst 
the  warmer  localities  of  this  sub-section  those  of  the  Mediterranean  coasts 
are  of  the  greatest  interest  to  us.  They  are  all  under  the  powerful 
influence  of  this  remarkable  inland  sea,  which  differs  from  the  Atlantic 
and  Pacific  in  its  freedom  from  polar  currents,  and  in  its  temperature 
which  down  to  its  greatest  depths  (1500  to  2000  fathoms)  is  54°  to  56° ; 
while  in  the  Atlantic,  outside  the  Straits  of  Gibraltar,  the  temperature 
at  the  same  depth  is  only  35-6°  to  37°.  The  Strait  of  Gibraltar  is  so 
shallow  that  it  does  not  admit  the  polar  stream  of  the  Atlantic. 

Although  all  the  localities  on  the  shores  of  the  Mediterranean  have 


262  SYSTEM  OF  MEDICINE 

some  points  in  common,  yet  the  several  tracts  offer  considerable  differ- 
ences.    The  Riviera  has  the  first  claim  on  our  attention. 

The  Riviera  stretches  from  Toulon  to  Genoa.  The  region  consists  for 
the  most  part  of  a  plain  from  two  to  four  miles  in  width,  extending  from 
the  sea  to  the  lower  spurs  of  the  mountains  which  everywhere  guard 
the  coast.  From  these  lower  slopes  the  mountains  rise  rather  steeply  to 
a  height  of  from  2000  to  3000  feet,  affording  everywhere  a  shelter  from 
the  north,  and  generally  from  the  north-east  and  north-west.  The  coast 
consists  of  a  series  of  headlands,  between  which  stretch  gently-curved 
bays,  on  whose  shores  the  main  resorts  are  situated.  The  character- 
istics of  the  climate  are  as  follows  :  — 

(a)  Warmth.  —  Greater  than  that  of  other  localities  in  the  same  lati- 
tude. This  greater  warmth  is  due  to  three  causes :  (1)  The  complete 
shelter  from  northerly  winds  ;  (2)  Radiation  from  the  mountains  during 
the  colder  parts  of  the  day  and  year;  (3)  The  presence  of  the  Mediter- 
ranean Sea,  wliich  is  some  5°  warmer  than  the  atmosphere.  The  mean 
temperature  for  the  six  winter  months  varies  from  50-8°  to  51-5° ;  for  the 
months  of  December,  January,  and  February,  it  varies  from  47°  to  49°  F. 

(h)  Dryness.  —  Unlike  most  of  the  marine  climates,  the  Riviera  is 
distinguished  for  its  dryness,  the  mean  relative  humidity  being  about 
65°  to  70°  during  the  winter  months. 

(c)  Abimdant  Sunshine.  —  During  the  six  months  of  winter  generally 
from  100  to  120  days  are  fine. 

(d)  Small  Rainfall.  —  With  few  rainy  days,  the  rainfall  varies  from 
28  to  31  inches,  and  a  great  part  of  this  falls  between  the  end  of  Sep- 
tember and  the  beginning  of  November.  In  such  a  climate  some  hours 
of  almost  every  day  can  be  passed  out  of  doors. 

There  are,  however,  several  very  distinct  drawbacks  to  the  climate : 
(a)  The  great  frequency  of  high  winds,  principally  in  the  spring,  mainly 
from  the  north-east  and  north-west.  (/3)  The  great  difference  between 
sun  and  shade  temperature,  thus  increasing  the  danger  of  chill,  (y)  The 
rapid  fall  of  temperature  at  sunset,  which  compels  the  invalid  to  return 
home  before  that  hour. 

The  physiological  effects  of  the  climate  are  exerted  for  the  most  part 
on  the  nervous  system;  the  climate  is,  with  a  good  deal  of  truth, 
described  as  exciting.  Sleeplessness  is  a  common  complaint  on  first 
reaching  the  coast,  but  in  most  cases  soon  passes  off.  Neuralgia,  on  the 
other  hand,  is  often  aggravated,  and  any  hysterical  or  melancholic 
tendency  is  frequently  made  worse.  Most  persons,  however,  feel 
invigorated  both  in  mind  and  body.  Considerable  care  is  necessary  to 
avoid  catching  a  chill.  Exposure  to  sudden  changes  of  temperature  does 
not  so  frequently  lead  to  a  cold  in  the  head,  or  tracheo-bronchitis,  as  at 
home,  but  more  often  causes  an  attack  of  diarrhoea  or  even  of  colitis. 

The  several  resorts  to  be  considered  are :  — 

(i.)  Hyh'es,  situated  about  three  miles  from  the  sea.  The  mean  winter 
temperature  is  50-6°  F.  (Biden).  Relative  humidity  73°.  It  is  not, 
however,  very  well  protected  from  the  north,  and  is  much  exposed  to  the 


CLIMATE  IN   THE    TREATMENT  OF  DISEASE  263 


north-west,  whence  the  mistral  blows  in  the  spring.  In  other  respects, 
being  somewhat  more  distant  from  the  sea,  it  is  not  so  exciting  as  are 
the  other  resorts ;  patients  sleep  better,  and  hysterical  women  suffer  no 
aggravation  of  their  symptoms. 

(ii.)  Costa  Belle,  nearer  the  sea,  is  much  better  protected  from  winds, 
is  more  wooded,  and  not  quite  so  dry. 

(iii.)  St.  Raphael  and  Valescure,  near  Frejus.  The  former  is  near 
the  sea-shore,  the  latter  some  short  distance  inland.  They  are  not  very 
Avell  protected  by  mountains,  but  are  surrounded  by  pine  woods.  The 
mean  temperature  is  somewhat  lower  than  that  of  the  other  resorts. 
They  are  better  suited,  perhaps,  to  a  more  vigorous  class  of  case,  and 
are  not  so  exciting  as  the  more  easterly  resorts.  Some  forms  of  asthma, 
neuralgia,  and  irritability  of  the  skin  do  better  there  than  at  the  more 
eastern  places  of  the  Riviera  di  Ponente. 

(iv.)  Cannes  has  a  mean  temperature  of  50-85°  for  six  winter  months, 
and  a  mean  relative  humidity  of  73°  (53)  ;  it  is  the  largest  of  the  mere 
health  resort  towns  along  the  coast.  To  the  north  the  protection  is  not 
by  any  means  complete ;  the  higher  ridges  of  the  Alps  are  too  far  re- 
moved from  the  sea  to  afford  adequate  shelter  from  this  quarter.  It  is 
well  protected,  however,  on  the  east  and  west.  The  mistral  blows  fre- 
quently in  February  and  March.  The  majority  of  the  patients  find  the 
climate  bracing  to  the  body  and  exhilarating  to  the  mind,  but  it  pos- 
sesses to  a  marked  degree  the  quality  of  an  excitant  to  the  nervous  sys- 
tem. Invalids  requiring  much  shelter  can  do  better  elsewhere  than  at 
Cannes ;  on  the  other  hand,  patients  who  require  a  bracing  and  yet  warm 
climate  will  fare  better  at  Cannes.  Cannes  enjoys  the  advantage  of  offer- 
ing several  residential  localities  with  distinct  varieties  of  climate.  There 
is  a  warmer  district  near  the  sea,  while  more  bracing  and  less  exciting 
situations  inland  can  be  found  on  the  Californie  and  in  the  district  of 
Cannet.  Patients  who  find  the  sea-shore  too  exciting  often  benefit  by  a 
removal  to  the  latter. 

(v.)  Grasse,  situated  behind  Cannes  at  an  elevation  of  1000  feet, 
possesses  a  cooler  climate,  and  forms  a  useful  intermediate  station  dur- 
ing April  and  May  for  patients  who  find  the  heat  in  those  months 
already  too  oppressive  at  Cannes. 

(vi.)  Antibes,  situated  on  the  headland  of  that  name,  now  possesses 
an  excellent  hotel.  It  is  perhaps  not  sufficiently  sheltered  for  serious 
invalids,  but  hardier  ones  find  it  a  pleasant  climate  and  the  centre  of 
beautiful  excursions. 

(vii.)  Nice,  the  largest  town  upon  the  coast,  was  formerly  also  its 
principal  health  resort.  Latterly,  however,  it  has  somewhat  fallen  into 
disfavour  on  account  of  the  piercing  winds  which  visit  it  in  winter  and 
the  irritating  dust  of  the  roads.  The  suburbs,  however,  of  Carabacel, 
Cimiez,  and  Mont  Boron  present  many  attractions;  they  are  moderately 
sheltered  and  possess  one  advantage,  namely,  distance  from  the  sea. 
Some  persons  when  residing  near  the  sea  always  suffer  from  constipa- 
tion or  other  digestive  disturbance,  or  are  troubled  by  insomnia.     Such 


264  SYSTEM   OF  MEDICINE 

symptoms  are  often  entirely  removed  by  a  change  to  a  residence  a  mile 
or  two  inland. 

(viii.)  Villefranclie  and  Beaulieu  lie  between  Nice  and  Monaco  ;  both 
possess  considerable  advantages  as  to  shelter  and  temperature. 

(ix.)  Monte  Carlo  is  certainly  one  of  the  most  sheltered  situations 
on  the  coast.  The  presence  of  the  gaming  tables,  however,  offers  an 
insuperable  objection  to  its  being  seriously  considered  as  a  health  resort. 

(x.)  Mentone.  —  Mean  temperature  for  winter  months  51 -o",  mean 
relative  humidity  72-8°.^  This  place,  owing  to  the  advocacy  of  the  late 
Henry  Beunst,  has  perhaps  obtained  the  greatest  celebrity  as  a  health 
resort.  The  town  proper  is  situated  on  a  tongue  of  land,  which  sepa- 
rates the  bay  into  an  eastern  and  western  portion.  The  eastern  bay  of 
Mentone  is  admirably  sheltered,  the  mountains  rising  on  all  sides  sharply 
from  the  sea.  It  possesses  the  warmest  temperature  for  the  winter 
months  of  any  resort  on  the  Riviera.  For  cases  requiring  absolute 
shelter  and  warmth  it  is  superior  to  any  locality  on  the  coast.  Many 
persons,  however,  find  it  relaxing,  while  the  steep  rise  of  the  mountains 
compels'  a  residence  close  to  the  sea,  with  the  ill  effects  which  such  a 
position  exerts  upon  some  temperaments.  On  the  whole,  however,  in 
those  qualities  by  virtue  of  which  the  Riviera  climate  is  most  to  be 
esteemed  it  may  be  considered  rich.  The  western  bay,  on  the  other 
hand,  is  less  sheltered  and  more  bracing,  and,  owing  to  the  larger  space 
away  from  the  sea,  is  adapted  to  a  larger  number  of  cases,  though  not  so 
peculiarly  suitable  for  a  few.  Cap  Martin,  in  the  vicinity,  must  also  be 
mentioned. 

(xi.)  Borclighera  is  well  protected  from  the  north-east  and  the  west, 
but  through  the  valleys  in  the  north-west  the  wind  finds  access.  The 
chief  hotels  and  villas,  however,  are  not  situated  by  the  sea-shore,  and 
by  the  intervention  of  a  spur  of  the  mountains  obtain  adequate  protec- 
tion from  that  quarter.  The  temperature  is  for  the  winter  months 
somewhat  lower  than  at  Mentone,  but  the  climate  is  more  bracing. 
The  exciting  effects  of  the  Riviera  climate  are  also  not  so  marked  as  at 
places  farther  westward. 

(xii.)  San  Remo  has  a  mean  temperature  for  six  months  of  50-55° 
(36)  ;  a  mean  relative  humidity  of  68°.  It  lies  eight  miles  from  Bordi- 
ghera,  and  Avell  sheltered  from  the  north  and  north-west,  the  mistral 
occurring  but  once  or  twice  in  the  winter  months.  On  the  other  hand 
the  east  Avind  is  prevalent.  The  exciting  effects  of  the  climate  are  not 
so  marked,  but  to  some  cases  it  will  not  be  found  so  well  adapted  as 
the  east  bay  of  Mentone. 

(xiii.)  Alassio,  twenty-eight  miles  east  of  San  Remo,  is  well  sheltered 
from  the  north  and  north-west  and  west ;  it  is,  however,  exposed  to  the 
east  and  north-east.  The  loAver  spurs  of  the  mountains  are  admirably 
sheltered  from  this  quarter,  but  unfortunately  all  the  hotels  are  situated 
on  the  sea-shore,  and  are  consequently  exposed. 

(xiv.)  Pegli,  six  miles  from  Genoa,  the  last  of  the  resorts  on  the 
1  Andrew,  quoted  by  Marcet. 


CLIMATE  IN   THE    TREATMENT  OF  DISEASE  265 

Western  Eiviera,  is  sheltered  on  the  north,  north-west,  and  west,  but 
exposed  to  the  east.  It  is,  however,  not  sufficiently  organised  for  the 
reception  of  other  than  the  hardier  class  of  invalids.  The  climate  is  more 
humid  and  less  exciting  than  the  westerly  resorts. 

By  the  end  of  October  the  weather  will  be  cool  enoiigh  to  render  any 
of  these  resorts  suitable  for  invalids.  It  is  rarely  prudent  to  prolong 
the  stay  beyond  the  end  of  April,  and  never  to  spend  the  summer  on 
the  coast. 

Eastern  Riviera.  —  The  continuation  of  the  coast-line  from  Genoa  to 
Pisa,  usually  called  the  Riviera  di  Levante,  is  less  dry  than  that  between 
Cannes  and  San  Remo,  and  somewhat  less  protected  froni  cold  winds, 
the  mountain  chain  being  low  and  broken;  otherwise  there  is  some 
similarity  between  them.  Nervi,  near  Genoa,  has  the  principal  claim  as 
a  health  resort.  It  is  fairly  well  protected  from  cold  winds,  and  is  less 
exciting  than  the  majority  of  localities  on  the  Western  Riviera.  The 
mountains  come  so  near  to  the  coast  that  the  excursions  for  the  invalid 
are  limited ;  but  those  requiring  repose  find  it  helpful,  the  more  so  as 
there  is  not  much  temptation  to  social  dissipation.  Other  localities 
picturesquely  situated,  but  not  so  well  protected,  are  Spezia,  Chiavari, 
Ra'pallo,  and  Santa  Margherita.  A  rising  health  resort,  for  bathing  in 
summer  and  shelter  in  winter,  is  Viareggio,  about  twelve  miles  north  of 
Pisa.  The  shelter  is  principally  due  to  the  large  pine  forests  in  the 
neighbourhood. 

Pisa,  although  six  miles  from  the  sea,  may  likewise  be  mentioned 
here,  since  the  climate  partakes  both  of  marine  and  of  inland  characters. 
It  is  rather  humid,  and  not  well  protected ;  the  sky  is  often  dull,  but 
it  is  comparatively  free  from  mists.  The  winter  temperature  is  about 
2°  to  21°  lower  than  at  the  Western  Riviera.  It  is  now  less  frequented 
than  in  former  years. 

Genoa  and  Leghorn  are  too  much  exposed  to  be  regarded  as  health 
resorts. 

Southern  Italy  is  rich  in  charms  of  nature  and  historical  associations. 
The  accommodation  at  the  principal  places  is  good,  and  the  hygienic 
arrangements  are  improving ;  the  climate  is  sunny,  but  by  no  means  free 
from  cold  northerly  and  north-westerly  winds,  especially  in  spring. 
Naples  has  considerably  gained  of  late  by  a  good  water  supply.  Castella- 
mare,  Sorrento,  and  Amalfi  have  good  autu.mn  climates,  and  Amalfi  is  also 
well  sheltered  in  spring.  The  islands  of  Capri  and  Iscliia  have  many 
attractions,  but  are  not  sufficiently  sheltered  from  cold  winds,  nor  are 
they,  as  yet,  thoroughly  hygienic. 

The  island  of  Sicily  is  not  much  recommended  by  English  physicians, 
nor  can  careful  medical  supervision  be  had  there  ;  but  the  great  beauty 
of  the  country,  and  the  many  historical  and  archaeological  points  of  inter- 
est, have  their  favourable  influence,  and,  combined  with  light  and  sun, 
have  led  to  recovery  or  great  improvement  in  many  cases  of  overwork, 
of  invalidism  allied  to  the  neurasthenic  type,  of  rheumatism,  slighter 
degrees  of  glycosuria,  and  tendency  to  premature  senile  decay  in  its 


266  SYSTEM  OF  MEDICINE 

various  forms.  The  sirocco  is  occasionally  irritating  and  depressing. 
Rain  rarely  falls  in  summer,  but  abundantly  in  late  autumn  and  winter. 
The  mean  humidity  is  moderate  —  rather  higher  at  Palermo  and  the  north 
coast  than  on  the  east  coast.  Good  accommodation,  with  fair  sanitary 
arrangements,  is  to  be  found  at  Palermo,  Taormina,  Acireale,  Catania,  and 
/Syracuse.  '  The  Hotel  des  Temples  at  Girgenti  is  now  open  again. 

On  the  south-west  of  the  Mediterranean,  Tanrfiersin  Morocco  is  under 
the  combined  influence  of  the  Atlantic  and  the  Mediterranean,  and,  owing 
to  the  former,  approaches  more  the  humid  than  the  dry  class  of  marine 
climates.  The  winter  temperature  lies  between  57°  and  62° ;  the  prin- 
cipal rains  in  jSTovember  and  December.  The  late  Dr.  Leared  and  most 
of  those  who  have  resided  there  describe  the  winter  and  spring  as 
delightful.  The  absence  of  carriage  roads  and  the  want  of  public  security 
are  for  the  present  great  draAvbacks  to  its  usefulness. 

Gibraltar  may  be  mentioned  in  this  group,  bat  it  can  scarcely  be 
called  a  health  resort. 

Valencia  has  often  been  recommended  on  account  of  its  mild  and 
equable  climate,  but  the  effects  of  the  irrigation  of  adjacent  rice  fields  are 
injurious  to  most  invalids.  Barcelona  is  rathered  sheltered  by  a  range  of 
hills  from  northerly  winds,  has  good  accommodation  and  fine  walks. 
Alicante,  like  the  v/hole  coast  of  Murcia,  is  rather  more  dry.  Malaga  is 
described  by  Dr.  Francis,  who  has  studied  the  climates  of  Spain,  as  the 
mildest  place  in  Europe ;  it  has  a  dry  soil,  a  south-eastern  aspect,  and 
is  surrounded  by  a  semicircle  of  mountains,  but  it  is  not  sufficiently 
sheltered  from  the  cold  north-west  winds.  The  temperature  in  winter  is 
about  5o°  ¥.,  in  spring  62° ;  the  daily  range  scarcely  o°.  The  number 
of  rainy  days  is  about  40. 

Algiers  consists  of  the  old  Moorish  town  and  the  French  settlement,  of 
which  the  slope  of  Mastapha  Sup&rieur  and  the  road  thence  to  El  Biar  are 
the  most  satisfactory  localities  for  residence.  The  mean  temperature 
during  the  invalid  season,  from  the  end  of  October  to  the  end  of  April, 
is  about  57°  to  52°  F.,  and  the  average  number  of  rainy  days  is  between 
45  and  65.  The  soil  is  so  porous  that  the  rain  seldom  keeps  an  invalid 
at  home  the  whole  day.  Rain  usually  falls  heavily ;  there  is  rarely 
a  drizzle.  The  sirocco  is  rare  dunng  the  invalid  season,  but  it  blows 
occasionally,  and  exerts  on  some  persons  a  relaxing  effect,  being  hot, 
sultry,  and  dry.  At  few  places  is  the  difference  of  winters  so  great 
as  at  Algiers ;  two  seasons  are  rarely  alike.  As  a  rule,  however,  No- 
vember, April,  and  part  of  May  are  like  a  fine  summer  in  England  ; 
December  to  March  like  autumn,  but  with  a  greater  share  of  sunshine. 
The  air  of  Algiers  is  much  less  dry  than  at  the  Western  Riviera;  the 
hills  are  covered  with  evergreen  shrubs  and  woods.  The  neighbourhood 
of  Mustapha  is  rich  in  beautiful  walks,  and  good  carriage  roads  extend 
in  every  direction. 

People  who  stay  the  winter  in  Algiers  may  spend  part  of  their  time 
at  Hammam  Meskouttin  or  Hamman  Tflrlia,  with  their  well-known  hot 
springs ;  or  at  Biskra. 


CLIMATE  IN-  THE    TREATMENT   OE  DISEASE  267 


Biskra,  a  place  of  growing  importance,  is  a  union  of  several  villages 
or  urban  quarters,  lying  among  plantations  of  date-palms  and  evergreen 
trees,  N.  lat.  34°  51',  on  the  outskirts  of  the  Algerian  Sahara,  at  an 
elevation  of  about  360  feet  above  sea-level.  It  thus  partakes  of  the 
characters  of  desert  climates,  excepting  when  northern  winds  prevail ; 
and  enjoys  during  the  six  colder  months  of  the  year  many  climatic 
advantages.  It  is  much  drier  and  sunnier  than  the  neighbourhood 
of  Algiers  itself ;  but  it  is  subject  to  violent  winds  which  for  days 
together  may  prevent  outdoor  exercise.  Another  disadvantage  is  that 
the  water  contains  too  much  salt  for  drinking  and  some  cooking  pur- 
poses. There  is  good  hotel  accommodation,  and  the  place  is  likely  to 
become  a  satisfactory  health  resort  for  fairly  hardy  invalids  requiring 
warm  and  dry  air.  The  railway  journey  occupies  at  present  from  Al- 
giers two  days,  from  Constantine  one.  There  are  hot  springs  a  few  miles 
from  Biskra,  at  "'  Fontaine  chaude,"  Hammam  Salaliin  ("■'  Bath  of  the 
Saints '')  but  the  arrangements  are  not  yet  suited  even  for  moderately 
fastidious  people. 

Tlie  Slopes  of  the  Leba7io:i  offer  an  excellent  climate,  only  varying  with 
the  height  above  sea-level  —  the  higher,  of  course,  the  colder.  The  view 
of  the  hills  and  of  the  sea  below  is  glorious.  In  the  summer  months 
grapes,  figs,  and  other  fruits  abound.  The  hotels  are  said  to  be  good, 
especially  at  Alai,  three  hours'  drive  above  Beyrout  (or  two  hours  by  the 
new  railway).  The  cost  of  board  and  lodging  is  usually  about  seven 
shillings  a  day  per  head.  Dr.  Canney,  of  Luxor,  tells  us  that  Brumana, 
on  a  fir-clad  crest  near  Beyrout,  is  a  pleasant  health  resort,  and  probably 
a  little  better  than  Alai. 

Ajaccio  in  Corsica  has  a  mean  annual  temperature  of  62-5°  F.  ■ — 
autumn  66-7°,  winter  52°,  spring  60-3°,  summer  76-7°.  The  number  of 
clear  sunny  days  is  great ;  the  humidity  is  greater  than  on  the  Eiviera. 
It  is  almost  completely  protected  from  cold  winds.  The  accommodation 
is  good.  The  climate  is  less  exciting  than  that  of  the  Biviera,  and  some 
invalids,  who  suffer  from  sleeplessness  and  neuralgia  at  the  Biviera,  feel 
better  at  Ajaccio.  The  best  time  is  from  the  beginning  of  November  to 
the  middle  of  April.  Summer  stations  can  be  found  on  the  mountains 
for  those  who  are  not  fastidious. 

The  Sanguinaires,  small  rocky  islands  near  Ajaccio,  have  a  still  more 
decided  marine  climate,  but  the  accommodation  is  as  yet  poor. 

The  climates  of  the  shores  and  islands  of  the  Adriatic  Sea  are  very 
different  from  those  on  the  western  side  of  Italy.  The  predominant 
defects  are  the  prevalence  of  the  dry  and  cold  wind  from  the  north,  the 
bora  or  tramontana  —  a  land  wind;  and  the  moist  and  warm  sirocco  — 
a  sea-wind.  The  change  between  these  two  winds  is  accompanied  by 
great  variations  in  the  temperature  and  in  the  relative  humidity  of  the 
air,  which  are  not  well  borne  in  irritable  states  of  the  nervous  system 
or  by  pulmonary  invalids. 

Venice,  the  best  known  of  these  localities,  enjoyed  in  former  years  a 
great  reputation  in  the  treatment  of  consumption,  and  has  the  advantage 


268  SYSTEM  OF  MEDICINE 

of  being  free  from  dust  and  having  good  accommodation  and  artistic 
attractions.  Goerz,  near  the  north-west  corner  of  the  Adriatic,  and  Vo- 
losca  and  Abhazia  near  the  north-east  shore,  possess  some  shelter  and 
beautiful  positions,  but  cannot  compete  for  English  invalids  with  the 
Riviera  di  Ponente.  Amongst  the  islands  only  Lesina  and  Lissa  need 
be  mentioned;  they  possess  rather  more  equable  climates  than  the 
shores,  and  some  accommodation. 

In  the  Ionian  Islands  the  only  place  which  has  some  pretension  to  be 
a  health  resort  is  Corfu.  The  beauty  of  the  position  of  the  town  of  Corfu 
is  great,  and  the  whole  island  is  beautiful ;  but  it  is  too  much  exposed 
to  wind,  and  the  temperature  and  humidity  of  air  vary  considerably. 

The  south-west  coast  of  France  possesses  a  few  localities  which  deserve 
to  be  mentioned. 

Biarritz  is  fully  exposed  to  the  influence  of  the  Atlantic ;  it  is  bright, 
and  exercises  on  most  people  a  bracing  influence  in  spite  of  a  rather  high 
degree  of  humidity  and  frequent  rains.  It  is  not  suitable  to  persons 
requiring  shelter  ;  but  many  old  Indians  with  their  complicated  cachexias 
derive  much  benefit  from  this  climate,  which  also  offers  a  useful  change 
to  invalids  wintering  at  Pau  and  Arcachon.  St.  Jean  de  Luz,  a  little  to 
the  south  of  Biarritz,  has  a  similar  climate. 

A  different  kind  of  climate  is  that  of  Arcachon,  which  is  situated  on 
the  shores  of  a  large  basin  of  salt  water  connected  with  the  actual  sea  by 
a  narrow  channel.  The  influence  of  the  sea  is,  therefore,  considerably 
modified.  The  houses  of  Arcachon  lie  within  a  large  pine  forest,  which 
is  spread  over  the  extensive  dunes  of  the  Atlantic.  It  is  thus  protected 
from  the  violence  of  the  Atlantic  winds,  and  the  inland  winds,  too,  are 
greatly  mitigated  by  the  trees.  The  climate  is  rather  humid,  equable, 
and  unirritating,  and  the  air  in  the  "  ville  d'hiver  "  is  impregnated  with 
emanations  from  the  pine-trees. 

The  western  portion  of  Southern  Ccdifornia  presents  several  localities 
suitable  for  invalid  residence.  The  country  consists  of  a  wide,  fertile 
plain  intersected  by  the  lower  spurs  of  the  Sierra  Madre  and  the  coast 
range.  The  climate  is  warm  and  dry,  with  a  large  proportion  of  sunshine 
and  small  rainfall.  The  daily  range  is  considerable,  the  prevalent 
westerly  wind  causing  a  fall  of  temperature  in  the  afternoon.  The 
damp,  chilling  sea-fogs,  rolling  in  from  the  Pacific,  are  a  drawback.  On 
the  other  hand,  the  variety  of  elevation  within  a  comparatively  small 
compass  fits  it  admirably  for  an  all  the  year  round  residence.  According 
to  Dr.  Davidson  (16)  a  few  hours'  ride  enables  one  to  escape  from  the 
heat  of  summer  to  a  cool  and  bracing  atmosphere.  Presenting  some 
resemblance  in  climate  to  the  Riviera,  it  shares  some  of  its  draw- 
backs, treachery  amongst  them.  Very  good  results,  however,  are 
reported  in  cases  of  phthisis,  while  its  fi'uit-growing  industries  offer  a 
means  of  livelihood  and  permanent  occupation.  Dr.  Davidson  cautions 
the  invalid  against  staying  near  the  coast;  the  best  residences  are 
sheltered  spots  in  the  foot-hills  or  at  the  base  of  the  mountains. 

The  chief  resorts  where  good  accommodation  can  be  had  are :  — 


CLIMATE  IN    THE    TREATMENT   OF  DISEASE  269 

Los  Angeles,  with  a  mean  annual  temperature  of  61°  and  relative 
humidity  of  69'' ;  its  suburb,  Pasadena,  at  an  elevation  of  830  feet,  may 
also  be  mentioned.  San  Diego  has  a  temperature  of  54°  in  January 
and  69°  in  August ;  Santa  Barbara,  on  the  coast  jjlain,  a  temperature 
of  50°  to  55°  in  winter  and  60°  to  70°  in  summer. 

The  coast  climates  of  Great  Britain  and  Ireland  may  be  placed  among 
the  cooler  marine  climates  with  moderate  humidity.  Some  localities 
might  more  justly  find  a  place  amongst  the  humid  climates,  but  for  the 
sake  of  brevity  we  will  consider  them  together.  Between  the  coasts  of 
these  islands  there  are  considerable  differences,  especially  between  the 
resorts  on  the  east  coast  and  those  on  the  west ;  but  certain  features 
more  or  less  common  to  all  give  them  a  special  character.  The 
mean  temperature  is  much  higher  than  is  due  to  latitude.  This  is 
strikingly  illustrated  by  A.  Buchan.  "If  no  more  heat  were  re- 
ceived than  is  due  to  the  position  on  the  globe  in  respect  to  latitude, 
the  mean  winter  temperature  of  Shetland  would  be  only  3°,  and  that  of 
London  17".  But  chiefly  owing  to  the  heat  given  out  by  the  Gulf 
Stream  during  winter,  and  carried  to  the  places  by  the  winds,  their 
winter  temperatures  are  respectively  39°  and  38°  —  Shetland  being 
benefited  36°  and  London  21°  from  their  proximity  to  the  warm  waters 
of  the  Atlantic."  Part  of  this  increase  of  temperature  is  due  to  the 
actual  contact  with  the  warmer  sea. 

Mild  winters  and  cool  summers,  comparative  absence  of  extremes,  and 
a  rather  humid  air,  with  many  rainy  days  and  comparatively  many  rainy 
hours,  are  the  effects  of  these  influences.  The  air,  rich  in  water  vapour,  is 
less  transcalent  and  translucent  than  in  drier  regions  ;  hence  direct  sun- 
heat  and  sunlight  are  less  than  on  the  Alps  (Waters  and  Frankland)  and 
on  the  Eiviera  (Marcet).  On  the  other  hand,  the  water  vapour  checks 
radiation  at  night  and  equalises  the  temperature  of  night  and  day.  The 
chill  at  sunset  is  less  than  on  the  brighter  and  drier  Eiviera.  The 
climatic  characteristics  are,  therefore,  comparatively  high  annual  tem- 
perature, a  fairly  high  degree  of  humidity,  great  equability  as  regards 
seasons  and  periods  of  the  day,  dulness  of  atmosphere  with  but  a  small 
amount  of  direct  sunlight  and  sunheat,  and  more  than  average  windi- 
ness.  The  combined  effect  produces  health-giving  and  tonic,  though 
not  uniformly  agreeable  and  exhilarating  climates,  which  require  some 
vigour  of  constitution  to  bear  them.  Speaking  roughly,  we  may  desig- 
nate the  west  coast  as  warm  and  moist,  the  east  as  dry  and  cold ;  the 
western  part  of  the  south  coast,  as  far  as  Sidmouth,  as  moist  and  spe- 
cially warm ;  the  line  from  Bournemouth  to  Hastings,  including  the  Isle 
of  Wight,  as  fairly  dry  and  warm  ;  the  south-eastern  part,  with  Folke- 
stone and  Dover,  as  approaching  the  characters  of  the  east  coast. 

During  the  early  part  of  the  winter  the  temperature  on  the  west  and 
south-west  coasts  of  England  is  between  2°  and  6°  higher  than  on  the  east 
coasts ;  it  gradually  rises  from  the  south-east  to  the  south-west  coasts. 
Towards  summer  this  difference  gradually  disappears,  and  then  some- 
times the  east  coasts  are  warmer  than  the  west. 


270  SYSTEM  OF  MEDICINE 

We  may  roughly  divide  the  sea-side  resorts  into  (a)  summer  and  (6) 
winter  resorts  —  adding,  however,  that  some  of  the  latter  can  occasionally 
be  beneficially  employed  in  summer,  and  vice  versa. 

(a)  Summer  Resorts.  —  There  is  no  other  country  which  is  so  well 
provided  with  good  summer  sea-side  places.  The  majority  of  them  are 
situated  on  the  east  coast,  and  are  decidedly  bracing.  Going  from  north 
to  south  we  have  ISTairn,  St.  Andrews,  Portobello,  ISlorth  Berwick,  Redcar, 
Saltburn,  Whitby,  Scarborough,  Filey,  Bridlington,  Hunstanton,  Cromer, 
Yarmouth,  Lowestoft,  Aldborough,  Felixstowe,  Walton,  Westgate,  Mar- 
gate, Broadstairs,  Ramsgate,  St.  Lawrence,  Deal,  Walmer  and  St.  Marga- 
ret's. On  the  south-east  and  south  coasts,  Dover,  Folkestone,  Sandgate, 
Hythe,  Eastbourne,  Seaford,  Brighton,  Worthing  and  Littlehampton, 
Bognor,  Southsea.  In  the  Isle  of  Wight,  Sea  View,  Cowes,  Byde,  Alum 
Bay,  Freshwater,  Sandown  and  Shanklin ;  farther  west,  Swanage,  Wey- 
mouth, Lyme  Eegis,  Seaton,  Exmouth ;  the  Channel  Islands;  New  Quay 
and  Bude,  Ilfracombe  and  Lynton  on  the  north  coasts  of  Cornwall  and 
Devon  ;  Minehead,  Weston-super-Mare,  Clevedon  and  Portishead  on 
the  Bristol  Channel ;  Tenby,  Aberystwith,  Barmouth,  Beaumaris,  Pen- 
maenmawr,  Llandudno,  in  Wales  ;  Southport  and  Grange-over-Sands  in 
Lancashire;  Douglas  and  Ramsay  on  the  Isle  of  Man  have  almost 
thoroughly  marine  climates.  Silloth  in  Cumberland,  and  Ardrossan, 
Oban,  and  Rothesay  on  Bute  in  Scotland  have  cool  and  rather  humid 
summers,  the  last  has  mild  autumns  and  winters. 

The  coasts  of  Ireland  possess  a  mild,  equable  and  rather  humid 
climate ;  Bray,  Howth,  Kingstowni,  Dundrum,  Holy  wood,  Queen  stown 
and  Glengariff  are  good  representatives  ;  Bundoran  and  Kilkee  are  under 
the  full  influence  of  the  Atlantic  ;  Port  Rush  and  Port  Stewart  in  the 
north  are  somewhat  more  bracing;  Rostrevor  and  Warrenpoiut  are  not 
quite  exposed  to  the  sea,  and  offer  the  advantages  of  beautiful  inland 
country,  protection  from  wind,  and  modified  influence  of  the  sea-air. 

(h)  Winter  Resorts.  — If  we  proceed  from  east  to  west  we  begin  with 
Hastings  and  St.  Leonard's,  which  are  less  warm  and  somewhat  more 
bracing  than  the  localities  farther  west  and  south-west,  and  would  be 
similar  to  the  other  places  on  the  south-east  coast  were  it  not  for  the 
greater  shelter  which  the  Downs  afford  from  north-west,  north,  and 
north-east  winds.  Those  requiring  a  warm,  humid  and  equable  atmos- 
phere are  better  farther  west  and  south-west,  but  cases  of  atonic  catarrh 
of  the  mucous  membranes  are  mostly  benefited  in  the  autumn  and 
winter,  up  to  the  end  of  February  when  the  east  winds  begin. 

The  Undercliff  on  the  Isle  of  Wight,  and  the  fair  results  obtained  at 
the  National  Hospital  for  Consumption  at  Ventnor,  are  well  known. 
This  is  also  the  case  with  Bournemouth  and  Boscombe,  which  offer 
abundant  accommodation  at  the  hotels  and  in  numerous  villas  scattered 
about  on  the  cliffs  and  in  the  pine  woods  ;  these  unfortunately  are 
suffering  from  the  rapid  increase  of  the  buildings. 

Salcombe,  Sidmouth,  Budleigh-Salterton,  Exmouth,  Dawlish  and 
Teignmouth  have  all  fairly  warm  and  equable  winters,  and  in  their 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  271 


climatic  characters  resemble  Torquay,  which,  however,  by  its  situation 
iu  a  large  bay  surrounded  by  three  hills,  oifers  opportunities  for  extensive 
exercise  on  level  as  well  as  on  rising  ground,  with  ever  varying  beautiful 
views.  In  spring  the  east  wind  sweeps  round  the  protecting  rocks  and 
promontories,  but  is  felt  less  severely  than  on  the  eastern  part  of  the 
coast.  Farther  west  Falmouth  in  Cornwall  claims  our  attention  by 
similar  qualities,  and  Penzance,  which  has  less  shelter  from  wind,  but 
fair  equability  of  temperature.  On  the  coast  of  Wales,  Pwllheli  on  the 
Cardigan  Bay  deserves  our  appreciation  by  its  sheltered  situation  from 
north  and  east  winds ;  and  Llandudno,  although  principally  a  summer 
resort,  offers  also  some  advantages  in  winter.  Grange  on  Morecambe 
Bay  has  good  shelter.  More  northward  the  coast  and  the  islands  on  the 
west  of  Scotland  have  a  remarkably  mild  and  equable,  but  at  the  same 
time  humid  winter  climate ;  Rothesay,  on  the  island  of  Bute,  offers  the 
best  accommodation.  Glengariff  and  Queenstown  in  Ireland,  among  the 
humid  climates,  have  good  claims  to  be  regarded  as  winter  resorts. 

The  climate  of  the  north  and  still  more  of  the  north-west  coast  of 
France  has,  owing  to  the  Gulf  Stream,  some  analogy  to  that  of  the  south 
and  south-west  coast  of  England,  especially  in  summer.  There  is  very 
little  shelter  in  winter,  but  the  climate  in  summer  is  rather  more  dry  and 
stimulating  than  on  the  opposite  coast  of  England.  Dinard,  Cabourg, 
Houlgate,  Villers-sur-Mer,  Trouville,  Deauville,  Etretat,  Fecamp,  Dieppe, 
St.  Valery  en  Caux,  Treport  and  Boulogne  offer  satisfactory  accommoda- 
tion and  good  sands  for  bathing.  The  same  may  be  said  of  Ostend,  Blank- 
en  berghe  and  Heyst  in  Belgium,  and  Scheveningen  on  the  Dutch  coast. 

More  bracing  still  are  the  sea-side  and  island  resorts  on  the  north 
coast  of  Germany,  exposed  to  the  German  Ocean ;  Borkum,  ISTorderney, 
Baltrum,  Langeroog,  Spikeroog,  Wangeroog,  Wyk  on  Fohr  and  Wester- 
land  on  Sylt,  but  the  accommodation  at  them  is  often  primitive.  The 
island  of  Heligoland  has  a  much  more  decided  marine  climate. 

The  shores  of  the  Baltic  are  less  stimulating,  but  have  beautiful 
forests. 

B.  Inland  Climates.  —  We  must  be  satisfied  with  the  subdivision  of 
the  great  variety  of  these  climates  into,  I.  Elevated  or  Mountain  climates, 
and  II.  Lowland  or  Plain  climates. 

I.  Elevated  or  TJountain  Climates.' —  Great  as  is  the  difference  be- 
tween the  various  resorts  belonging  to  this  subdivision,  elevation  above 
the  surrounding  regions  produces  modifications  in  the  climatic  character 
which  are  common  to  them  all.  It  is  impossible  by  the  mere  elevation 
above  the  sea  to  define  the  limits  which  entitle  a  place  to  be  called  a 
mountain  health  resort.  Latitude  and  the  features  of  the  surrounding 
country  exercise  great  influence  in  this  respect,  which  manifests  itself 
quite  as  much  in  the  nature  of  the  vegetation  as  in  the  meteorological 
character ;  and  from  both  combined  we  may  draw  some  inferences  as  to 
the  probable  physiological  and  therapeutic  effects  on  the  human  constitu- 
tion. In  tlio  low  parts  of  Northern  Europe,  for  instance,  we  find  at  an 
elevation  of  about  1200  to  IGOO  feet  the  vegetation  peculiar  to  much 


272  SYSTEM  OF  MEDICINE 

higher  elevations  in  Southern  Europe,  unless  the  nearness  of  the  sea  or 
surrounding  higher  mountains  exercise  modifying  influences.  In  lati- 
tudes  nearer  the  equator  a  much  higher  elevation  is  required  to  produce 
analogous  effects.  Thus  J.  M.  Toner  says,  "  On  Chimborazo  the  palms, 
bananas,  and  oranges  grow  at  5000  feet ;  at  10,000  feet,  Indian  corn  and 
wheat ;  and  at  15,000,  barley  and  the  more  hardy  grasses."  In  a  rough 
way  we  may  assume  that  in  Northern  Europe  (above  50°  lat.)  an  elevar 
tion  of  1000  to  1500  feet  produces  a  mountain  climate,  unless  nearness 
of  the  sea  or  of  higher  mountains  interfere  ;  while  in  the  centre  of 
Europe  (between  48°  and  50°  lat.),  1400  to  2500  feet  are  required ; 
between  47°  and  48°,  2400  to  3500  feet ;  and  in  the  tropics  6000  to 
9000  feet.  The  upper  limits  of  elevation  for  health  resorts  likewise 
vary  according  to  latitude  and  local  circumstances. 

We  will  begin  our  description  with  the  Swiss  Alps. 

The  general  characteristics  of  the  climate  of  the  Swiss  Alps  in 
winter  are :  — 

1.  Low  barometric  pressure  due  to  the  altitude.  2.  Great  diather- 
mancy of  the  atmosphere.  3.  Low  temperature.  4.  Absence  of  fog  and 
comparative  rarity  of  cloud.  5.  Loav  absolute  and  relative  humidity. 
6.  Rareness  of  wind. 

The  patient  is  thus  placed  in  an  atmosphere  of  dry,  still,  cold,  and 
rarefied  air,  and  exposed  to  very  powerful  sunlight  and  sunheat. 

What  then  are  the  effects  of  this  climate  upon  the  body?  On 
arriving  at  one  of  the  Alpine  resorts  the  patient  first  experiences  a 
certain  amount  of  difficulty  in  breathing ;  any  exertion  causes  him  to 
pant;  frequently  he  cannot  sleep;  sometimes  there  is  headache;  the 
bowels  are  often  constipated,  and  there  is  a  general  feeling  of  listlessness ; 
thirst  and  dryness  of  the  throat  are  prominent  symptoms.  On  examina- 
tion the  respirations  are  found  to  be  quicker  and  the  pulse  accelerated. 
Marcet  (54)  has  shown  that  the  amount  of  carbonic  acid  and  water 
exhaled  by  the  lungs  is  increased.  Acclimatisation  may  take  from  three 
or  four  days  to  as  many  weeks ;  when  this  is  established  the  pulse  will 
have  fallen  to  its  normal  condition,  the  respiration  will  be  fuller  and 
deeper  than  on  the  plain  (94),  the  bowels  regular,  sleeplessness  gone, 
and  appetite  improved. 

These  effects  are  merely  those  of  altitude,  as  they  may  be  observed 
in  the  summer  to  the  same  degree,  and  quite  as  frequently  as  in  the 
winter.  In  the  winter  we  have  further  to  consider  the  bracing  effect  of 
the  dry,  cold  air.  The  influence  which  the  cold  air  produces  is  probably 
seen  chiefly  in  increasing  appetite  and  digestion  ;  at  the  same  time  an 
increased  amount  of  water  is  exhaled  by  the  lungs,  and  the  exhalation 
of  carbonic  acid  is  promoted  by  the  cold  air  of  the  Alps  (Marcet). 
Taken  altogether,  it  appears  that  altitude  and  cold  combined  produce  a 
more  rapid  interchange  in  the  tissues,  and  that  in  consequence  of  this 
greater  activity  the  tissues  acquire  an  increased  resistance  to  the  action 
of  micro-organisms.  The  paramount  constitutional  benefit  of  climate  in 
jjlithisis  must  lie  in  the  increase  of  this  resistance  of  the  tissues,  and  such 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  27 j 

is  the  unanimous  opinion  of  all  who  have  had  much  experience  of  the 
climates  of  high  altitudes,  and  for  these  reasons  :  — 

(a)  Signs  of  constitutional  improvement ;  gain  in  weight,  and  increase 
of  appetite  frequently  precede  any  local  improvement  discernible  by 
auscultation. 

(6)  Many  patients,  who  have  improved  in  the  high  altitudes,  on  going 
down  to  a  lower  level  where  the  atmosphere  may  be  equally  pure  and 
dry,  begin  to  lose  weight;  while  the  disease  shows  signs  of  fresh  activity. 

This  increased  resistance  seems  to  be  brought  about  by  the  following 
factors : — 

1.  The  large  amount  of  time  which  is  passed  in  the  open  air  in 
a  still  atmosphere.  2.  The  tonic  action  of  the  dry  cold  air.  3.  The 
purity  of  the  atmosphere.  4.  The  large  amount  of  sunlight.  5.  Per- 
haps a  general  tonic  influence  exerted  by  rarefied  air  upon  the  metab- 
olism of  the  body. 

In  past  years  much  more  importance  was  attached  to  the  extreme 
rarity  of  phthisis  among  the  natives  of  the  high  Alpine  valleys.  This 
rarity  is  rather  to  be  explained  by  the  outdoor  life  of  the  people,  and 
the  smallness  of  the  communities ;  the  absence  or  rarity  of  microbes  is, 
however,  well  established. 

The  alleged  fact  that  phthisis  is  unknown  amongst  the  inhabitants 
of  the  steppes  indicates  that  altitude  may  not  be  the  only  factor  in  con- 
ferring immunity ;  an  outdoor  life  is  at  least  as  habitual  to  these  people 
also. 

Increased  resistance  is  brought  about  not  only  by  increased  appetite, 
but  also  by  improved  digestion  and  assimilation.  The  patient  finds, 
to  his  surprise,  that  he  can  eat  a  heavy  meal  without  any  subsequent 
lassitude  and  torpor.  Viault  and  Egger  have  shown  that  there  is  a 
somewhat  rapid  increase  in  red  corpuscles  in  patients  taken  to  a  high 
altitude.  Further,  Bert's  experiments  in  Peru  (9)  prove  that  the  blood 
at  high  altitudes  takes  in  a  much  greater  percentage  of  its  volume  of 
oxygen. 

Besides  the  constitxitional  effects  of  the  dry,  cold,  thin  air,  there  are 
certain  purely  physical  effects  produced  upon  the  lungs  themselves. 
Owing  to  the  rarefied  atmosphere  each  breath  taken  must,  to  supply  the 
due  measure  of  oxygen,  be  deeper  than  on  the  plain.  The  effect  of  this 
is  to  enlarge  the  circumference  of  the  chest ;  Williams  (108)  gives  this 
enlargement  at  from  one  to  three  inches  ;  other  observers  are  inclined 
to  put  it  at  somewhat  less,  though  all  are  agreed  that  it  does  occur  \yide 
art.  on  "Artificial  Aerotherapeutics"].  A  further  result  of  this  deeper 
manner  of  breathing  is  thoroughly  to  open  up  all  the  air  vesicles,  and 
thus  to  prevent  any  accumulation  of  secretions  in  them.  After  a  more 
])rolonged  residence  at  high  altitudes  a  state  is  reached  which  has  been 
termed  "hypertrophy  of  the  lung."  The  chest  is  enlarged  to  some 
extent  and  is  hyper-resonant ;  the  breath-sounds,  instead  of  being  weak, 
are  puerile  or  exaggerated,  but  expiration  is  not  prolonged.  Whether 
this  be  merely  a  form  of  emphysema,  or  an  actual   increase   in   the 

VOL.    I  T 


274  SYSTEM  OF  MEDICINE 

respiratory  area  of  tlie  lungs,  we  cannot  say;  but  after  considerable 
experience,  both  of  the  natives  of  the  high  Alpine  valleys  and  of  con- 
sumptive patients,  we  can  assert  that  this  condition  is  very  rarely 
associated  with  the  ordinary  symptoms  of  emphysema. 

The  principal  resorts  are  :  — 

Davos  (5200  feet).  Is  less  windy  than  the  other  resorts,  but  receives 
less  sun  during  the  day.  It  is  adapted  to  a  greater  variety  of  cases,  and 
the  accommodation  and  nursing  arrangements  are  excellent.  It  is  con- 
nected with  Zurich  by  rail. 

St.  Moritz  (6000  feet).  Is  more  windy  than  Davos,  but  has  a  slight 
advantage  in  the  matter  of  sun.  It  is  admirably  suited  to  more  vigorous 
cases,  but  severe  cases  are  better  at  Davos.     The  accommodation  is  good. 

Ley  sin  (4712  feet).  Above  Aigle.  Is  well  protected  and  receives  a 
large  share  of  sunlight.  An  admirably -conducted  sanatorium  has  been 
established  there,  and  thorough  supervision  of  the  patients  is  carried 
out. 

Wiesen  (4771  feet).  Chiefly  used  as  a  halting-place  to  and  from 
Davos. 

Arosa  (6100  feet).  Admirably  sheltered,  and  at  the  Kulm  receives  a 
fair  share  of  sunlight. 

Les  Avants,  above  Montreux  (3500  feet),  may  be  of  iise  where  the 
higher  elevations  are  ill  borne.  An  equally  sheltered  and  sunny  estab- 
lishment at  an  elevation  of  over  5000  is  being  built. 

The  elevated  resorts  of  the  liocJcy  Mountains  have,  of  late  years,  come 
into  repute,  and,  thanks  to  the  admirable  accounts  given  by  Dr.  C.  T. 
Williams  (107),  and  the  earlier  ones  by  Denison,  their  main  features 
are  becoming  well  known.  These  resorts  are  situated  in  the  State  of 
Colorado,  on  the  eastern  slopes  of  the  chain  as  it  traverses  that  terri- 
tory, at  altitudes  of  from  5000  to  7000  feet.  Meteorological  observa- 
tions tend  to  show  that  the  climate  is  somewhat  drier  than  that  of  the 
Swiss  Alps,  and  has  a  very  distinct  advantage  in  the  matter  of  sunshine  ; 
at  Colorado  Springs  during  the  winter  the  sun  shines  during  the  greater 
part  of  the' day  for  165  days  out  of  182  (77),  and  the  mean  temperature 
is  higher  than  in  the  Swiss  Alps,  the  snow  only  lying  for  a  few  days  at 
most  during  the  winter.  On  the  other  hand,  there  is  very  much  more 
wind  and  much  more  dust  than  in  Alpine  resorts.  Electrical  manifesta- 
tions are  a  prominent  feature  of  the  climate,  but  as  to  whether  these 
influence  the  body  for  good  or  ill,  we  know,  scientifically  speaking, 
nothing.     Their  advantages  are  :  — 

1.  Altitude,  the  effects  of  which  we  have  already  discussed.  2.  Dry- 
ness.    3.  Abundant  sunshine. 

The  climate,  although  not  possessing,  some  of  the  advantages  of  the 
Swiss  Alps,  is  better  adapted  on  the  whole  for  an  all  the  year  round 
residence ;  there  is  no  snow-melting  time,  and  the  summer,  although 
hotter,  is  more  constant  than  in  the  Alps.  Colorado,  moreover,  offers 
better  facilities  for  employment,  sport  and  exercise,  than  any  other 
resort.     Subjects    of   constitutional   erethism  will  probably  fare  even 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  27$ 

worse  in  Colorado  than  in  the  Swiss  Alps.  The  accommodation  is  good, 
though,  owing  to  the  American  fashion  of  meals,  the  food  may  not  be  so 
acceptable  to  the  invalids  as  that  of  the  Swiss  hotels.  It  must  be  remem- 
bered also  that  the  living  expenses  are  heavier  than  in  Europe. 

The  principal  resorts  are  :  — 

Denver  (5000  feet).  A  town  of  150,000  inhabitants  covering  about 
five  square  miles.  The  mean  annual  temperature  is  50°,  the  month  of 
January  showing  a  mean  of  27-2°,  and  August  72-8°.  Rainfall  14-17 
inches  (107).  The  accommodation  is  good,  and  the  place  presents  all  the 
advantages  of  a  large  town,  though  this  can  hardly  be  regarded  as  an 
unmixed  benefit. 

Colorado  Springs  (6022  feet).  Seventy-five  miles  south  of  Denver;  a 
town  of  15,000  inhabitants.  The  mean  temperature  is  46*4°.  Colorado 
Springs  possesses  an  advantage  over  Denver  in  being  almost  exclusively 
a  health  resort,  while  the  latter  is  a  large  commercial  town. 

Glenwood  (5000  feet),  on  the  Pacific  slope,  may  also  be  mentioned ; 
it  possesses  a  most  admirably-conducted  hotel.  The  climate  is,  however, 
damper  than  that  of  the  other  slope. 

N^ew  Mexico  seems  to  possess  a  valuable  winter  climate,  but  is  practi- 
cally unavailable,  owing  to  the  absence  of  suitable  accommodation  which, 
even  at  El  Paso,  is  far  from  good. 

The  Andes.  —  Another  class  of  mountain  climates,  which  may  with 
advantage  be  touched  on  here,  contains  those  of  the  Andes,  since  it  was 
by  experience  gained  in  them  that  Archibald  Smith  was  first  enabled  to 
draw  attention  to  the  benefit  in  the  treatment  of  phthisis  likely  to  be 
obtained  by  residence  in  elevated  regions. 

The  main  resorts  are  situated  on  the  Pacific  slope  of  the  Andes  —  in 
Peru,  and  New  Granada,  at  elevations  varying  from  8000  to  12,000  feet. 
The  chief  characteristics  of  these  climates  are  :  — 

1.  Moderate  warmth  even  in  the  highest  resorts,  owing  to  their  prox- 
imity to  the  equator.  2.  Remarkable  equability  of  temperature.  At 
Jauja,  according  to  Archibald  Smith,  during  a  whole  year  the  tempera- 
ture never  rose  above  60°,  or  fell  below  50°.  3.  Considerable  atmos- 
pheric dryness.     4.    Abundant  sunshine. 

We  have  thus  a  temperate  and  extremely  equable  climate,  with  the 
additional  advantage  of  rarefaction  of  the  atmosphere.  The  admirable 
results  obtained  there  among  the  consumptive  natives  of  the  plain  prove 
the  curative  properties  of  the  climate.  Unfortunately,  however,  at  none 
of  the  resorts  is  the  accommodation  good  enough  for  invalids.  Eor 
English  patients,  also,  the  length  of  the  journey  is  prohibitive,  except 
in  the  case  of  vigorous  men  with  limited  disease.  For  such  as  these, 
and  for  arrested  cases,  who  wish  to  have  a  settled  home  in  a  good  cli- 
mate, and  who  are  willing  to  build  their  own  houses,  these  resorts  offer 
decided  advantages.  Dr.  Smith  points  out  that  patients,  as  a  rule, 
do  better  at  an  elevation  of  8000  to  10,000  feet  than  at  the  higher 
levels. 

The  principal  resorts  are :  — 


276  SYSTEM   OF  MEDICINE 

Huancayo  (10,000  feet),  in  Peru ;  the  temperature  of  the  whole  year 
ranges  between  51°  and  63"  (Williams). 

Jauja,  10,000  feet,  also  in  Peru,  with  a  temperature  ranging  between 
60°  and  60°  for  the  whole  year  round. 

Quito,  in  Ecuador;  a  town  of  80,000  inhabitants,  situated  at  an 
altitude  of  9500  feet,  and  with  an  all  the  year  round  temperature  of 
about  60°. 

Santa  Fe  de  Bogota,  in  New  Granada,  at  an  elevation  of  8648 
feet.  The  temperature  is  59°,  and  is  fairly  constant  all  the  season 
through. 

In  India  there  are  several  hill-stations,  situated  in  the  Himalayas  and 
Nilgiris ;  but,  except  for  those  who  cannot  leave  India,  they  possess  no 
particular  advantages.  The  atmosphere  is  said  to  be  very  damp  in  the 
summer,  owing  to  the  heavy  rainfall.  The  chief  resorts  are  Simla  (8000 
feet)  and  Darjeeling  (8000)  in  the  Himalayas,  with  Ootacamund  (7361) 
and  Wellington  (5840)  in  the  Nilgiris.  In  considering  the  hill-stations 
of  India  we  must  bear  in  mind  the  nearness  to  the  equator,  by  which  the 
influences  of  altitude  are  considerably  modified ;  and  further,  that  the 
peninsula  is  surrounded,  excepting  at  its  broad  base,  by  large  masses  of 
warm  Avater.  The  periodical  moisture-laden  winds  coming  from  these 
seas  must,  on  reaching  the  colder  mountain  ranges,  necessarily  deposit 
a  large  portion  of  their  humidity,  rendering  the  soil  damp,  and  the  air 
emanating  from  it  moist  and  impure. 

Very  different  are  the  mountain  climates  on  the  north  and  north-west 
of  the  Himalayas,  for  the  atmosphere  on  reaching  them  has  lost  a  great 
part  of  its  moisture  on  the  southern  slopes.  Hence  Tibet  to  the  north, 
at  9000  to  11,000  feet,  and  Cashmere  on  the  north-western  chain,  at  5000 
to  6000  feet,  possess  healthy  climates,  and  offer  sites  for  most  useful 
health  resorts. 

A  class  of  resorts  of  moderate  altitude  (aboiit  1700  feet),  presenting 
peculiarities  worthy  of  notice,  are  Gbrhersdorf  in  Silesia,  i^aiA'en.stem  in  the 
Taunus,  Reiboldsgriln  (2250  feet)  in  the  Erzgebirge,  and  Hohenlionnef  in 
Rhenish  Prussia.  These  resorts  base  their  efficacy  not  so  much  upon 
their  climate  as  u.pon  the  manner  m  which,  by  careful  management  and 
artificial  shelters,  an  open-air  life  is  rendered  possible  to  the  consumptive, 
even  in  a  somewhat  inferior  climate.  Further,  the  patients  reside  in 
sanatoria,  in  which  every,  even  the  smallest,  detail  of  their  daily  life  is 
under  the  immediate  control  of  the  physician,  while  obedience  to  his 
orders  is  a  condition  of  residence.  This  system  of  treatment  was  inau- 
gurated by  Dr.  Brehmer  at  Gorbersdorf  some  forty  years  ago ;  his  main 
contention  being  that  the  essential  point  in  the  cure  of  phthisis  was 
supervision  of  the  minutest  particulars  of  the  patient's  life,  aided  by 
drugs  and  hydrotherapy  when  necessary.  The  soundness  of  his  views 
has  been  abundantly  proved  by  the  high  percentage  of  cures  amongst 
his  cases,  while  to  his  teaching  is  due  the  sytematisation  of  the  mode 
of  life  at  Davos  and  other  health  resorts.  We  cannot  help  remarking 
here  that  Brehmer's.  results,  obtained  in  an  inferior  climate,  are  better 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  277 

than  most  of  those  obtained  in  far  more  suitable  localities,  where  the  old 
haphazard  traditions  of  treatment  still  reign.  The  difficulties  of  establish- 
ing such  a  system  amongst  English  patients  are  great ;  but  some  modi- 
fied form  of  Brehmer's  system  could  easily  be  brought  into  vogue  by  a 
determined  effort  on  the  part  of  the  medical  profession.  We  have  yet 
much  to  learn  from  the  German  physicians  as  to  the  best  possible  method 
of.  utilising  each  climate.  Brehmer's  system  is  carried  out  at  the  estab- 
lishment which  he  founded  at  Gorbersdorf,  situated  in  a  xjine-clad  valley 
in  Silesia,  at  an  elevation  of  1700  feet.  Dr.  Dettweiler,  one  of  Brehmer's 
assistants,  and  Dr.  Hess  now  direct  the  establishment  of  Falkenstein, 
situated  in  a  sheltered  valley  of  the  Taunus,  at  an  elevation  of  1500 
feet ;  to  this  is  now  attached  a  sanatorium  of  100  beds  for  patients  of 
small  means.  Dr.  Meissen,  another  former  assistant  of  Dr.  Dettweiler, 
directs  yet  another  sanatorium  at  Hohenhonnef,  about  1600  feet  high. 
Dr.  Trudeau,  again,  carries  out  a  system  similar  to  Brehmer's  at  his 
sanatorium  in  the  Adirondacks,  in  the  United  States  of  America ;  here 
the  patients  lie  during  the  greater  part  of  the  day  in  open  verandahs, 
even  in  a  temperature  of  10°  below  zero. 

The  large  number  of  excellent  hotels  in  the  mountainous  part  of 
Switzerland,  Italy,  and  France,  at  elevations  of  about  5000  to  6000  feet, 
may  be  ascertained  from  the  current  guidebooks. 


The  Eastern  Alps,  with  the  Dolomites  and  the  Tyrol,  contain  many 
beautiful  localities  which  are  gradually  being  provided  with  hotels 
suitable  for  delicate  persons.  In  the  Dolomites  we  may  specially  men- 
tion Campiglio  (Madonna  di  San  Campiglio),  San  Martino  di  Castrozza, 
Schluderbach,  Landro  or  Holdentlial,  and  Cortina  d'Ampezzo.  In  the 
Tyrol,  St.  Gertrud,  in  the  Sulden  Valley,  is  above  6000  feet,  all  the 
others  are  below  5000,  and  the  majority  below  4000,  descending  to  about 
2000 :  the  Mendelhof,  near  Botzen ;  the  hotels  on  the  Semmeriyig  Pass ; 
Gossenap,  near  the  Brenner  Pass  ;  Innigen,  Niederdorf,  Toblach,  and  Neu 
Tohlacli,  in  the  Puster  Valley ;  Kreutli  and  the  Achensee;  Oberstdorf; 
Berchtesgaden,  with  Steinhaus  and  Vordereck;  Zell  am  See;  Parten- 
kirchen  and  Kainzenbad ;  Aussee  and  Altaussee;  Innsbruck,  with  Igls. 

There  are,  besides,  many  even  less  elevated  localities,  which,  owing  to 
the  beauty  of  the  situation  and  the  comfort  of  the  hotels,  may  be  selected 
for  shorter  or  longer  stays,  such  as  Reichenhall,  Salzburg,  Ischl,  Gmunden. 

Italian  Mountain  Stations.  —  The  mountain  ranges  of  Italy,  excepting 
the  southern  valleys  of  the  Alps,  included  in  the  Alpine  resorts  (Macug- 
naga,  Gresoney,  Alagna),  do  not  yet  offer  many  localities  which  have 
adequate  accommodation.  Ceresola,  Reale  in  Piedmont,  5100  feet  high, 
and  Abetone  and  Serrabassa  in  the  Apennines,  at  an  elevation  of  about 
5000  feet,  deserve  to  be  mentioned;  and  at  lesser  elevations,  St.  Martin 
Lantosf/ue  and  the  Certosa,  di  Val  Pesio,  in  the  Maritime  Alps.  Perugia 
and  Siena  are  scarcely  elevated  enough  to  be  regarded  as  hill  stations, 
but  they  arc  delightful  in  spring  and  autumn. 


278  SYSTEM  OF  MEDICINE 

In  the  Pyrenees  we  have  the  different  spas,  which  can  also  be  used 
as  climatic  health  resorts  —  Bareges,  Cauterez,  Bagn^res  de  Luchon,  Bag- 
ndres  de  Bigorre,  Eaux  Bonnes,  etc.,  but  they  are  less  bracing  than  many 
of  the  Alpine  localities. 

In  the  mountains  of  the  Auvergne  Mont  Dore  has  a  claim  to  be  re- 
garded as  a  mountain  health  resort,  but  widely  useful  accommodation  in 
this  district  might  be  provided  on  the  Pay-de-Dovie,  near  E-oyafc. 

The  health  resorts  of  the  Black  Forest  are  of  lesser  elevation  than 
those  of  Switzerland,  but  exercise,  nevertheless,  a  moderately  bracing 
though  less  stimulating  influence.  In  addition  to  elevation,  most  of  these 
localities  have  in  their  neighbourhood  large  pine  forests,  which-  exercise 
a  purifying  and  equalising  action.  Hochenschwand  and  Schbmvald  are 
the  only  places  worth  mentioning  above  3000  feet ;  the  other  available 
localities  are  between  3000  and  1400  —  Scliluchsee,  Titissee,  St.  Blasien, 
Triberg,  Freudenstadt,  AllerheiUgen,  Rippoldsau,  Griesbach,  Badenweiler. 

Rather  similar  in  character  are  some  localities  in  the  Vosges  Moun- 
tains, of  which  Hohwald,  Dreiaejiren,  and  Odilienberg  are  the  best  known. 

Besides  Gorbersdorf  smd  Reiboldsgriin,  Falkenstein,  and  Hohenhonnef, 
already  mentioned  as  sanatoria  for  the  treatment  of  consumption,  the 
eastern  mountain  ranges  of  Germany  are  rich  in  well-wooded  health 
resorts  of  local  fame,  ranging  from  1500  to  2500  feet. 

The  Harz  Mountains  in  the  north  of  Germany  offer  many  useful 
summer  resorts  between  1400  and  nearly  3000,  especially  Clausthal, 
Andreasberg,  Alexisbad,  and  Harzburg ;  the  two  first  are  already  in  use 
as  sanatoria  for  phthisis  all  the  year  round. 

The  mountains  and  elevated  places  of  Great  Britain  differ  in  climatic 
characters  from  those  on  the  Continent.  The  atmosphere  is  more  humid, 
less  transparent  and  transcalent,  the  sun  heat  is  less  high,  the  tempera- 
ture is  more  equable.  There  are  scarcely  any  health  resorts  higher  than 
1000  feet,  but  the  climate  at  such  and  at  lower  elevations  is  much  more 
bracing  than  at  similar  elevations  on  the  Continent.  This  is  owing  partly 
to  the  greater  coolness  of  the  summer,  partly  to  the  absence  of  high 
mountains  around  them,  preventing  free  access  of  air.  There  are  no 
elevated  winter  resorts.  The  air  on  the  Scotch  and  Yorkshire  moors  is 
thoroughly  invigorating,  but,  unfortunately,  the  owners  do  not  as  yet 
tolerate  hotels  or  sanatoria  on  them.  There  is,  however,  a  considerable 
choice  of  localities,  with  good  climates  and  fair  accommodation.  In 
Scotland — Braemar,  Ballater,  Grantown,  Forres,  Strathpeffer,  Blair  Athole, 
Pitlochrie,  Tnversnaid,  the  Trossachs,  Crieff,  and  Moffat.  In  England  — 
Buxton,  Harrogate,  llkley,  Gilsland,  Malvern,  Tunbridge  Wells,  and  Frant. 
In  Wales,  Llanberis  and  Llandrindod  are  best  suited  for  those  who  want 
some  comfort  with  mountain  air.  It  is  much  to  be  regretted  that  there 
are  no  good  inns  higher  up  on  the  mountains.  In  the  south  of  England 
Hind  Head  and  Black  Down  have  the  advantage  of  good  villas,  but  not 
of  hotels ;  and  the  same  is  the  case  with  the  chain  of  Leith  Hill.  On 
Dartmoor  moderate  accommodation  is  to  be  found  at  Princetown,  about 
1400  feet  high. 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  279 

South  Africa.  —  The  district  of  South  Africa  which  offers  several 
localities  possessing  a  climate  suitable  to  invalids,  is  the  Karroo,  a  roiling 
heath-like  country,  varying  in  elevation  from  2500  feet  to  6000  feet. 
It  is  divided  by  the  Nieuw^eld  Mountains  into  two  districts,  Central  and 
Upper  Karroo.  Of  these  the  former  slopes  gradually  southward,  while 
the  latter  stretches  northward  as  far  as  the  Orange  liiver.  The  climate 
is  characterised  by  extreme  dryness  of  the  atmosphere,  great  heat  in  the 
summer,  and  small  rainfall.  The  winter  nights  are  cold,  but,  according 
to  Dr.  Saunders,  the  days  are  bright  and  sunny.  The  advantages  of 
this  climate  are  its  altitude  and  the  abundant  opportunities  it  offers 
for  outdoor  life,  without  danger  of  taking  cold ;  its  drawbacks  are  the 
large  amount  of  dust  and  the  extreme  heat  of  summer,  though,  oAving  to 
the  dryness,  the  latter  is  not  severely  felt.  The  climate  is  bracing,  but 
too  exciting  for  persons  of  a  nervous  temperament.  In  timing  the 
arrival  of  patients  it  m.ust  always  be  remembered  that  the  seasons  are 
the  reverse  of  our  own.  The  simple  character  of  the  accommodation, 
moreover,  should  deter  the  fastidious  and  any  invalid  not  possessed  of 
a  fair  amount  of  constitutional  vigour. 

Of  the  resorts  whose  capabilities  have  been  so  admirably  summarised 
by  Dr.  Symes  Thompson  (89),  we  may  mention  — 

1.  In  the  Great  Karroo :  Craddock  (2855  feet)  and  Beaufort  West 
(2792  feet). 

2.  In  the  Upper  Karroo:  Burgersdorp  (4552  feet)  and  Tarkastad 
(4280),  at  which  good  results  have  been  obtained  in  the  treatment  of 
phthisis ;  also  the  flourishing  townships  of  Aliwal  North  (4348), 
Kimberley  (4012),  and  Bloemfontein  (4500).  Pretoria  in  the  South 
African  Republic  is  also  rising  into  favour  as  a  health  resort.  Ceres 
(1493),  with  its  sanatorium,  and  Grahamstown  (1800),  form  excellent 
intermediate  stations  between  the  coast  and  higher  altitude  sanatoria. 

Australia.  —  The  regions  of  Australia,  possessing  climates  suitable 
to  invalids,  are  the  inland  plains,  certain  localities  in  the  Blue  Moun- 
tains and  the  Australian  Alps.  The  climate  of  the  coast  region,  in 
which  all  the  chief  towns  are  situated,  is  too  variable,  owing  to  the  cold 
southerly  winds  and  the  hot  winds  which  blow  from  the  central  desert. 
The  mountains,  which  fringe  the  coast  from  the  South  Australian 
border  to  Queensland  have  in  the  main  a  temperate,  dry  and  bracing 
climate.  Although  amongst  the  varieties  of  their  climates  there  are 
probably  some  which  would  be  of  great  value,  yet  the  want  of  accom- 
modation, except  at  two  or  three  places,  materially  lessens  their  utility. 
The  available  resorts  are  confined  to  those  on  Mount  Macedon  in  Vic- 
toria, with  Catoomha  and  Mount  Victoria  in  New  South  Wales.  The 
former,  situated  44  miles  from  Melbourne,  consists  of  Upper  (3000  feet) 
and  Lower  Macedon  (1660  feet),  with  the  excellent  sanatorium,  Braemar 
Wood  End  (2500  feetj.  The  mean  annual  temperature  of  Macedon  is 
53°  F.  The  locality  forms  a  good  place  of  sojourn  for  those  spending 
a  short  time  in  the  colony  (8). 

Mount  Victoria  (3490  feet),  77  miles  from  Sydney,  mean  annual 


28o  SYSTEM  OF  MEDICINE 


temperature  53°  I".,  provides  an  excellent  change  from  the  climate  of  the 
inland  plains. 

Catoomba  (3349  feet)  is  slightly  move  humid  than  the  last  named. 

The  chief  characteristics  of  the  Inland  Plains  are  extreme  dryness  of 
the  atmosphere,  abundant  sunshine,  and  small  rainfall.  All  these  con- 
ditions mean  ample  opportunities  for  outdoor  life.  The  drawbacks  to 
the  climate  are  the  large  amount  of  dust,  the  occasional  occurrence  of  a 
hot  north  wind,  and  the  possibility  of  a  drought.  The  climate  is  un- 
doubtedly bi'aeing,  the  danger  of  chills  is  slight,  and  there  are  no 
marked  ill  effects  upon  the  nervous  system,  such  as  sleeplessness,  etc. 

The  Inland  Plains  divide  themselves  into  two  districts  :  the  Riverina 
in  Victoria,  lying  to  the  north  of  the  Murray  River,  and  the  Darling 
Downs  in  Queensland,  an  upland  plateau  (2000  feet)  lying  to  the  east  of 
the  former. 

According  to  Dr.  Lindsay  (47)  the  heat  in  summer  in  the  Riverina 
is  considerable,  though  easily  borne.  In  winter  there  are  slight  frosts, 
but  the  days  are  warm.  The  Darling  Downs  are  somewhat  cooler  and 
less  exposed  to  the  hot  wind.  In  both  districts  the  accommodation  is 
rough,  and  the  climate  is  best  enjoyed  by  residence  on  a  station. 

For  some  cases  of  phthisis  the  climate  is  admirably  suited;  the 
patient,  however,  must  possess  a  good  share  of  constitutional  vigour,  and 
must  be  ready  and  willing  to  content  himself  with  the  monotonous  fare 
of  a  station  or  up-country  township.  Accommodation  can  be  obtained 
at  Deniliguin  in  the  Riverina,  and  Warwick  and  Towoomba  in  the 
Darling  Downs. 

II.  The  Lowland  Climates.  —  After  having  considered  so  many 
regions  under  the  heads  of  Marine  and  of  Mountain  Climates,  we  can 
throw  but  a  rapid  glance  at  some  of  lower  regions  not  included  in  the 
former.     Our  foremost  attention  is  claimed  by  Egypt. 

Egypt  owes  its  virtue  as  a  climate  chiefly  to  its  being  composed 
mainly  of  desert,  so  much  so  that  the  fertile  spots  included  in  the 
wastes  share,  on  the  whole,  the  characteristics  of  the  desert  air.  The 
main  characteristics  of  the  climate  are :  — 

1.  Warmth,  the  mean  temperature  at  Cairo  for  the  winter  months 
being  58-3°.  2.  Large  Daily  Range,  the  difference  between  day  and 
night  temperatures  varying  from  35°  to  19°.    3.    Low  Relative  Humidity. 

4.  Abundant  Sunshine.  —  Blue  sky  was  chronicled  on  all  but  fifteen  days 
during  five  months  at  Assouan,  in  the  winter  of  1892-93  (Longmore). 

5.  Small  Rainfall.  —  Six  rainy  days  only  in  five  months  were  chronicled 
at  Assouan  in  1892-93.  6.  The  extremely  aseptic  character  of  the  air, 
which  is  constantly  refreshed  by  a  breeze  blowing  over  hundreds  of  miles 
of  desert  whence  no  emanations  rise. 

Most  of  the  observations  have  been  taken  in  localities  situated  on 
the  cultivated  land.  Dr.  Canney's  observations,  however  (supported 
by  Dr.  Longmore's  personal  communications),  taken  in  the  desert  at 
Luxor,  and  in  other  situations  in  Egypt,  tend  to  show  that  the 
climate  in  the  desert  itself  has  a  smaller  daily  range  (17°  in  Luxor 


CLIMATE  IN  THE    TREATMENT  OF  DISEASE  281 

desert  as  against  32^  in  Luxor)  and  a  lower  relative  liumidity  (54° 
in  Luxor  desert  as  against  69°  in  Luxor).  The  advantages  of  the 
climate  are  dry,  warm,  sunny  days  with  cool  nights,  and  a  marvellously 
pure  atmosphere.  The  drawbacks  to  the  climate  are  the  not  infrequent 
presence  of  cold  winds  (though  not  to  the  same  extent  as  on  the  Riviera), 
and  the  occasional  occurrence  of  hot  winds  laden  with  dust;  these  are 
not  only  constitutionally  most  depressing,  but  intensely  irritating  to  the 
lungs. 

The  physiological  effects  of  the  climate  may  be  described  as  bracing 
to  the  organism  as  a  whole,  and  sedative  to  the  nervous  system.  Dr. 
Sandwith  (70)  gives  records  of  105  cases  of  phthisis  ;  improvement  took 
place  in  72. 

In  Egypt  the  invalid  can  spend  the  greater  part  of  the  day  in  a  warm 
climate,  while  at  the  same  time  sleep  is  encouraged  rather  than  interfered 
with,  and  the  nervous  system  is  soothed.  The  danger  of  chill  at  sunset 
is,  however,  always  present,  and  has  to-be  guarded  against  as  carefully 
as  on  the  Riviera.  The  length  of  the  journey  and  the  great  expenses 
of  living  necessarily  exclude  a  certain  number  of  invalids. 

The  chief  individual  resorts  to  be  considered  are  :  — 

Cairo.  —  This  should  be  avoided,  as  it  is  a  crowded  town,  offering  too 
many  social  temptations.  Although  the  sanitation  and  water-supply  of 
the  hotels  are  good,  the  town  itself  is  far  from  being  in  a  sanitary  condition. 

Helouan.  —  About  15  miles  from  Cairo,  standing  in  an  oasis  in  the 
desert.  There  is  more  wind  than  at  some  other  resorts  ;  the  accommoda- 
tion is  excellent.  As  it  is  a  little  above  the  level  of  the  Delta  Helouan 
can  be  utilised  also  from  November  to  January. 

Mena  House. — Near  the  pyramids,  an  admirably  kept  hotel.  The 
climate  m  the  late  winter  and  early  spring  is  much  the  same  as  that  of 
Helouan.  Owing  to  its  proximity  to  the  Delta  the  best  season  to  visit 
Mena  House  is  from  the  middle  of  February  onwards ;  before  that  date 
there  is  too  much  moisture  in  the  air,  owing  to  the  drying  up  of  the 
inundated  plain. 

The  Nile  Voyage.  —  This  may  be  made  in  two  ways :  (a)  by  steam- 
boat, (6)  by  dahabeyah.  (a)  The  steamboat  voyage  is  shorter,  but  less 
repose  is  obtained  than  on  the  dahabeyah.  There  is,  moreover,  far  too 
much  wind  for  serious  invalids,  and  often  a  difference  of  10°  between 
different  parts  of  the  boat,  and  much  more  between  sun  and  shade. 
Patients  suffering  from  the  throat  often  catch  cold  and  become  feverish. 
Here,  too,  the  belief  prevails  that  climate  must  do  everj^thing,  and  that 
the  doctor  need  not  be  consulted.  The  long  and  hurried  excursions  to 
tombs  and  temples  afford  another  source  of  danger  to  many  invalids. 
Dr.  Longmore,  as  the  result  of  his  experience,  is  inclined  to  regard  the 
voyage  during  the  months  of  January  and  February  as  unsuitable  to  the 
pulmonary  invalid,  particularly  so  far  as  lower  Egypt  is  concerned. 

(b)  The  dahabeyah,  on  the  other  hand,  affords  perfect  leisure,  while 
the  contrasts  of  temperature  are  not  so  great.  It  is,  however,  costly, 
and  the  patient,  unless  he  can  afford  a  travelling  physician,  will  be 


282  SYSTEM   OF  MEDICINE 

away  from  medical  supervision ;  e-ven  in  promising  cases  this  is  rarely 
advisable.  During  the  months  of  January  and  February  the  dahabeyah 
should  be  kept  south  of  Luxor  (Longmore). 

Luxor,  situated  on  the  Nile,  450  miles  south  of  Cairo,  possesses  a 
milder  climate  than  lower  Egypt,  being  warmer  and  not  so  subject  to 
cold  winds.  Luxor  is  admirably  suited  as  a  residence  for  the  invalid 
from  the  end  of  Xovember  to  the  middle  of  March.  Moreover,  the 
invalid  can  travel  by  train  within  a  day's  boat  journey  of  Luxor ;  this  is 
a  great  boon  to  those  arriving  late  in  the  season,  for  whom  the  boat 
voyage  is  unsuitable. 

There  is  an  admirable  site  for  a  sanatorium  south  of  the  hills  above 
the  tombs  of  the  kings.  Here,  owing  to  the  conformation  of  the  country, 
the  full  advantage  of  desert  air  could  be  enjoyed  to  a  greater  degree 
than  in  any  of  the  present  resorts. 

Assouan  stands  at  the  first  cataract ;  it  is  somewhat  more  bracing, 
drier,  and  warmer,  but,  on  the  wliole,  a  little  more  Avindy  than  Luxor. 
The  accommodation  is  fair  in  the  new  hotel,  but  there  are  few  arrange- 
ments for  sitting  in  the  open  air  without  exposure  to  draughts  and  dust. 
This,  however,  we  hear  is  to  be  remedied,  and  with  judicious  manage- 
ment Assouan  can  be  made  an  excellent  resort  for  sufferers  from 
rheumatism,  early  phthisis,  and  the  like. 

On  the  whole  the  great  advantages  of  desert  air  are  not  yet  suffi- 
ciently available.  We  may  say,  "however,  that  our  experience  of  treat- 
ment by  continued  residence  during  several  entire  years  in  the  Nubian 
Desert,  under  tents  shifted  from  one  place  to  another,  has,  in  several 
advanced  cases  of  consumption,  given  results  which  are  altogether 
superior  to  any  obtained  from  any  health  resort  or  frcm  any  other  treat- 
ment. Yet  if,  at  the  site  indicated  near  Luxor,  a  hotel  were  constructed 
on  an  improved  plan  as  regards  ventilation,  air  spaces  for  the  night,  food, 
and  so  forth,  the  conditions,  to  judge  from  the  medical  and  scientific  ob- 
servations that  have  been  made  on  the  climate,  would  be  nearly  perfect. 

Pau,  in  the  south-west  of  France,  about  630  feet  above  sea-level, 
owes  the  peculiarities  of  its  climate  to  its  situation  north  of  the  Pyrenees, 
not  far  removed  from  the  Atlantic,  a.nd  to  its  being  surrounded  by  a 
wide  circle  of  hills.  Thus  it  enjoys  considerable  calmness  of  atmosphere 
Avith  the  exception  of  occasional  storms.  The  air  is  less  dry,  and  the 
number  of  rainy  days  is  greater  than  at  the  Riviera.  The  mean  temper- 
ature from  November  to  April  is  about  48 "o^  F.  which  is  nearly  5°  F. 
less  than  at  the  AVestern  Riviera  resorts,  but  it  is  rather  more  equable. 
There  is  less  sunshine  and  sun  heat ;  the  difference  betAveen  sun  and 
shade,  and  between  day  and  night  is  less.  On  the  whole  the  climate 
may  be  called  sedative,  and  is  therefore  more  suitable  to  cases  with  an 
irritable  mucous  membrane  and  an  irritable  nervous  system  than  the 
Eiviera  (85). 

Dax,  in  the  south-west  of  France,  has  a  somewhat  similar  climate, 
but  is  less  sheltered  and  more  under  the  influence  of  the  Atlantic. 

Arcachon,  which  has  been  mentioned  under  the  marine  climates,  but 


CLIMATE   IN   THE    TREATMENT   OF  DISEASE  283 

has  almost  equal  right  to  a  place  here,  has  some  points  in  common 
with  Pan. 

The  interior  of  Italy  is  rich  in  delightful  localities,  which  may  tem- 
porarily serve  as  residences  to  invalids,  but  few  of  them  can  be  regarded 
as  health  resorts. 

Rome  will  always  claim  the  attention  of  physicians  called  upon  to 
advise  on  climates,  although  it  has  long  lost  its  great  reputation  in  the 
cure  of  phthisis.  November  is  often  rainy ;  December,  January,  and 
February  are  frequently  cold;  but  March,  April,  and  part  of  May 
are  mostly  pleasant,  and  may  be  useful  in  cases  of  arrested  phthisis, 
cases  with  chronic  bronchial  catarrh,  chronic  rheumatism,  gout,  and 
mental  depression,  provided  due  care  be  taken  to  avoid  over-fatigue 
in  sight-seeing,  and  changes  from  the  hot  sun  into  cold  galleries  and 
churches.  The  climate  of  E-ome  should  not  be  called  relaxing,  it  may  be 
said  to  take  an  intermediate  place  between  Pau  and  the  Eiviera.  Dr. 
Charles  and  other  physicians  residing  in  Rome  describe  the  hygienic  con- 
dition as  much  improved,  especially  in  consequence  of  the  excellent  water- 
supply. 

In  the  north  of  Italy  the  Lake  district  offers  some  climatic  advantages, 
■especially  the  Lago  Maggiore,  the  lakes  of  Como,  Varese,  and  Lugano, 
and  the  Lago  di  Garcia.  The  climates  of  the  different  localities  on  these 
lakes  are  by  no  means  the  same,  but  all  have  in  common  the  position  to 
the  south  of  the  sheltering  Alps,  and  the  influence  of  the  large  sheets  of 
water  near  which  they  are  situated.  They  offer  less  warmth,  less  shelter, 
and  less  sun  than  the  Eiviera,  and  have  more  rain ;  but,  compared  with 
England,  the  number  of  clear  days  is  greater  and  the  relative  humidity 
is  smaller.  The  late  Dr.  Scharrenbroich,  in  a  carefully-written  work  on 
Pallanza,  gives  the  relative  humidity  as  67-6°  F.,  the  number  of  bright 
days  during  the  colder  seasons  185,  of  rainy  61.  Pallanza,  which  is  open 
throughout  the  year,  has  a  mean  winter  temperature  of  only  39-1°  F., 
which  is  scarcely  more  than  the  inland  localities  in  the  south  of  England, 
but  in  spring  54-4°,  in  summer  71-4°,  in  autumn  55-65°.  The  climate 
may  be  regarded  as  moderately  dry  and  stimulating.  That  of  Locarno, 
likewise  open  in  winter,  is  somewhat  similar.  Stresa  and  Baveno  are 
rather  less  .sheltered,  and  are  suitable  only  for  spring,  summer,  and 
early  autumn.  On  the  Lake  of  Como,  the  Villa  d'Este,  Menaggio, 
Cadenabbia,  and  Bellagio  are  favourite  resorts  in  spring  and  autumn. 
Lugano  in  winter  and  spring,  according  to  Dr.  Thomas,  is  slightly  cooler 
than  Pallanza.  Varese,  on  the  lake  of  the  same  name,  deserves  likewise 
to  be  mentioned  ;  it  lies  higher  (1250  feet)  than  the  localities  on  the  four 
other  lakes,  which  lie  between  600  and  1000  feet.  The  accommodation 
at  Orta,  with  its  beautiful  little  lake,  is  not  yet  quite  so  good  as  at  the 
other  jjlaces  mentioned. 

The  Lago  di  Garda,  south-east  of  the  Lake  district  mentioned,  at  the 
foot  of  a  precipitous  mountain  range,  possesses  a  much  more  sheltered 
tract  of  shore  than  any  of  the  other  Italian  lakes.  It  offers  a  very 
remarkable  instance  of  the  power  of  configuration,  by  which  a  limited 


284  SYSTEM  OF  MEDICINE 

Riviera-like  climate  is  produced :  here  many  delicate  plants  grow  in  the 
open  air,  and  even  lemon-trees  on  steep  terraces.  At  a  village,  called 
Oardone- Riviera,  a  winter  resort  has  sprung  up  which  offers  many 
advantages  to  those  requiring  much  shelter. 

Arco,  which  has  fair,  though  not  the  same  amount  of  shelter,  lies  very 
near  to  the  Lago  di  Garda,  in  an  easterly  direction ;  it  has  for  many 
years  been  used  as  a  winter  resort.  All  these  localities  are  less  dry,  less 
warm,  and  less  stimulating  than  the  Italian  Riviera,  but  less  sedative 
than  Pau. 

We  may  here  allude  to  two  other  localities,  which  have  in  former 
years  enjoyed  a  wide  reputation,  especially  in  the  treatment  of  phthisis, 
viz.,  Meran  with  Obermais,  and  Botzen  with  Gries,  both  at  the  southern 
slopes  of  the  Tyrolese  Alps.  They  have  bright,  sunny  climates,  with  a 
certain  amount  of  shelter  and  moderate  relative  humidity. 

Third  Section. — Utilisation  of  Climates 

We  cannot  regard  climatic  treatment  in  the  narrow  sense  of  treat- 
ment by  the  mere  physical  elements  of  climate,  but  we  must  include  in 
it  and  avail  ourselves  of  all  the  agencies  associated  or  associable  with 
the  change  of  climate.  Some  of  these  agencies  act  principally  on  the 
bodily  functions,  while  others  bear  directly  on  the  mental  functions,  and 
through  them  on  the  organs  and  tissues. 

Physicians  who  are  consulted  about  the  choice  of  a  climate  often 
meet  with  misconceptions  on  the  part  of  the  patients.  The  latter  not 
rarely  think  that  it  is  sufficient  to  know  that  they  have  "gout,"  or 
"  dyspepsia,"  or  "  rheumatism,"  to  enable  the  physician  to  recommend 
the  "  best  climates  "  for  those  complaints :  they  do  not  consider  that 
"  gout "  is  often  complicated  with  other  affections,  and  differs  so  widely 
in  different  persons  and  constitutions,  as  to  need  widely  different  treat- 
ment ;  and  that  the  same  is  the  case  with  "  dyspepsia,"  with  "  rheuma- 
tism," and  with  almost  all  other  complaints.  The  patient,  moreover, 
frequently  regards  the  "  climate  of  a  place  "  as  a  fixed  agent,  comparable 
to  a  fixed  dose  of  a  particular  drug,  —  say  a  grain  of  calomel,  or  three  grains 
of  quinine,  or  five  of  iodide  of  potassium,  —  while  in  reality  the  climate 
of  a  place  during  a  certain  season,  say  winter  or  spring,  is  an  unstable 
agent,  varying  with  the  weather.  Some  physicians  are  in  the  habit  of 
saying  that  all  climates  are  uncertain  with  the  exception  of  Egypt,  but 
after  the  personal  experience  of  a  winter  in  Egypt  we  cannot  allow  even 
this  exception. 

To  ansAver  a  question  frequently  asked.  What  is  a  good  climate  ? 
our  answer  is :  A  good  climate  is  that  in  which  all  the  organs  and 
tissues  of  the  body  are  kept  evenly  at  work  in  alternation  with  rest. 
A  climate  with  constant  moderate  variations  in  its  principal  factors  is  the 
best  for  the  maintenance  of  health.  It  calls  forth  the  energy  of  the 
different  organs  and  functions,  their  power  of  adaptation  and  resistance, 
and  keeps  them  in  working  condition.     Such  are  the  climates  of  England 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  285 


all  the  year  round,  and  they  belong  to  the  most  health-giving  in  the  world. 
They  produce  the  finest  trees,  the  linest  animals,  the  finest  men,  and  are 
most  conducive  to  longevity.  They  are,  it  is  true,  not  the  most  agree- 
able or  exhilarating  climates ;  but  the  brightest  and  most  exhilarating 
climates  —  such  as  those  of  Egypt,  Spain,  Italy,  Greece,  Asia  Minor  — 
are  not  the  best  for  health  and  longevity ;  they  are  in  many  respects 
very  inferior  to  those  of  England. 

The  best  climates,  however,  for  healthful  development  and  for 
maintenance  of  health  need  not  be  the  best,  may  even  be  injurious  to 
delicate  or  diseased  persons  whose  organs  and  tissues  have,  temporarily 
or  permanently,  lost  their  energy  and  their  power  of  resistance  and 
adaptation.  We  must,  therefore,  endeavour  to  find  climates  for  invalids. 
And  here  we  must  say  at  once  there  are  no  perfect  climates  for  invalids. 
Relatively  good  climates  for  a  given  case  are  those  in  which  the  influences 
injurious  to  this  case  are  either  absent,  or  prevail  only  in  a  much  less 
degree  ;  and  where  at  the  same  time  other  influences  exist  which,  when 
properly  utilised,  effect  a  general  improvement  of  the  whole  constitu- 
tion, and  thus  facilitate  the  recovery  of  the  diseased  or  weakened  organs 
and  tissues,  as  far  as  possible.  Pure  air  and  water,  the  possibility  of 
spending  a  great  part  of  the  day  in  the  open  air,  good  hygienic  and 
dietetic  arrangements,  and  the  presence  of  a  good  local  physician  con- 
versant with  the  peculiarities  of  the  climate  and  of  the  entire  locality, 
are  the  most  necessary  conditions. 

The  physician  is,  indeed,  a  very  important  part  of  a  health  resort  and 
of  a  climatic  cure,  although  the  invalid  is  often  disinclined  to  see  this. 
Many  lives  are  needlessly  lost  by  trusting  to  the  climate  alone.  The 
exhilarating  influences  of  a  climate,  the  many  interesting  objects  of  a 
place  and  its  neighbourhood,  and  the  social  entertainments,  are  sources 
of  temptation,  lead  often  to  undo  exposure,  to  over-exertion,  or  to  chills, 
and  may  destroy  the  chances  of  recovery  for  ever  ;  on  the  other  hand, 
with  the  help  of  a  judicious  physician,  not  only  may  the  dangers  result- 
ing from  the  defects  of  a  place  be  escaped,  but  these  very  circum- 
stances may  also  be  employed  to  the  benefit  of  the  invalid. 

The  invalid  must  begin  by  studying,  with  the  guidance  of  his 
physician,  the  following  essential  points  :  — 

(1)  The  selection  and  arrangement  of  his  rooms  for  air  and  sun,  and 
other  hygienic  influences.  (2)  The  arrangement  of  his  meals  as  to 
quality,  quantity  and  time.  (3)  How  to  be  as  much  as  possible  in  the 
open  air.  (4)  What  kind  and  amount  of  exercise  to  take,  and  at  what 
times  of  the  day,  and  when  to  rest.  (5)  How  to  clothe  himself  at  dif- 
ferent times  of  the  day  and  of  the  season.  (6)  How  to  manage  the  skin. 
(7)    How  to  occupy  the  mind. 

Without  due  attention  to  these  points  many  cases,  even  at  the  best 
resorts,  are  not  benefited ;  with  it,  good  results  can  be  obtained  even  at 
inferior  localities. 

In  former  times  climatic  treatment  was  almost  limited  to  diseases  of 
the  respiratory  organs,  but  at  present  we  know  that  the  treatment  of 


286  SYSTEM  OF  MEDICINE 

almost  every  chronic  deviation  from  health  may  be  assisted  by  judicious 
change  of  climate.  Our  survey  of  the  principal  conditions  in  which  cli- 
matic treatment  is  usually  resorted  to  must,  however,  be  a  summary  one. 

The  Treatment  of  Phthisis  by  Climate.  —  The  utilisation  of  climate 
for  the  alleviation  or  arrest  of  phthisis  is  perhaps  the  most  important 
office  Avhich  change  of  air  can  fulfil.  From  its  very  nature  it  is  only 
within  the  reach  of  the  richer  of  the  victims  of  this  malady.  Too  often, 
moreover,  the  change,  either  owing  to  the  relentless  march  of  the  disease, 
the  unsuitable  locality  selected,  or  indeed,  and  more  commonly,  the 
imprudence  of  the  patient  himself,  ends  in  disappointed  hopes.  The 
selection  of  a  locality  is  often  one  of  the  most  difficult  problems  with 
which  the  physician  is  confronted.  Accumulated  clinical  experience,  it 
is  true,  has  given  us  a  series  of  fairly  definite  indications  to  guide  us  in 
the  choice;  more  frequently  than  not,  however,  Ave  have  to  be  governed 
in  our  selection  by  the  poverty  of  the  patient ;  and,  instead  of  the  best 
possible  climate,  have  rather  to  consider  where  he  may  find  an  oppor- 
tunity of  earning  a  livelihood. 

The  cases  Avhich  will  receive  most  benefit  from  a  stay  in  the  Siviss 
Alps  require  somewhat  careful  selection.  Early  cases  of  either  unilateral 
or  bilateral  phthisis  in  young  and  fairly  vigorous  persons,  in  which  the 
disease  is  of  a  limited  character  and  the  pyrexia  moderate,  should  be 
sent  to  the  Swiss  Alps  in  preference  to  any  other  resort.  In  young  per- 
sons a  sojourn  of  one  or  two  years  in  the  Alps  will  probably  not  only 
arrest  the  disease,  but  so  establish  the  constitution  that  the  patient  may 
cautiously  resume  his  ordinary  occupation  at  home.  It  has  been  urged 
that  these  cases  will  do  well  anywhere ;  but  not  only  do  statistics  show 
that  m.ore  first  stage  cases  are  arrested  in  the  Swiss  Alps  than  elsewhere, 
but  the  experience  of  all  those  who  have  compared  cases  coming  from 
various  resorts  testifies  in  favour  of  the  greater  quickness  and  certainty 
of  the  cure  in  the  Swiss  Alps. 

In  the  early  days  of  high  altitude  treatment  a  history  of  haemoptysis 
was  looked  upon  as  a  bar  to  the  employment  of  the  climate  ;  the  reasons 
for  this  belief  were  mainly  theoretical,  and  a  more  extended  experience 
has  shown  that  the  very  reverse  is  the  fact,  and  that  the  hsemorrhagic 
cases  do  particularly  well  there. 

When  a  case  has  passed  on  to  the  stage  of  excavation,  although  the 
ultimate  outlook  may  be,  on  the  whole,  less  hopeful,  clinical  experience 
warrants  us  in  saying  that  a  greater  benefit  may  be  anticipated  from  a 
prolonged  or  indeed  an  indefinite  sojourn  in  the  Alps  than  from  any  other 
form  of  climatic  treatment.  The  presence  even  of  considerable  pyrexia, 
so  long  as  we  can  be  sure  that  it  arises  rather  from  septic  absorption  than 
from  active  tuberculosis,  forms  no  bar  to  sending  the  patient  away.  In 
the  bronchiectatic  form  of  phthisis  progress  is  certain  to  be  extremely 
slow.  Since,  however,  the  majority  of  these  cases  arise  directly  from  a 
pleuritic  effusion,  we  should  take  early  advantage  of  the  very  definite  in- 
fluence for  good  which  the  rarefied  -air  is  likely  to  exert  upon  collapsed 
lung;  at  the  same  time  we  shall  put  the  whole  constitution  in  a  better 


CLIMA  TE  IN   THE    TREA  TMENT  OF  DISEASE  287 

condition  to  withstand  tlie  inevitable  strain  which  following  years  will 
bring.  In  this  form  of  disease  a  constantly  high  bodily  temperature,  or 
occasional  rushes  of  temperature  up  to  a  great  height,  form  no  imjoedi- 
ment  to  sending  the  case  to  the  Alps. 

A  further  class  of  cases  which  should,  except  in  the  face  of  obvious 
contra-indications,  be  so  treated,  is  that  in  which  the  phthisis  supervenes 
after  a  pleuritic  effusion  in  a  young  subject.  From  the  climate  of  the 
Alps,  in  such  cases,  we  may  almost  always  anticipate  the  happiest  results 
due  not  only  to  the  expansion  of  the  compressed  lung,  but  to  the  strength- 
ening of  a  constitution  of  whose  proneness  to  tubercle  the  effusion  was 
but  a  manifestation. 

What  are  then  the  symptoms  or  conditions  which  contra-indicate  the 
High  Alps  in  cases  of  phthisis  ?  We  will  consider  first  the  more  dis- 
tinct and  absolute  of  these. 

The  presence  of  albuminuria  forms  an  absolute  contra-indication. 
Any  affection  of  the  kidneys  bars  the  employment  of  the  climate  of  the 
Alps ;  such  cases  are  invariably  aggravated. 

Cases  in  which  there  is  valvular  disease  of  the  heart  or  degeneration 
of  the  arteries  should  never,  except  under  very  exceptional  circumstances, 
seek  the  climate  of  the  Alps ;  indeed  this  rule  is  absolute  as  regards 
the  condition  of  the  arteries.  In  those  rare  cases  of  affection  of  the 
mitral  valve  in  which  the  compensation  is  thoroughly  good  the  patient 
may  be  sent  without  much  hesitation.  In  disease  of  the  aortic  valves  the 
experiment  is  a  more  hazardous  one,  and  we  should  be  very  well  assured 
that  compensation  is  perfect  before  sending  the  case  to  high  elevations. 

The  next  complication  which  would  contra-indicate  the  Alpine  cli- 
mate is  the  presence  of  diarrhoea  due  to  tubercular  ulceration ;  diarrhoea 
of  a  merely  catarrhal  nature  may,  however,  derive  benefit  from  the  cli- 
mate. As  regards  laryngeal  complications  when,  as  is  Commonly  the 
case,  there  is  slight  hoarseness  with  the  laryngoscopic  appearances  of 
laryngeal  catarrh,  even  though  the  appearances  are  such  that  tubercle 
cannot  be  definitely  excluded,  the  patient  may  be  sent.  Where  there 
is  a  tubercular  ulcer  on  one  vocal  cord,  provided  that  the  arytenoids 
are  free,  he  may  also  seek  the  Alpine  air,  appropriate  treatment  being 
at  the  same  time  applied  to  the  throat.  When,  however,  the  arytenoids 
are  involved,  or  when  perichondritis  is  present,  the  case  should  on  no 
account  be  sent  thither. 

When  there  is  high  fever  due  to  the  rapid  extension  of  the  tubercular 
process  in  the  lungs  the  Alps  must  be  forbidden ;  but  if  the  fever  yield 
to  treatment  and  the  inflammatory  process  lessen  in  intensity,  the  ques- 
tion may  be  reconsidered.  In  cases  where  the  disease  is  far  advanced, 
and  the  amount  of  diseased  lung  large,  the  Alpine  air  should  not  be  tried  ; 
the  respiratory  area  will  probably  be  insufficient  to  meet  the  added 
strain,  and  the  fatal  event  will  be  hastened.  The  subjects  of  constitu- 
tional erethism  —  persons,  that  is,  with  habitually  quick  pulse,  subject 
to  feverish  attacks,  and  with  an  irritable  condition  of  the  nervous  systeni 
—  almost  invariably  get  worse  rather  than  better  in  the  rarefied  air. 


288  SYSTEM   OF  MEDICINE 


There  are,  besides,  a  certain  number  of  persons  who  cannot  bear  cold ; 
elderly  persons  especially,  in  spite  of  the  hot  sun,  are  injuriously  affected 
by  the  cold  air  of  the  Alps.  The  exclusion  of  such  cases  from  the  Al- 
pine treatment  is  often  a  matter  of  di£6lculty.  It  is  rarely  safe  to  place 
much  faith  in  the  patient's  statement  that  he  cannot  bear  cold ;  but  such 
a  statement  should  ensure  a  careful  estimate  of  his  constitutional  vigour. 

The  length  of  residence  in  the  High  Alps  which  is  likely  to  secure 
restoration  to  health  must  necessarily  vary  with  the  progress  of  the  case. 
We  should  never,  however,  lead  the  patient  to  expect  thorough  restora- 
tion to  health  from  a  residence  of  less  than  two  winters.  This  term  has 
often  to  be  cut  down  for  pecuniary  reasons,  but  it  should  never  be  short- 
ened in  deference  to  the  wishes  of  the  patient.  If  the  case  progress 
favourably  the  patient  Avill  probably  have  got  most  of  the  benefit  he  is 
likely  to  obtain  from  the  treatment  at  the  end  of  two  years.  There  are 
always  a  certain  number  of  persons,  however,  who  relapse  if  long  away 
from  the  high  altitudes.  For  these  there  is  nothing  for  it  but  to  settle 
for  the  winter,  at  all  events,  at  one  of  the  Alpine  health  resorts.  A  late 
distinguished  man  of  letters  was  a  remarkable  instance  of  a  life  so 
spent,  and  literature  is  the  richer  for  his  courage  and  prudence. 

A  point  upon  Avhicli  the  local  physicians  justly  lay  great  stress,  is  that 
the  residence  should  be  continuous  ;  that  is,  two  winters  and  one  summer 
at  least  should  be  spent  in  the  High  Alps.  It  has  been  the  custom  for 
invalids  to  go  down  to  a  lower  level  during  the  snow-melting  time  in  the 
spring.  Latterly,  however,  the  physicians  only  allow  patients  who  are 
doing  well  to  do  this,  and  rather  to  provide  a  change  of  scene  than  for 
other  reasons.  A  critical  case  is  likely  to  lose  more  by  the  journey  to 
and  fro  than  by  remaining  during  the  few  damp  days.  The  places  most 
usually  resorted  to  in  the  spring  are  Ragatz  and  Thusis.  Sometimes  a 
descent  to  the  Italian  lakes  or  Montreux  is  permissible  in  the  autumn. 

The  Alpine  sanatoria,  Davos  and  St.  Moritz  particularly,  owe  not  a 
little  of  their  success  to  the  very  thorough  and  efficient  manner  in  which 
every  detail  of  the  patient's  life  is  supervised  by  the  local  physicians, 
as  contrasted  Avith  the  somewhat  haphazard  method  only  too  much  in 
vogue  at  other  health  resorts.  The  opportunities  for  over-indulgence 
in  violent  outdoor  sports  which  these  places  offer,  and  the  temptations 
in  large  hotels  to  an  irregular  way  of  living,  are  in  most  cases  controlled 
by  the  physicians. 

The  time  of  year  at  which  the  patients  should  be  sent  is  a  matter 
of  some  importance :  the  end  of  September  is  the  best  time,  since  the 
patient  then  becomes  acclimatised  before  the  winter  sets  in.  Often, 
however,  the  patient  falls  ill  later  in  the  year.  It  is  a  sound  rule  not 
in  any  case  to  send  a  patient  after  the  end  of  January ;  he  will  then 
get  but  little  benefit  before  the  snow  begins  to  melt,  and  it  would  prob- 
ably be  better  to  wait  until  June.  In  a  doubtful  case  it  is  better  to 
make  the  ascent  gradually,  stopping  a  few  days  at  a  moderate  elevation. 

During  the  summer  in  the  Alps  the  invalid  can  find  change  of  scene 
at  a  like  elevation  at  Pontresina,  Maloja,  and  other  localities. 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  289 

The  special  utility  of  the  Colorado  resorts  lies  in  the  fact  that  profit- 
able occupation,  or  at  least  a  livelihood,  can  be  obtained  in  a  climate 
little  if  at  all  inferior  to  that  of  the  Swiss  Alps.  The  expanse  of 
country  possessing,  with  very  minor  modifications,  a  uniform  climate  is 
large ;  while  one  of  the  resorts,  Denver,  is  a  great  city  Avitli  flourish- 
ing industries.  In  the  selection  of  cases  for  treatment  in  Colorado  the 
same  contra-indications  hold  as  in  the  case  of  the  Swiss  Alps  ;  we  should, 
however,  be  more  rigorous  in  excluding  doubtful  cases,  seeing  that  the 
experiment  entails  long  journeys  by  sea  and  land. 

Some  persons,  indeed,  with  a  limited  area  of  damaged  lung,  w^ho  find 
the  Alpine  climate  too  cold,  may  seek  the  equally  elevated  yet  warmer 
climate  of  Colorado,  with  better  prospects  of  recovery  than  would  be 
given  by  a  descent  to  a  lower  level.  Moreover,  Colorado  presents  advan- 
tages to  that  class  of  cases  to  which  we  have  before  referred  —  those 
cases,  namely,  w^hich  remain  quiescent  in  the  mountains,  but  relapse  in 
the  plains.  Young  subjects,  the  children  of  phthisical  parents,  not 
themselves  tubercular,  but  for  whom  a  change  of  climate  is  thought 
advisable  as  a  prophylactic  measure,  —  as,  for  instance,  after  a  pleural 
effusion,  —  will  do  better  in  Colorado  than  elsewhere. 

The  cases  which  are  likely  to  receive  benefit  from  Australia  are  :  — 

1.  Cases  of  early  consolidation,  in  ivhich  there  is  no  fever.  2.  Quiescent 
cavity  cases. 

In  every  case  there  must  be  a  sufficient  amount  of  constitutional 
vigour  to  support  an  outdoor  life,  and  all  the  more  serious  complications 
—  laryngitis,  intestinal  ulceration,  or  high  fever  —  are  absolute  contra- 
indications. With  regard  to  eniployment,  we  must  point  out  that  a 
sedentary  occupation  followed  in  one  of  the  coast  towns  holds  out  no 
prospect  of  cure  ;  for  such  cases  the  higliland  townships  of  South  Africa 
or  Colorado  would  offer  greater  advantages. 

With  regard  to  South  Africa,  the  same  rules  as  to  choice  of  cases  hold 
good.  Practically,  unless  the  patient  have  plenty  of  vigour,  and  there 
seems  solid  ground  to  hope  for  early  subsidence  of  the  disease,  he  had 
much  better  seek  some  climate  nearer  home.  Haemoptysis  occurring 
early  in  the  course  of  the  disease  is  no  bar ;  late  haemoptysis  proceeding 
from  a  cavity  is  an  absolute  bar. 

The  advantage  of  the  Egyptian  climate  in  the  treatment  of  phthisis 
lies  in  the  warm,  sunny  days,  the  dryness  of  the  atmosphere,  and  the 
aseptic  character  of  the  air.  Its  drawbacks  are  :  the  short  time  of  year 
during  which  it  is  available,  and  the  danger  of  contracting  chills,  chiefly 
abdominal.  The  cases  of  phthisis  most  likely  to  derive  benefit  from  it 
are :  —  (a)  Cases  complicated  by  bronchitis  in  which  emphysema  is  also 
present,  (h)  Cases  of  bronchiectatic  phthisis,  for  wdiich  a  winter  or  two 
in  the  Alps  have  already  been  prescribed,  will  often  derive  great  benefit 
from  Egypt,  (c)  Cases  for  which  the  Riviera  is  too  cold,  or  in  which 
chills  often  recur,  (d)  Cases  of  early  consolidation  in  which,  either 
owing  to  susceptibility  to  cold  or  some  other  reason,  the  Alps  are  contra- 
indicated,     (e)  Cases  with  albuminuria  in  which  the  destruction  of  lungs 

VOL.    I  u 


290  SYSTEM  OF  MEDICINE 

is  not  very  great.  (/)  Cases  in  wliich  insomnia  and  nervous  irritability 
form  prominent  symptoms. 

On  the  other  hand  we  are  not  justified  in  sending  cases  presenting 
the  following  complications  :  — 

1.  Intestinal  Ulceration,  or  indeed  any  tendency  to  diarrhoea  what- 
ever. This  is  sure  to  be  aggravated.  2.  Laryngeal  Ulceration.  The 
dryness  of  the  air  always  aggravates  the  symptoms.  3.  Cases  beginning 
with  acute  pneumonic  symptoms.  These  should  not  be  sent  on  account 
of  the  length  of  the  journey  and  the  short  time  during  which  the  climate 
is  available. 

The  main  virtues  of  the  Riviera  climate  are  that  it  permits  the  patient 
to  pass  several  hours  of  most  days  in  a  fairly  warm  and  dry  atmosphere 
which,  owing  to  the  vicinity  of  the  sea  and  mountains,  is  comparatively 
free  from  impurities.  Its  drawbacks  are  the  winds  Avhich  materially 
curtail  the  amount  of  open-air  life,  and  the  danger  of  chills  from  the 
contrast  of  sun  and  shade  temperature.  Early  cases,  as  a  rule,  will  do 
better  in  the  Alps,  but  there  always  remains  a  residuum  for  whom  the 
Riviera  will  be  the  most  appropriate  climate.  Patients  for  whom  the 
Alps  are  too  cold  Avill  generally  do  very  well  on  the  Riviera  without  going 
so  far  afield  as  Egypt,  while  the  more  bracing  climate  will  increase  the 
resistance  of  the  body  more  than  will  that  of  Madeira.  Some  persons,  after 
one  or  two  winters  passed  in  the  Alps,  find  that  they  do  not  stand  the 
cold  so  well  as  at  first ;  such  persons  will  generally  continue  to  improve  on 
the  Riviera.  A  continuous  residence  in  the  Alps  sometimes  also  impairs 
the  appetite ;  this  symptom  will  generally  be  removed,  and  the  general 
condition  of  the  patient  ameliorated,  by  a  change  to  the  Mediterranean. 

When  the  time  of  the  year  at  which  the  disease  manifests  itself  is  too 
late  to  admit  of  the  possibility  of  Alpine  treatment,  the  spring  may  with 
advantage  be  passed  on  the  Riviera. 

Phthisical  patients,  in  whom  the  disease  is  characterised  by  a  great 
deal  of  irritation,  as  evidenced  by  signs  of  catarrhal  pneumonia,  probably 
do  better  on  the  Mediterranean  coast  than  elsewhere.  This  form  of 
phthisis  frequently  follows  influenza,  and  such  cases  generally  do  well. 
When  the  bronchitic  element  is  marked  the  Riviera  will  often  be  found 
practically  as  efficacious  as  Egypt,  and  is  nearer  and  less  expensive. 

Cases  of  laryngeal  phthisis  often  improve  under  appropriate  treat- 
ment at  Mentone  and  San  Remo.  Even  in  the  more  advanced  cases 
patients  may  be  sent,  if  willing  to  take  the  risk ;  for  though  there  may 
be  but  slight  hope  of  recovery,  yet  their  life  will,  on"  the  whole,  be  easier 
than  in  England.  They  must,  however,  be  pecuniarily  in  a  position  to 
afford  every  possible  comfort. 

Amongst  the  serious  drawbacks  of  the  Riviera  must  be  mentioned 
the  numerous  social  temptations.  The  Riviera  has  become  the  favourite 
resort  of  healthy  and  wealthy  people  who  crave  for  excitement  and 
amusement,  the  charms  of  which  are  irresistible  to  their  invalid  friends, 
who  not  rarely  lose  through  them  the  last  chance  of  recovery.  The 
danger  is  much  aggravated  by  the  mischievous  habit  amongst  patients 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  291 

at  the  Riviera,  not  to  place  themselves  under  the  entire  guidance  of  a 
physician,  not  to  consult  him  at  the  beginning  and  during  the  whole 
stay  about  the  manner  of  living,  —  hygienic,  dietetic  and  social,  —  but  to 
act  as  it  pleases  themselves  and  their  healthy  friends,  and  to  fly  to  the 
doctor  only  when  acutely  ill.  The  climate  itself  would  offer  very  good 
chances  to  a  great  many  consumptive  patients  if  they  were  placed  in 
well-arranged  sanatoria,  or  at  all  events  under  strict  medical  guidance ; 
but  the  present  fashions  render  this  almost  impossible. 

Madeira  is  often  more  useful  in  consumptive  cases  with  much  irrita- 
bility of  constitution,  and  especially  of  the  mucous  membranes,  accom- 
panied by  a  dry  cough ;  and  in  cases  complicated  with  emphysema.  It 
deserves  a  trial  also  in  patients  with  laryngeal  irritation.  Patients  with 
much  expectoration,  or  with  a  weak  intestinal  mucous  membrane,  ought 
not  to  be  sent  to  Madeira. 

The  Canaries  have  a  wider  range  of  usefulness  than  Madeira ;  they 
are  less  humid,  and  the  principal  localities  offer  more  chance  for  exercise 
on  level  or  gently-rising  ground.  Life  there  is,  unfortunately,  very 
raonotonoiis. 

Pan  and  Arcachon  are  suitable  in  senile  cases,  and  in  complications 
with  dry  cough  and  constitutional  irritability,  where  shelter  from  wind 
is  important. 

AJaccio  has  much  analogy  with  the  Riviera,  but  is  better  for  patients 
with  great  irritability  of  the  system.  The  same  is  the  case  with  Algiers . 
on  the  other  hand,  cases  with  much  expectoration  and  with  albuminuria 
generally  do  better  in  Egypt  and  on  the  Riviera. 

TJie  Ocean.  —  The  patients  most  likely  to  derive  benefit  from  the 
sea-voyage  are :  — 

1.  Those  in  whom  symptoms  of  phthisis  form  only  part  of  a  general 
breakdown  from  overwork.  2.  Cases  of  limited  consolidation  without 
fever.  (But  it  must  be  borne  in  mind  that  the  percentage  of  cures 
amongst  such  cases  is  higher  in  the  Alps.)  3.  Quiescent  cavity  cases 
often  seem  to  do  better  at  sea  than  elsewhere;  the  constitutional  and 
local  improvement  is  most  striking. 

The  contra-indications  to  a  sea-voyage  may  be  enumerated  as  :  — 

1.  The  graver  complications,  laryngeal  and  intestinal.  2.  Debility. 
3.    Fever. 

It  must  be  remembered  that  serious  illness  at  sea  is  a  greater 
misery  than  on  shore.  Early  haemoptysis  seems  not  to  be  aggravated, 
but  cases  of  haemoptysis  from  cavities  should  on  no  account  be  sent  to 
sea,  owing  to  the  difficulty  of  carrying  oat  efficient  treatment.  The 
victims  of  phthisis  suffer  but  little  from  sea-sickness  ;  the  discomforts  of 
sea^life,  however,  tell  so  much  more  on  women  than  on  men  as  prac- 
tically to  exclude  the  former.  Old  people,  also,  the  subjects  of  heart- 
disease  and  arterial  degeneration,  are  injuriously  affected  by  the  sea. 

The  treatment  of  phthisis  by  climate  in  the  British  Isles  may  be 
regarded  in  two  main  divisions  :  — 

1.    The  provision  of  a  summer  residence  for  those  who  winter  abroad. 


292  SYSTEM   OF  MEDICINE 

2.  Tlie  choice  of  a  winter  resort  for  those  whose  condition  or  cir- 
cumstances forbid  their  going  farther  afield. 

The  climate  of  England,  although  changeable,  is,  during  the  summer, 
bracing  and  sedative  to  the  nervous  system ;  in  this  respect  it  provides 
a  most  useful  change  to  those  who  have  wintered  in  the  more  exciting 
climates  of  the  south.  The  choice  will  have  to  be  made  between  the  dry 
and  bracing  east  coast  towns,  and  the  moister,  more  sedative,  and 
warmer  resorts  of  the  south  and  west.  For  more  vigorous  patients,  and 
particularly  for  those  coming  from  the  Eiviera,  the  east  coast  resorts  — 
Hunstanton,  Cromer,  Yarmouth,  Lowestoft,  Felixstowe,  Ramsgate  and 
Margate  —  are  suitable  during  summer.  These  are  often  more  benefi- 
cial to  the  Riviera  patient  than  the  Swiss  resorts.  The  less  vigorous, 
markedly  catarrhal,  and  febrile  cases  will  generally  be  more  benefited 
by  the  resorts  of  the  south  coast  —  Bournemouth,  Hastings,  and  Vent- 
nor,  or,  in  the  west,  Ilfracombe,  Torquay,  and  Falmouth.  Ilkley, 
Malvern,  and  Tunbridge  Wells,  again,  are  excellent  resorts  for  those  who 
are  injuriously  affected  by  sea-air.  Unfortunately,  the  English  winter 
climate,  owing  to  its  changeableness  and  number  of  rainy  days,  precludes 
a  great  deal  of  that  outdoor  life  so  necessary  to  the  well-being  of  the 
consumptive.  Were  the  existing  opportunities  for  outdoor  life,  however, 
more  fully  utilised  —  by  sun  galleries,  etc.  —  as  at  Folkestone  and  still 
better  at  Falkenstein,  far  better  results  would  be  obtained. 

Dr.  Williams'  statistics  (105)  show  a  slightly  smaller  proportion  of 
cures  from  winters  at  health  resorts  in  England  than  on  the  Riviera,  and 
distinctly  less  than  those  reported  from  the  Swiss  Alps.  Although, 
therefore,  the  chances  of  cure  are  somewhat  less  than  in  the  foreign 
resorts,  yet  the  risks  are  smaller.  Early  cases,  in  which  the  course  of 
the  disease  requires  to  be  watched  before  deciding  upon  the  trial  of  a 
foreign  climate,  may  have  the  benefits  of  one  of  the  home  resorts.  For 
cases  of  early  consolidation,  without  fever,  or  for  partially  arrested 
cases,  England  is  a  safe  abode  all  the  year  round.  There  remain  ber 
sides,  as  Dr.  Wilson  Fox  (31)  pointed  out,  a  certain  number  of  patients 
who,  after  trying  foreign  resorts  without  benefit,  improve  even  in  the 
most  unlikely  situations  in  England.  Bat  we  have  no  indications  to 
guide  us  to  their  recognition.  Cases  of  laryngeal  phthisis  should  seek 
the  milder  resorts  on  the  south  coast  if  there  be  any  doubt  as  to  the 
advisability  of  their  going  abroad.  More  severe  and  advanced  cases 
will  find  opportunities  for  a  fair  amount  of  outdoor  life  without  the 
discomforts  of  a  probably  fruitless  journey  abroad. 

The  choice  of  a  locality  rests  between  Bournemouth,  Ventnor,  Torquay, 
Queenstown  and  Hastings.  Hastings  is  not  adapted  for  other  than  the 
hardier  cases ;  Torquay  and  Queenstown  are  relaxing,  but  well  suited  to 
patients  with  little  constitutional  vigour.  Bournemouth  and  Ventnor 
are  more  suitable  for  earlier  cases  in  the  first  and  second  stages. 

In  conclusion,  it  must  be  borne  in  mind  that  though  we  have  some 
few  clinical  rules  which  may  help  us  in  the  selection  of  a  climate,  yet  the 
issue  of  the  selection  lies  mainly  in  the  patient's  own  hands.     Those 


CLIMA  TE  IN  THE    TREA  TMENT  OF  DISEASE  293 

patients  do  best  who  bear  in  mind  that  climatic  change  is  the  smallest 
factor  in  the  treatment  which  is  to  restore  them  to  health,  and  setting 
before  themselves  the  recovery  of  health  as  their  single  aim,  submit 
to  a  regulated  manner  of  life.  Nor  can  we  ignore  in  this  respect  the 
sanatorium  method  of  treatment  against  which  such  unfortunate  preju- 
dice exists,  but  which  has  undoubtedly  yielded  admirable  results. 

Bronchitis,  or  Chronic  Bronchial  Catarrh,  in  young  people  is  in  gen- 
eral better  influenced  by  mountain  climate  than  by  the  sea-side ;  but  in 
old  persons  the  mountains  are  often  injurious,  and  amongst  the  localities 
abroad  the  warm  sea-side  places  of  the  Riviera  or  the  climate  of  Egypt, 
of  Algeria,  of  the  south-west  of  France  or  of  the  Canaries,  are  beneficial ; 
or  Hastings,  Bournemouth,  Ventnor,  Falmouth,  Penzance  in  England. 
Whenever  there  is  much  expectoration  the  drier  climates  are  better  than 
the  more  humid  ;  but  if  there  be  irritable  cough  without  expectoration, 
the  latter  are  preferable,  such  as  Madeira,  Algiers,  Pau,  Arcachon, 
Torquay,  Queenstown.  In  albuminuria,  however  slight,  the  mountain 
climates  are  to  be  avoided,  while  Egypt  and  the  Riviera  are  often  bene- 
ficial ;  the  same  is  mostly  the  case  with  gouty  bronchitis. 

Emphysema  with  much  expectoration  is  favourably  influenced  by  dry 
and  warm  inland  and  coast  climates ;  if  it  be  attended  with  dry  cough, 
the  more  humid  climates  of  Madeira,  Pau,  Algiers  and  Torquay  are 
preferable.  High  elevations  are  not  suitable,  but  moderate  elevations 
are  so  in  summer. 

Asthma  often  does  not  allow  a  decided  opinion  without  a  trial.  Of  two 
apparently  similar  cases  one  may  bear  a  certain  place  well,  the  other  not. 
In  general  we  can  say  that  younger  subjects  are  more  benefited  by  long 
residence  in  the  Alps  than  by  any  other  climate  or  place.  If  possible 
their  education  should  be  conducted  at  high  elevations.  Senile  patients 
with  much  expectoration  ought  to  try  Egypt  or  the  Riviera;  with  little 
expectoration  and  irritating  cough,  Pau,  Arcachon,  Algiers,  Ajaccio,  or 
South  Devon  and  Cornwall  in  England,  or  Queenstown  in  Ireland.  Many 
asthmatic  persons  are  better  in  London  than  elsewhere.  In  nervous 
asthma  a  cautious  trial  is  required  to  find  the  most  suitable  localities. 

Scrofula  in  its  various  forms  requires  improvement  of  nutrition,  and 
mostly  acceleration  of  tissue  change.  Residence  at  the  sea-side  is 
most  useful.  Scrofulous  children  ought  to  be  educated  at  the  sea-side. 
The  sea-coasts  of  England  are  pre-eminently  adapted  to  this  treatment ; 
but  in  delicate  children,  with  little  reactive  power,  the  winters  ought 
to  be  spent  at  warmer  coasts,  such  as  the  Mediterranean,  or  Ajaccio,  or 
Algiers,  or  Biarritz,  or  Arcachon.  Sea-voyages  are  likcAvise  very  useful. 
Alpine  climates,  too,  offer  advantages,  but  in  the  majority  of  cases  the 
sea  is  to  be  preferred. 

Gouty  and  rheumatic  affections  are  aggravated  by  damp  cold  and 
winds.  They  require  dry  soil  and  warm  and  dry  inland  climates,  such 
as  the  desert  of  Egypt  or  Algeria,  and  southern  slopes  of  mountains,  or 
fairly  warm  sea-shores. 

Affections  of  the  heart  include  so  many  varieties  that  each  class  of 


294  SYSTEM   OF  MEDICINE 

case  requires  special  management.  On  the  whole  high  elevation  ought  to 
be  avoided,  excepting  in  mitral  cases  with  good  compensation.  Moderate 
elevations  from  500  to  2500  feet  with  level  walks  are  mostly  preferable 
to  the  sea-shore.     The  winter  should  be  spent  in  warm  inland  climates. 

In  diseases  of  the  kidneys  and  chronic  catarrh  of  the  bladder  warm 
and  dry  climates  act  beneficially,  by  rendering  the  skin  more  active, 
and  thus  relieving  the  work  of  the  kidneys.  Good  milk  ought  to  be 
obtainable  at  the  resorts  for  these  complaints.  Elevated  regions  are 
mostly  unsuitable. 

The  diseases  of  the  organs  of  digestion  are  so  multiform  that  one 
cannot  lay  down  general  rules.  In  convalescence  from  chronic  catarrh 
of  the  colon  and  dysentery  of  malarious  origin,  dry  elevated  regions  are 
useful.  The  same  is  the  case  with  chronic  flatulent  dyspepsia,  which 
often  disappears  rapidly  on  ascending,  for  instance,  from  Italy  to  the 
Engadine.  Dry  and  warm  inland  climates  may  likewise  be  recommended, 
especially  where  high  elevations  and  sea-voyages  are  not  suitable. 
Localities  which  offer  inducement  to  open-air  exercise  deserve  special 
attention.  If,  as  frequently  is  the  case,  these  complaints  are  only  symp- 
toms of  nerve  affections,  the  latter  demand  the  principal  consideration. 

Malarious  affections  in  general  are  benefited  by  high  elevations  with 
dry  and  sunny  air,  and  in  sujumer  especially  by  the  air  of  glaciers. 

Cases  of  anaemia  and  chlorosis  require  climates  where  the  invalids 
can  sit  or  lie  the  whole  day  in  the  open  air  without  fatigue  —  such  as 
sunny  moderate  elevations,  and  the  cooler  marine  resorts  in  summer  and 
the  warmer  in  winter.  Sea-voyages  and  yachting  are  useful  for  good 
sailors.  Only  a  moderate  amount  of  exercise  is  to  be  permitted,  with 
easy  and  genial  mental  and  social  occupation,  and  inducement  to  take 
a  proper  amount  of  food. 

In  the  treatment  of  affections  of  the  nervous  system,  especially  in 
those  cdl\%di  functional,  climate  can  take  a  fair  share.  In  mental  depression, 
ti,nd  also  in  different  forms  of  hypochondriasis,  travelling,  sea-voyages, 
frequent  change  of  residence  to  places  of  historical  interest,  which  afford 
at  the  same  time  social  attractions  and  facilities  for  open-air  life  and 
exercise,  are  often  attended  with  excellent  results.  Rome,  Florence, 
Naples,  Sicily,  Egypt,  Athens  and  Greece,  Palestine  and  Asia  Minor, 
have  in  our  experience  often  assisted  recovery,  and  enabled  the  sufferer 
to  return  to  home  life  and  active  mental  occupation. 

In  cerebral  exhaustion  from  overwork,  or  from  ill-regulated  and 
unsuccessful  work,  and  in  the  numerous  forms  of  nerve  failure  in  men  as 
well  as  women  (Weir  Mitchell's  Wear  and  Tear),  often  comprised  under 
the  much-abused  term  of  "  neurasthenia,"  change  of  climate  and  surround- 
ings is  often  an  essential  help ;  but  the  nature  of  the  change  must  depend 
on  the  degree  of  exhaustion  and  on  the  mental  and  physical  constitu- 
tion of  the  invalid.  In  cases  not  too  advanced  occurring  in  fairly  robust 
persons,  prolonged  residence  near  glaciers,  or  at  all  events  in  the  Alps, 
in  winter  as  well  as  in  summer,  with  graduated  exercise  and  in  cheerful 
company,  has  often  proved  most  beneficial ;  while  in  cases  of  greater 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  295 


exhaustion  or  of  low  resisting  power,  better  remedies  will  be  found  in 
yachting  in  warmer  regions  ;  and  in  wintering  in  the  Riviera,  in  Algiers, 
in  Sicily,  in  Rome,  in  Naples,  or  in  Egypt,  where  under  such  circum- 
stances tlie  Nile  journeys  on  a  dahabeyah  are  more  restful  and  mostly 
preferable  to  those  on  steamboats.  Time,  however,  is  necessary,  varying 
from  some  months  to  some  years. 

Neuralgia  is  to  be  treated  according  to  its  nature.  If  it  be  of  gouty 
or  rheumatic  or  dyspeptic  origin,  it  falls  under  these  several  heads ;  if, 
as  is  often  the  case,  it  is  one  of  the  earlier  symptoms  of  nervous  exhaus- 
tion, the  suggestions  given  above  are  applicable  to  it. 

Diabetes,  if  acute,  requires  strict  treatment  at  home ;  but  in  persons 
affected  with  chronic  diabetes,  or  Avith  different  degrees  of  glycosuria 
(which  are  of  widely  varying  nature),  climatic  treatment  can  be  rendered 
more  or  less  beneficial  according  to  the  nature  of  the  case.  In  gouty  con- 
stitutions, for  instance,  where  corpulence  is  not  rare,  and  where  glucose 
in  the  urine  often  alternates  with  excess  of  uric  acid,  the  indications  are 
similar  to  those  in  gouty  and  corpulent  persons.  In  invalids,  where  gly- 
cosuria is  one  of  the  manifestations  of  nerve  failure,  we  may  recommend, 
according  to  the  degree  of  strength  and  resisting  power,  long  residence  at 
high,  elevations,  or  sunny  inland  and  sea-shore  localities.  In  addition  to 
the  considerations  mentioned  under  the  head  of  affections  of  the  ner- 
vous system,  we  have  in  glycosuric  cases  to  bear  dietetics  in  mind,  and 
see  that  the  plan  of  diet  recommended  can  be  carried  out. 

Polyuria  or  diabetes  insipidus  is  mostly  a  symptom,  sometimes  one 
of  the  earliest,  of  disorder  of  a  nerve  centre.  As  valerianate  of  zinc  and 
similar  remedies  have  a  beneficial  action,  so  have  Alpine  climates  com- 
bined with  open-air  life,  but  without  fatigue. 

In  the  state  of  convalescence  from  acute  disease  climatic  treatment  is 
often  very  useful,  especially  in  tardy  convalescence.  We  have  to  bear 
in  mind  that  the  whole  system  is  weakened,  and  that  there  is  increased 
liability  to  disease  of  different  organs  from  over-fatigue  in  travelling, 
injudicious  exercise  or  food,  cold  winds,  damp,  etc.  It  is,  therefore,  often 
advisable  to  begin  with  change  to  a  good  place  within  easy  reach,  and  to 
proceed  later  to  more  distant  localities.  Great  heat  and  cold  are  equally 
to  be  avoided,  and  much  patience  is  often  required.  Important  though 
this  subject  be,  in  a  climatic  point  of  view,  we  must  restrict  ourselves  to 
these  cursory  remarks,  and  leave  more  detailed  suggestions  to  the  authors 
on  the  several  diseases. 

Climacteric  changes,  in  the  wider  sense  of  the  term,  frequently  need  cli- 
matic treatment.  The  deviations  connected  with  the  so-called  "  change 
of  life"  in  women  are  well  recognised;  but  in  both  sexes  the  quick  rise 
to  a  higher  stage  of  development,  as  well  as  the  rapid  descent  to  a  lower 
stage,  and  also  the  delay  of  development,  are  often  attended  by  a  vari- 
ety of  disorders  of  the  nervous  system  which  manifest  themselves  in 
physical  and  mental  disorders  of  most  varied  nature.  The  development 
and  the  cessation  of  the  sexual  functions  are  the  most  j^erceptible  signs 
of   climacteric   periods;    but  other  important  functions  undergo  like 


296  SYSTEM  OF  MEDICINE 

changes,  and  the  harmony  or  equilibrium  of  the  whole  organism  be- 
comes sometimes  disturbed  for  shorter  or  longer  periods.  The  more 
invigorating  climates  are  mostly  preferable,  but  diversion  of  the  mind 
greatly  assists  the  adaptation  of  the  altered  functions  to  the  system  at 
large.  We  have  to  bear  in  mind  that  there  is  increased  "  vulnerability," 
and  that  over-exertion  and  other  risks  are  to  be  avoided ;  otherwise  the 
physical  climatic  elements  of  places  need  not  be  so  carefully  selected, 
while  localities  offering  change,  exhilaration  and  mental  recreation 
deserve  special  recommendation,  such  as  Florence,  Home,  the  Gulf  of 
ISTaples,  Sicily,  Greece,  Spain,  Asia  Minor,  Egypt,  Algeria,  the  United 
States  of  America,  the  artistic  centres  of  France,  Germany,  Holland  and 
Belgium,  and  so  forth,  according  to  the  nature  of  the  individual  cases. 

Senile  decay,  whether  simply  natural,  or  premature,  is  to  be  regarded 
as  one  of  the  climacteric  changes ;  but  in  these  cases  we  have  to  meet 
permanently  diminished  vital  powers ;  hence  the  necessity  of  looking 
for  localities  Avhere  the  demands  on  the  weakened  organism  are  more 
moderate  than  at  home,  and  the  mental  faculties  are  at  the  same  time 
gently  stimulated.  The  first  Lord  Brougham  showed  his  wisdom  in 
spending  the  winters  of  his  advanced  life  at  Cannes. 

We  could  go  on  almost  indefinitely  to  enumerate  morbid  conditions 
which  can  be  benefited  by  judicious  use  of  climatic  changes,  but  for  a 
mere  survey  we  have  probably  said  enough.  We  must  content  our- 
selves with  a  mere  allusion  to  the  prophylactic  value  of  climates.  As 
we  have  alluded  under  the  head  of  scrofula  to  the  advisability  of 
educating  children  with  scrofulous  tendencies  at  the  sea^side,  so  we  may 
say  that  in  hereditary  or  acquired  tendency  to  tubercular  phthisis 
education  at  well-selected  elevated  localities  is  much  to  be  recom- 
mended, for  instance  at  St.  Moritz,  Davos,  or  "  les  Avants." 

Moreover,  we  constantly  meet  with  persons  who  have  no  measur- 
able disease,  but  are  in  a  state  of  health,  physical  or  mental,  in  which 
slight  injurious  influences  may  do  mischief.  In  such  states  a  judi- 
ciously arranged  climatic  change  will  often  lead  to  the  recovery  of 
health  and  energy. 

Utilisation  of  Home  and  Home  Climates.  —  We  will  restrict  ourselves 
in  this  chapter  to  the  life  of  the  invalid  in  English  climates  and  in  his 
own  house.  We  must  consider  the  disadvantages  as  well  as  the  advan- 
tages. We  cannot  help  acknowledging  that  there  is  some  truth  in  the 
description  which  that  sympathetic  observer,  the  elder  Dumas,  puts  into 
the  mouth  of  D'Artagnan  in  Vinrjt  Atis  Apr^s,  the  "pays  oil  il  fait  froid 
toujours,  oil  le  beau  temps  est  dii  brouillard,  le  brouillard  de  la  pluie,  la 
pluie  du  deluge ;  oil  le  soleil  resemble  a  la  lune,  et  la  lune  a  un  from- 
age  a  la  creme."  Nor  can  we  forget  that  Ave  frequently  meet  with  cases 
similar  to  that  of  a  singer  from  Spain  whom  we  often  found  on  her  sick- 
bed humming  words  from  Geibel's  "  Spanish  Gipsy  Boy  in  the  North."  ^ 

1  She  was  a  consumptive  patient  who  was  unable  or  disinclined  to  eat,  and  whom  we 
could  only  induce  to  do  so  by  the  constant  promise  to  send  her  to  Malaga,  where  she 
ultimately  recovered. 


CLIMATE  IN   THE    TREATMENT   OF  DISEASE  297 


Dieser  Nebel  driickt  mich  nieder 
l>er  die  Sonne  mir  entfernt 
Und  die  alten  liist'gen  Lieder 
Hab'  ich  alle  fast  verlernt. 

Immer  in  die  Melodien 
Schleicht  der  Eine  Klang  sich  ein  ; 
In  die  Heiniatli  moclit'  ich  Ziehen, 
In  das  Land  vol!  Sonnenscheinl 

We  must  acknowledge  that  the  climates  of  England  are  rather  moist, 
that  the  air  is  often  dull  and  sunless,  that  rain  falls  on  comparatively 
many  days,  and  is  distributed  over  many  hours,  that  the  wind  is  often 
high  and  chilling,  and  that  the  shelter  is  limited.  On  the  other  hand, 
the  hygienic  conditions  are  better  than  anywhere  else,  the  food  is  good, 
and  the  separation  from  the  family  is  less.  The  climates  of  England 
belong,  as  we  have  said,  to  the  most  health-giving  climates  for  the  fairly 
vigorous,  but  are  less  good  for  the  delicate  invalid.  If,  however,  a 
delicate  person  is  obliged  to  stay  at  home  or  near  home,  it  is  often 
possible  for  him  by  judicious  management  to  obtain  great  benefit  by 
availing  himself  of  all  the  advantages,  and  defending  himself  from  the 
injurious  influences  of  the  home  climates. 

It  is  doubly  necessary  for  him  to  attend  under  medical  guidance 
to  the  seven  points  which  we  formulated  on  page  285.  If  we  carefully 
examine  the  good  results  obtained  at  foreign  climatic  health  resorts,  we 
often  find  that  they  are  not  so  much  due  to  the  climatic  advantages  of 
those  localities  as  to  the  hygienic  and  dietetic  management  and  the 
whole  manner  of  living.  We  see,  for  instance,  that  the  results  obtained 
at  Gorbersdorf,  at  Falkenstein,  and  at  Hohenhonnef  are  at  least  as  good 
as  those  gained  at  Davos,  at  St.  Moritz,  and  Colorado;  and  yet  in  the 
prominent  climatic  conditions  —  namely,  the  elevation,  the  number  of 
sunny  hours,  the  diathermancy  of  the  atmosphere  —  the  three  former 
localities  are  decidedly  inferior  to  the  three  latter;  but  in  these  the 
hygienic  and  dietetic  arrangements,  and  especially  the  open-air  treatment 
and  the  limits  of  exercise,  are  under  careful  supervision.  We  could  give 
many  instances  from  which  we  ought  to  gain  hope  that  in  our  home 
climates,  inferior  as  they  are  for  the  management  of  many  delicate 
persons,  satisfactory  results  may  be  obtained.  A  great  source  of  difficulty 
is  that  at  home  the  invalid  is  not  inclined  to  devote  the  whole  day  to 
health  matters,  to  walking  or  lying  in  the  open  air,  to  taking  the  neces- 
sary numerous  meals  ;  but  if  it  be  once  recognised  that  life  depends  on 
it,  the  majority  of  invalids  will  endeavour  to  obey. 

Most  important  points  for  an  invalid  at  home  are  the  selection  of  a 
residence  and  the  arrangement  of  the  rooms  he  lives  in.  If  it  be  possible 
for  him  to  choose  his  house,  let  it  be  on  a  dry  soil  or  rock,  on  a  southern 
slo]je,  and  not  at  the  bottom  of  a  valley;  let  it  be  in  the  neighbourhood 
of  woods,  pine  woods  by  preference,  and  let  the  woods  be  between  the 


29S  SYSTEM  OF  MEDICINE 

prevalent  cold,  winds  and  the  house.  An  abundant  supply  of  good  water 
is  likewise  necessary.  The  house  ought  to  have  a  sunuy  verandah  with 
movable  glass  walls.  All  the  rooms  inhabited  by  the  invalid  should  be 
towards  the  sun,  and  ventilated  by  day  and  by  night.  Couches  for  lying 
out  of  doors  or  in  open  verandahs  or  galleries,  and  seats  with  shelter, 
movable  against  the  Avind,  ought  to  be  provided.  Such  arrangements 
are  expensive  for  single  persons  ;  but  it  ought  not  to  be  difficult  to  found 
establishments  for  a  number  of  cases,  with  diminution  of  expense  and 
increase  of  convenience,  with  well-arranged  walks,  with  large  screens 
against  the  cold  winds  ;  such  establishments  ought  to  be  under  constant 
medical  guidance.  There  is,  we  know,  a  certain  amount  of  prejudice  in 
England  against  strict  medical  supervision,  but  if  it  were  once  realised 
that  many  lives  can  be  saved  in  such  establishments  and  under  such 
judicious  guidance,  Avhich,  even  at  the  best  climatic  health  resorts,  are 
otherwise  lost,  the  opinion  of  the  profession  and  the  public  would  gradu- 
ally become  favourable  to  them. 

It  is  a  matter  of  great  importance  that  the  invalid  who  remains  at 
his  home  or  in  his  own  country  should  feel  that  he  is  not  doomed  to  die, 
that  he  should  retain  his  energy  and  his  firm  will  to  regain  his  health. 
Every  one  of  us  has  many  pleasant  memories  of  patients  whose  cases  did 
not  look  promising  at  first,  but  who,  by  their  firm  will  and  their  judicious 
and  dutiful  perseverance,  entirely  recovered  under  indifferent  external 
circumstances.  The  qualities  of  energy,  perseverance,  and  hope  cannot 
be  over-estimated  in  the  treatment  of  chronic  disease  by  climate. 

Hermann  Weber. 
Michael  G.  Eoster. 

REFERENCES 

1.  Allbutt,  T.  Clifford.  "The  Climate  of  Davos,"  Lancpt,  1S77-78-79.  —  2. 
Bakewell,  R.  H.  "  On  Climate  of  Barbados,"  Practitioner,  1878.  —  ?•.  Bennett,  J.  H. 
Winter  and  Spring  on  the  Shores  of  the  MediterraJiean,  5th  ed.  1875. — 4.  Bennett, 
J.  H.  On  the  Treatrw.nt  of  Pulmonani  Consumption,  18(i6.  —  5.  Bentley,  A.  J.  M. 
Wintering  in  Egypt,  181)4. — (>.  Bentley,  A.  J.  M.  Th".  M  dntenance  of  Ihalth  in 
Egypt,  1891. — 7.  Bird,  S.  Dougatj.  On  Australian  Climat-'s,  18fi3. — 8.  Bruck,  L. 
Guide  to  the  Health  B-'sorts  of  Australia,  Tasmania,  and  Neio  Ze'dand,  1888. — 9. 
Bert,  P.  La  Pression  Barom^tri.qw,  1870. — 10.  Bowles,  R.  L.  Suihurn  on  the 
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CLIMATE  IN  THE    TREATMENT  OF  DISEASE  299 

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Treatment  of  Pulmonary  Phthisis,  translated  by  Montagu  Lubbock.  —  40.  Klomelev- 
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1894.  —  41.  Lacassagne,  A.  Precis  d' Hygiene  prlvee  et  sociale,  1876. — 42.  Lang, 
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"  Les  Avants  as  Winter  Health  Resort,"  Med.  Chron.  1890. —45.  Leech,  D.  J. 
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300  SYSTEM  OF  MEDICINE 

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1895. 

H.  W. 
M.  G.  F. 


ARTIFICAL   AERO-THEEAPEUTICS 

By  artificial  aero-therapeutics  "we  mean  the  treatment  of  disease  by 
atmospheres  artificially  prepared,  and  differing  from  the  normal  either  in 
composition,  pressure,  or  temperature.  This  will  serve  as  a  rough  defini- 
tion of  our  subject,  but  it  must  not  be  considered  as  exhaustive,  for 
nature  herself  supplies  exceptions  to  the  normal  standard  in  the  varieties 
of  atmosphere  caused  by  the  emission  of  gases  in  volcanic  districts,  in 
the  density  of  air  in  mines,  and  in  its  rarefaction  on  mountains. 
The  subject  may  naturally  be  divided  into  two  portions  — 

A.  Artificial  atmospheres  produced  by  variations  in  the  relative  pro- 
portions of  the  gaseous  components  of  air,  or  those  produced  by  admix- 
ture with  gases  or  elements  other  than  those  of  the  atmosphere. 

B.  Artificial  atmospheres  produced  by  variation  in  the  barometric 
pressure. 

Of  artificial  atmospheres  we  have  a  familiar  example  in  the  air  of 
great  cities  which  contains  impurities,  varying  with  the  materials  used  for 
heating,  lighting,  and  manufactures.  In  foggy  states  of  the  air,  such  as 
occasionally  prevail  in  London  and  other  towns,  sulphuretted  hydrogen 
and  carburetted  hydrogen  have  been  detected  in  the  atmosphere ;  the 
former  arises  from  sewer  gas,  and  can  easily  be  demonstrated  by  the 
blacking  of  white  lead  paint  on  the  exterior  of  buildings ;  the  carburetted 
hydrogen,  the  result  of  the  escape  of  coal  gas,  may  be  detected  by  its 
odour,  unless  it  have  passed  through  some  thickness  of  earth.     In  addi- 


ARTIFICIAL   AERO-THERAPEUTICS  301 

tion  to  excess  of  carbonic  dioxide  and  aqueous  vapour,  carbonic  monoxide, 
sulphurous  acid  and  ammonia,  and  organic  matter  are  present;  and  if 
there  be  factories,  unless  the  Smoke  Abatement  Act  be  rigidly  observed, 
their  products  mingle  with  the  atmosphere,  making  it  deviate  still  more 
from  the  normal.  Thirty  years  ago  the  air  of  Manchester  contained  so 
much  sulphurous  acid  that  the  late  Dr;  Angus  Smith  was  in  the  habit  of 
saying  that  when  it  rained  in  Manchester  it  did  not  rain  water,  but 
dilute  sulphuric  acid  from  the  condensation  of  the  sulphurous  acid  fumes 
in  water. 

We  must,  however,  confine  ourselves  to  those  modifications  of  atmos- 
phere which  can  be  applied  to  the  treatment  of  disease,  and  we  must 
likewise  extend  our  observations  to  the  application  of  gases  of  different 
kinds  to  therapeutic  uses. 

A.  Medicated  Atmospheres.  —  Inhalation  is  the  most  common  form  of 
applying  medicated  atmospheres  to  the  human  body,  the  lungs  being  the 
medium  of  communication.  The  best  instances  of  inhalation  are  certain 
gases,  such  as  oxygen,  nitrous  oxide  and  carbonic  acid,  which  have  been 
used  for  therapeutic  purposes  ;  and  again  the  vapour  of  certain  medicines 
volatile  at  low  temperatures,  such  as  ether,  chloroform,  nitrite  of  amyl, 
tetrachloride  of  carbon,  iodide  of  ethyl  and  the  like. 

There  is  no  method  of  artificial  aero-therapeutics  so  successful  as  this ; 
in  most  cases  the  full  physiological  effects  of  the  drug  are  produced  very 
speedily,  as  is  seen  in  chloroform  inhalation,  where  a  few  seconds  or 
minutes  suffice  to  render  the  patient  unconscious  :  as  the  gaseous  nature 
of  the  agent  renders  it  easy  of  absorption  by  the  lungs,  it  passes  speedily 
by  the  circidation  to  the  Ijrain  and  spinal  cord,  producing  characteristic 
effects. 

The  methods  of  inhalation  principally  in  use  are  as  follows :  — 

I.  Inhalation  of  gases,  such  as  oxygen  and  nitrous  oxide.  II.  Inhala- 
tion of  vapours  of  certain  medicines  volatile  at  low  temperatures,  such  as 
ether  and  chloroform.  III.  Vapours  of  substances  requiring  heat  for 
volatilisation,  such  as  mercury  and  sulphur.  IV.  Moist  warm  inhala- 
tions.    V.    Cold  medicated  sprays. 

I.  Of  the  first  class  the  inhalation  of  oxygen  has  lately  come  into 
extensive  use  to  relieve  dyspnoea  and  cyanosis  in  pneumonia,  capillary 
bronchitis,  and  like  states.  It  would  appear  that  oxygen  combines  with  the 
haemoglobin  of  the  red  corpuscles  of  the  blood,  and  that  the  quantity 
absorbed  depends  upon  the  pressure  of  the  atmosphere  and  the  amount 
of  hfemoglobin  present  in  the  blood.  Paul  Bert  took  blood  which,  under 
the  ordinary  atmospheric  pressure,  absorbed  14  per  cent  by-volume  of 
oxygen,  and  shook  it  up  with  oxygen  under  increased  atmospheric 
pressure ;  he  found  mider  6  atmospheres  it  contained  19-2  per  cent  by 
volume  of  oxygen,  under  12  atmospheres  26  per  cent,  and  under  18 
atmospheres  31-1  per  cent,  thus  absorbing  the  element  in  accordance 
with  Dalton's  well-known  law  of  gases.  The  highest  limit  of  absorption 
reached  in  animals  inhaling  an  atmosphere  containing  oxygen  of  increased 
density  was  28  to  30  per  cent  by  volume  of  oxygen  in  arterial  blood. 


302  SYSTEM   OF  MEDICIXE 

Pure  oxygen  under  a  pressure  of  3-5  atmospheres  was  fatal  to  animals, 
inducing  first  slight  trembling  of  the  extremities,  followed  by  stronger 
convulsions  repeated  at  regular  intervals,  but  becoming  weaker  and 
weaker  till  death  supervened.  For  therapeutic  purposes  oxygen  is  sup- 
plied under  high  pressure  in  iron  cylinders ;  the  gas  is  admitted  into 
an  intermediate  india-rubber  bag  whence  it  flows  through  a  mouthpiece 
or  tube  into  the  mouth,  or  in  some  cases  through  a  pipe  inserted  into 
the  nostrils. 

This  means  has  been  tried  in  apparently  desperate  cases  of  pneu- 
monia and  of  capillary  bronchitis  where  cyanosis  and  unconsciousness 
have  been  the  striking  features.  In  almost  all  these  patients  improve- 
ment has  followed;  the  colour  has  brightened,  consciousness  has  re- 
turned, and  respiration  and  pulse  rates  have  fallen ;  but  in  many  of 
them  the  improvement  was  but  temporary,  though  the  rally  might 
be  repeated  more  than  once  before  death,  which  was  usually  sudden. 
Such  is  my  general  experience ;  but  in  one  case  it  certainly  bridged 
over  the  crisis,  and  permanently  relieved  the  dyspnoea  and  cyanosis. 
In  all  the  successful  cases  of  oxygen  administration  in  pneumonia 
the  improvement  and  ultimate  recovery  seem  to  have  depended  on 
the  continuous  use  of  the  remedy ;  it  is  therefore  better  to  administer 
oxygen  in  smaller  quantity  for  hours,  possibly  for  days,  than  in  a 
large  quantity  for  a  short  time.  It  is  possible  that  the  sudden  deaths 
recorded  may  be  due  to  over-stimulation  and  exhaustion  of  the  respira- 
tory or  cardiac  centre  by  the  oxygen.  This  inhalation  has  been  used  in 
the  cyanosis  of  advanced  emphysema  and  in  asthma,  but  only  with 
temporary  benefit  in  either.  During  their  balloon  ascents  the  French 
aeronauts  Croce-Spinelli  and  Sivel  succeeded  in  alleviating  and  even 
dispelling  the  symptoms  of  giddiness,  nausea,  faintness,  and  the 
increased  respiration  and  pulse  rate  by  inhaling  a  mixture  of  oxygen 
and  nitrogen  containing  from  40  to  70  per  cent  of  the  latter ;  this  they 
began  to  use  at  an  elevation  of  5000  metres. 

Nitrous  oxide,  or  laughing  gas,  on  account  of  its  harmlessness,  is 
largely  used  as  an  anaesthetic,  especially  by  dentists.  It  is  also 
employed  during  surgical  operations,  but  seldom  alone,  as  its  effect 
is  not  sufficiently  lasting. 

Carbonic  acid  in  small  quantities  has  been  inhaled  for  phthisis  and 
other  lung  affections,  and  is  reported  to  have  a  sedative  effect  on  the 
cough.  It  is  far  too  dangerous  a  gas  to  use  as  a  therapeutic  agent,-'  though 
we  often  witness  its  influence  on  man  in  atmospheres  rendered  impure 
by  human  exhalations :  here,  however,  the  percentage  of  carbonic  acid 
is  still  small,  and  possibly  some  of  the  evil  effects  may  be  due  to  other 

1  Carbonic  acid,  mixed  with  sulphuretted  hydrogen,  has  been  used  by  Dr.  Bergeon  of 
Lyons,  as  a  gaseous  injection  per  rectum.  Claude  Bernard  showed  that  certain  gases,  toxic 
when  inhaled,  might  be  absorbed  by  the  colon  in  large  quantities  without  any  bad  effecls. 
and  thence  passing  into  the  portal  system,  and  reaching  the  heart  and  pulmonary  circula- 
tion, be  eliminated  from  the  system  through  the  lungs.  Dr.  Bergeon  professed  to  cure 
lung  tuberculosis  in  this  way,  but  the  treatment  failed  after  a  fair  trial  at  the  hands  of 
myself  and  others. 


ARTIFICIAL   AERO-THERAPEUTICS  303 


impurities,  such  as  ttie  organic  matters  mingled  with  it.  The  symptoms 
of  excess  of  carbonic  acid  in  the  air  are  headache,  drowsiness,  vertigo, 
and,  in  time,  increasing  feebleness  of  the  heart's  action  with  slowness 
of  pulse,  the  respirations  being  quickened  even  to  gasping.  I  have 
often  thought  that  the  relief  which  suddenly  comes  to  asthmatics  at  the 
height  of  a  paroxysm,  when  lividity  and  feebleness  of  pulse  proclaim  the 
accumulation  of  the  products  of  respiration  in  the  blood,  may  be  due  to 
the  lowering  of  the  sensibility  of  the  nerve  centres  by  the  carbonic  acid. 
I  remember  a  female  asthmatic  in  whom,  during  a  severe  spasm,  there 
was  complete  cyanosis,  the  nails  and  lips  turning  quite  blue.  The 
respirations  became  fearfully  laboured,  the  pulse  slow  and  irregular, 
and  at  last  apparently  stopped  altogether.  She  fell  back  in  the  bed,  and 
my  assistant  thought  she  was  dead ;  but  at  the  next  moment  the  colour 
returned  to  her  lips  and  face,  the  pulse  beat  again,  she  heaved  a  deep 
sigh,  and  her  breathing  once  more  became  easy.  I  could  not  account  for 
these  phenomena  in  any  other  way  than  that  the  accumulation  of  the 
gases  of  respiration,  aird  principally  the  carbonic  acid,  acted  as  an 
anaesthetic  to  the  medulla  and  the  pulmonary  and  cardiac  plexus. 

Chlorine  was  largely  used  by  the  late  Dr.  A.  T.  Thomson,  who  con- 
sidered it  ''  the  best  topical  expectorant  and  the  most  salutary  excitant 
to  the  mucous  membrane  that  had  yet  been  inhaled  " ;  other  authorities, 
like  Laennec  and  Dr.  Stokes,  found  chlorine  too  irritating  for  inhalation. 
It  was  at  one  time  largely  used  for  disinfecting  purposes,  and  is  very 
effective,  but  its  strong,  pungent  smell  is  offensive.  A  useful  and  less 
pungent  form  of  inhalation  is  chloride  of  ammonium  vapour :  this  is 
made  by  mixing  the  vapours  of  liquid  ammonia  and  fuming  hydro- 
chloric acid,  the  chloride  of  ammonium  fumes  are  then  purified  from  any 
excess  of  hydrochloric  acid  by  passing  them  through  water.  Thence 
they  are  drawn  through  a  tube  into  the  pharynx,  larynx,  and  nasal 
passages,  and  prove  beneficial  in  pharyngeal  and  nasal  catarrh. 

Iodine  was  employed  for  inhalation  by  Laennec,  Berton,  Murray  and 
Scudamore  for  the  treatment  of  phthisis ;  the  patients  either  inhaling 
the  vapour  itself  for  a  short  period,  or  being  surrounded  by  an  atmos- 
phere strongly  impregnated  with  iodine.  All  these  authors  speak  very 
favourably  of  the  results  obtained.  My  personal  experience  of  the 
iodine  vapour  is  favourable,  but  I  have  never  seen  it  arrest  tuberculosis. 
Iodine  is  a  strong  antiseptic,  and  probably  exercises  a  bactericidal  action 
on  surfaces  immediately  exposed  to  its  influence,  but  that  it  has  any 
effect  on  the  progress  of  tuberculisation  in  the  lung  itself  I  much 
doubt.  Iodine  vapour  has  been  administered  with  advantage  in 
laryngeal  diseases. 

II.  In  the  second  method  certain  liquids  are  used  which  are  volatile 
at  low  temperatures,  such  as  ether,  chloroform,  bichloride  of  methylene, 
tetrachloride  of  carbon  and  the  like.  These  are  almost  entirely  em- 
ployed as  anaesthetic  inhalations,  either  in  a  pure  condition  or  occasion- 
ally, as  in  the  case  of  chlfjroforin,  mixed  with  a  certain  percentage  of 
air ;  their  uses  as  anaisthctics,  however,  will  not  be  considered  here. 


304  SYSTEM  OF  MEDICINE 

III.  The  chief  substances  requiring  heat  for  volatilisation  which  are 
used  in  aero-therapeutics  are  Mercury  and  Sulj^hur.  In  the  so-called 
mercurial  and  sulphur  baths  the  patient,  covered  up  with  a  sheet,  sits  on 
a  chair,  with  a  spirit-lamp  or  gas-jet  underneath  by  Avhich  the  drug  is 
heated  to  vaporisation ;  the  vapour  envelops  the  patient,  and  is  absorbed 
to  a  large  extent  by  the  skin.  If  the  evaporation  of  steam  accom- 
pany this  process  the  skin  is  better  prepared  for  the  reception  of  the 
drug.  From  time  immemorial,  mercurial  vapour  has  been  used  in  India 
and  Arabia  for  exciting  salivation  in  certain  diseases,  and  it  was  employed 
later  in  the  south  of  Europe.  In  England  the  practice  was  resuscitated 
by  Jackson,  and  more  completely  by  Mr.  Henry  Lee,  who  introduced 
mercurial  baths  largely  into  the  treatment  of  syphilis.  Mr.  Lee  used 
calomel,  and,  in  order  to  get  rid  of  the  possible  excess  of  hydrochloric 
acid,  baked  the  calomel  before  each  bath. :  in  this  method  the  powder  is 
laid  on  a  circular  plate,  surrounded  by  a  trough  containing  water  which  the 
flame  soon  converts  into  steam ;  at  the  same  time  the  calomel  is  vaporised. 
The  patient  is  enveloped  in  a  cloak  which,  fastened  round  the  neck,  pre- 
vents the  calomel  vapour  from  escaping ;  this  is  occasionally  unfastened 
during  the  fumigation  to  allow  of  a  short  period  of  inhalation  also.  Another 
method  of  mercurial  fumigation  is  by  Trousseau's  cigarettes,  which  con- 
sist of  blotting-paper  soaked  in  a  solution  of  nitrate  of  mercury  and 
nitric  acid.  These  were  recommended  by  Trousseau  for  chronic  laryn- 
gitis, as  well  as  for  syphilitic  pharyngitis  and  laryngitis.  The  sulphur 
baths  are  prepared  and  conducted  in  the  same  Avay  as  the  mercurial ;  and 
have  been  employed  for  scabies  and  other  parasitic  affections  of  the  skin. 

IV.  For  moist,  warm  inhalations,  where  steam  or  ivarm  water  vapour 
is  the  medium  for  applying  medicinal  agents  to  the  lungs,  the  apparatus 
vary  greatly.  The  simplest  form  is  a  wide-mouthed  jug  or  gallipot 
filled  with  boiling  water  into  which  a  drug  is  thrown;  the  patient, 
taking  deep  respirations,  draAvs  the  vapour  into  his  mouth  and  nostrils 
through  a  napkin  arranged  in  the  form  of  a  tube.  More  compli- 
cated are  the  steam  spray  apparatus  of  Siegle,  Oertel,  Robert  Lee, 
Codman  and  Shurtleff,  and  others.  In  some  hospitals,  as  in  the  Brompton, 
steam  and  sprays  are  fitted  up  in  separate  rooms,  so  that  the  patients  can 
inhale  without  admission  of  the  moist  air  into  the  ward.  This  class  of  in- 
halations beneficially  affects  the  bronchial  tubes,  specially  in  inflamma- 
tory or  catarrhal  conditions,  by  promoting  secretion ;  but  it  is  doubtful 
whether  they  penetrate  deeply,  or  go  beyond  the  primary  and  secondary 
bronchi.  Steam  .yjrays  saturate  the  atmosphere  with  moisture,  which  is 
not  always  desirable  in  lung  diseases ;  moreover,  they  cause  excessive  skin 
perspiration.  The  spray,  whether  it  be  a  steam  or  handball  apparatus, 
is  produced  by  a  strong  transverse  current  passing  over  a  perpendicular 
tube;  as  the  air  in  the  upper  part  of  that  tube  is  thus  rarefied, 
any  liquid  in  which  the  tube  may  be  immersed  ascends,  and,  as  it 
meets  the  current,  is  broken  into  spray.  Boyle's  well-known  ventilating 
extractors  act  in  the  same  manner.  The  apparatus  introduced  by  Sales- 
Giron,  Matthieu  and  Bergson  consisted  of  two  pointed  tubes  at  right 


ARTIFICIAL   AERO-THERAPEUTICS 


305 


angles,  placed  with  their  extremities  together,  and  so  joined  that  the 
extremity  of  the  perpendicular  tube  should  stand  in  front  of  the  axis  of 
the  horizontal  tube.  As  the  stream  of  air  or  steam  passes  along  the 
horizontal  tube  the  medicated  fluid  rises  in  the  vertical  tube,  and,  on 
meeting  the  air  current,  is  broken  into  fine  spray. 


Fig.  15.  —  Oertel's  Steam  Nebuliser. 


The  method  is  the  same,  whether  air  be  used,  as  in  the  well-known 
handball  spray  apparatus,  or  steam,  as  in  Siegle  or  Oertel's  "  steam 
nebulisers." 

The  handball  sprays  are  used  at  ordinary  temperatures,  and  as  a  rule 
are  not  so  grateful  to  the  patient  as  warm  vapours.  They  are  very  use- 
ful for  the  medication  of  the  mouth,  the  pharynx,  and  even  the  larynx ; 
and  solutions  of  quinine,  chlorine,  or  carbolic  acid  can  be  well  applied 
through  them.  They  seldom  penetrate  beyond  the  larynx  and  larger 
bronchi,  and  generally  condense  into  liquid  on  the  fauces  and  pharynx. 
The  sprays  of  mineral  water  in  use  at  Aix  les  Bains,  Pirrefonds,  Mont 
Dore,  Cauterets,  etc.,  belong  to  this  category,  and  are  of  use  in  laryngeal 
and  bronchial  affections,  but  seldom  in  lung  diseases.  The  free  applica- 
tion off  antiseptic  sprays  for  purifying  the  atmosphere  of  sick  chambers 
and  of  hospital  wards  is  excellent  —  carbolic  acid  (1  in  50),  thymol, 
eucalyptol,  or  chlorine  being  adapted  to  the  purpose. 

Artificial  atmospheres  for  invalids  may  be  made  by  respirators  which 

VOL.    I  X 


3o6  SYSTEM  OF  MEDICINE 

cover  the  mouth,  or,  still  better,  the  nose  and  mouth.  These  generally 
consist  of  metal  or  celluloid,  with  two  layers  of  wire  gauze  or  perforated 
iron  plates  containing  between  them  cotton  wool,  tow  or  sponge  on  which 
are  sprinkled  a  few  drops  of  carbolic  acid,  creosote,  terebene,  eucalyptol, 
or  other  disinfectant.  Thus  the  patient  with  each  respiration  breathes 
an  impregnated  air,  and  may  do  so  for  any  length  of  time  desired.  The 
advantages  of  these  respirators  are  —  1st,  that  they  admit  of  the  use  of 
certain  drugs  for  long  periods ;  2nd,  that  in  cases  of  foul  breath,  as  in 
bronchiectasis  and  abscess  of  the  lung,  the  wearing  of  an  antiseptic  respi- 
rator purifies  the  patient's  exhalations,  to  the  advantage  of  his  friends 
and  attendants.  The  patterns  are  very  numerous,  such  as  Roberts', 
Coghill's,  Curschmann's,  Hunter  Mackenzie's,  and  Wordsworth's.  The 
most  comfortable  is  Curschmann's  :  it  consists  of  half  a  globe  of  metal, 
enclosing  the  mouth,  nose,  and  a  portion  of  the  face,  from  which  a  short 
tubes  passes  for  the  admission  of  air.  This  contains  the  antiseptic 
sprinkled  on  wool  or  tow  between  two  folds  of  wire  gauze ;  a  strap 
behind  holds  the  instrument  on,  and  any  uncomfortable  pressure  of  the 
metal  against  the  face  is  prevented  by  a  layer  of  air  cushion  next  the 
skin.  The  great  objection  to  all  respirators  is  that  they  interfere  with 
free  respiratory  movement. 

On  the  efficacy  of  inhalations  as  a  method  of  artificial  aero-thera- 
peutics, some  experiments  made  by  myself  in  1888  throw  great  doubt ; 
these  show  that  inhalations  of  iodine,  supplied  by  steam  or  handball 
sprays,  even  when  given  for  a  considerable  period,  produce  no  trace  of 
iodine  in  the  urine ;  whereas  iodine  can  be  detected  in  the  urine  after 
a  few  doses  by  the  mouth.  Turpentine  inhalations,  on  the  other  hand, 
produced  the  characteristic  odour  in  the  urine,  but  not  to  so  marked  a 
degree  as  when  the  medicine  was  administered  by  the  mouth. 

The  late  Dr.  Hassall,  from  careful  experiments,  came  to  the  con- 
clusion that  the  greater  part  of  the  substances  inhaled  remained  in  the 
inhaler ;  and  that,  in  the  case  of  the  ordinary  ori-nasal  respirators,  four- 
fifths  of  the  carbolic  acid,  creosote  and  other  drugs  were  recoverable 
from  them  after  the  inhalations. 

B.  Artificial  Atmospheres  varying  in  Barometric  Pressure  must  now 
be  considered  as  therapeutic  agents  —  atmospheres,  that  is,  denser  or 
more  rarefied  than  at  sea-level. 

The  average  barometric  pressure  at  sea-level  is  29  to  30  inches,  at 
Davos  (5200  feet)  it  is  25  inches ;  on  the  summit  of  Pike's  Peak,  Colo- 
rado (14,147  feet),  it  is  17-54  inches ;  and  during  the  famous  balloon 
ascent  of  Glaisher  and  Coxwell,  at  a  height  of  29,000  feet,  a  pressure 
of  9 1  inches  was  registered ;  indeed,  so  low  a  pressure  as  7  inches  was 
seen  afterwards  by  Coxwell,  though  he  could  not  record  it.  On  the 
other  hand,  the  air  is  far  denser  in  the  deepest  mines  than  at  sea-level ; 
and  it  has  been  calculated  that  if  a  shaft  could  be  sunk  forty-five  miles 
into  the  earth,  the  air  at  the  bottom  of  it  would  be  as  dense  as  quick- 
silver. 

Junod  was  one  of  the  first  to  apply  air  at  diminished  barometric 


ARTIFICIAL   AERO-THERAPEUTICS 


IPl 


pressure  to  the  human  body  :  in 
1835  he  contrived  a  hollow 
copper  ball,  1\  metre  in  diam- 
eter, capable  of  containing  an 
adult  man,  and  by  an  exhaust- 
ing apparatus  he  reduced  the 
barometric  pressure  one-third, 
producing  distension  of  the 
membrana  tympani,  dyspnoea, 
chiefly  in  the  form  of  short, 
quick  respirations ;  turgescence 
of  the  superficial  vessels  of  the 
body,  as  seen  in  the  eyelids 
and  lips ;  and  diminution  of  the 
salivary,  renal,  and  other  glan- 
dular secretions.  Junod  did 
not  continue  his  experiments  on 
the  general  influence  of  rarefied 
air  on  the  human  body,  but 
turned  his  attention  to  the 
local  effects,  which  were  also 
being  studied  by  Neil  Arnott, 
Murray,  and  Clanny,  and  in- 
vented the  Junod  boot  and  the 
cupping-glasses,  which  are  still 
in  use.  The  Junod  boot  and 
Sir  James  Murray's  inctrumont 
are  apparatus  for  enclosing  a 
limb,  or  a  part  of  a  limb,  in  an 
air-tight  vessel,  and  exhausting 
the  atmosphere  by  an  air-pump ; 
the  atmospheric  pressure  being 
thus  removed  from  the  surface 
of  the  limb,  blood  is  drawn  to 
the  part,  the  vessels  become 
gorged,  and  blood  is  derived 
from  the  internal  organs.  The 
action  of  cupping-glasses  is,  of 
course,  the. same  in  principle. 

Dry  cupping  is  useful  in 
congestion  of  certain  internal 
organs,  such  as  the  lungs,  kid- 
neys or  brain.  From  the  eur.e 
and  readiness  of  its  application 
it  is  of  value  in  cases  where 
blood  is  to  be  drawn  rapidly 
from  an  organ,  and  especially 


FiO.  IC.  —  Wtildcnbury's  Apparatus. 


3o8 


SYSTEM  OF  MEDICINE 


in  hsemoptysis.  I  have  witnessed  some  of  the  most  profuse  haemorrhages 
from  the  lung  suddenly  brought  to  a  termination  by  the  use  of  dry  cup- 
ping to  the  chest- wall ;  and  I  have  often  observed  that  so  long  as  the 
cupping-glasses  are  kept  on  the  haemorrhage  has  been  controlled,  and 
that  on  their  removal  it  may  return.  Hence  the  great  advantage  of 
cupping-glasses  with  exhausters  attached  by  which  a  partial  vacuum 
can  be  maintained. 

This  treatment,  if  carefully  applied,  leaves  no  mark,  and  it  is  to  be 
preferred  to  blistering  or  strong  poulticing  in  cases  of  gouty  disposition 
or  where  the  patient  has  a  very  irritable  skin. 

The  Artificial  ApiMcation  of  Air  at  a  Varying  Pressure  to  the  Lungs 
is  carried  out  by  various  apparatus,  most  of  which  are  constructed  both 
for  rarefaction  and  for  condensation. 

It  is  possible  to  apply  air  to  the  lungs  in  four  different  ways :  — 
1.  Inspiration  of  rarefied  air.  2.  Expiration  into  rarefied  air.  3.  In- 
spiration of  compressed  air.     4.  Expiration  into  compressed  air. 

Of  these  varieties  the  only  ones  found  generally  useful  are  the 
second  and  third;  though  in  the  pneumatic  cabinet,  to  be  presently 
described,  the  other  changes  can  also  be  carried  out. 

The  earliest  instrument  for  condensing  and  rarefying  the  air  was 
constructed  by  Hauke,  of  which  Waldenburg's  well-known  apparatus  is 
a  modification  (Fig.  16).  This  last  consists  of  a  hollow  metal  cylinder  or 
bell,  containing  a  certain  volume  of  air,  which  is  plunged  into  a  second 
and  inverted  cylinder  containing  water.  By  means  of  pulleys  and  weights 
an  equilibrium  is  established,  and  a  pipe  is  passed  from  the  air  cylinder 

through  a  drying-box  to  a  mask 
fitting  the  patient's  mouth  ;  through 
this  he  respires  the  air,  which  can  be 
rarefied  or  condensed  by  raising  or 
lowering  the  cylinder  in  the  water. 
This  is  done  in  the  first  instance  by 
drawing  off  water,  in  the  second  by 
placing  weights  on  the  cylinder. 

Some  apparatus,  like  Cube's  and 
Schitzler's  second  form,  are  double, 
and  consist  of  two  cylinders,  one  for 
condensing  and  the  other  for  rarefying 
the  air ;  thus,  by  changing  the  tube 
connections,  expiration  into  a  rarefied 
atmosphere  can  be  followed  by  the 
inspiration  of  condensed  air.  Others, 
as  Biedert's  and  Eraenkel's,  contain 
a  kind  of  leathern  bellows  to  compress 
or  rarefy  the  air  as  required.  Fraen- 
kel's  ingenious  instrument  resembles 
a  concertina  with  a  tube  and  mouthpiece ;  it  is  simple  and  cheap,  and 
can  be  worked  by  the  patient  himself.     The  obvious  objections  to  it  are 


Fig.  17. — Fraenkel's  Apparatus. 


ARTIFICIAL   AERO-THERAPEUTICS  309 

the  contracted  attitude  of  the  patient,  and  the  impossibility  of  regulating 
the  pressure. 

Lastly,  the  principle  of  the  centrifugal  pump  is  adopted  in  Giegel 
and  Mayer's  machine,  which  seems  the  most  complete  apparatus  of  all ; 
in  it  air,  compressed  or  rarefied  by  the  action  of  water,  is  stored  up  in 
a  central  reservoir. 

"  By  the  simultaneous  use  of  two  apparatuses  placed  in  communica- 
tion with  the  mouth  of  the  patient  by  means  of  two  flexible  tubes  and 
a  double  respiratory  valve,  and  by  maintaining  the  constancy  and  con- 
tinuity, a  simultaneous  rarefaction  and  condensation  of  the  air  can  be 
established,  which  enables  the  patient  to  inspire  compressed  air  and  to 
expire  into  rarefied  by  one  and  the  same  expiratory  act."  For  further 
particulars  of  this  apparatus  the  reader  is  referred  to  Oertel's  article 
on  "  Respiratory  Therapeutics,"  in  the  3rd  vol.  of  Ziemssen^s  Handbook 
of  Geyieral  Therapeutics. 

One  of  the  newest  portable  instruments  for  using  air  at  various  press- 
ures is  the  pneumatic  cabinet  of  Mr.  Ketchum  of  the  United  States.  A 
rhomboidal  cupboard  on  wheels,  large  enough 
to  hold  a  man  in  a  sitting  position,  is  con- 
stnicted  of  steel  with  a  plate-glass  window  in 
front ;  at  the  back  is  an  air-tight  door,  which 
forms  the  whole  side.  Above  this  cabinet  is 
a  bellows,  worked  by  a  lever,  with  one  set  of 
valves  opening  into  the  cabinet,  and  a  sec- 
ond set  communicating  with  the  external  air : 
these  valves  can  be  reversed,  so  that  by  the 
bellows  the  air  of  the  cabinet  may  be  con- 
densed or  rarefied  at  will.  An  artificial  wooden 
glottis  regulates  the  air-stream  into  the  pa- 
tient's lungs,  passes  through  an  aperture  in 
the  glass  plate,  and  is  connected  by  india- 
rubber  tubing  with  the  patient's  mouth.  The  ^^«-  ^^- "  '^^^  Pneumatic  Cabinet. 
pressure  within  the  cabinet  is  increased  by  working  the  lever,  or  de- 
creased by  turning  a  tap  communicating  with  the  external  air.  In  this 
machine  a  pressure  of  two  inches  can  be  obtained. 

Various  modifications  of  the  respiratory  act  are  possible  with  this 
machine.  When  the  artificial  glottis  is  closed,  the  bellows  worked  for 
rarefaction,  and  the  patient  makes  deep  expirations  —  1.  Residual  air- 
expansion  results.  If  he  put  a  nose  clip  on  and  adjust  his  mouth  to 
the  glottis  tube,  which  is  opened  gradually,  air  from  the  outside  is 
admitted.  2.  Forced  inspiration  results,  and  a  larger  volume  than  usual 
enters  the  lungs.  The  alternation  of  these  two  movements,  viz.,  residual 
air-expansion  and  forced  inspiration,  constitutes,  3.  Respiratory  differen- 
ti/ition,  an  exercise  for  the  purpose  of  expanding  the  lungs.  4.  Forced 
expiration  takes  place  when  the  air  of  the  cabinet  is  condensed,  and  the 
patient,  having  taken  a  deep  breath,  expires  through  the  artificial  glottis. 

The  pneumatic  cabinet  is  used  for  lung  gymnastics  of  different  kinds. 


3IO  SYSTEM  OF  MEDICINE 

A  committee  of  the  Brompton  Hospital,  appointed  to  investigate  its 
capabilities,  showed  that  its  use  caused  (a)  increase  of  chest  circumfer- 
ence, (&)  increase  of  spirometric  capacity,  and  (o),  in  many  cases  of  con- 
solidation, diminution  in  the  area  of  dulness.  The  cabinet  was  found 
less  successful  as  a  vehicle  for  medicinal  agents,  and  the  remedial  effect 
of  medicated  sprays  in  this  machine  was  not  greater  than  at  normal  press- 
ures. Great  caution  is  necessary  in  the  selection  of  appropriate  cases, 
and  the  cabinet  must  not  be  used  in  cases  of  vascular  weakness  or  of 
pyrexia  —  haemoptysis  has  followed  its  use  in  the  former  and  increased 
temperature  in  the  latter  class  of  patients. 

Many  of  the  described  methods  of  aero-therapeutics  depend  for  suc- 
cess on  the  exact  adjustment  of  mouthpieces  or  masks,  which  are  often 
exceedingly  irksome  and  induce  headache  and  faintness.  Another  diffi- 
culty in  many  of  the  instruments  is  that  of  supplying  sufficient  fresh 
air  at  the  proper  pressure ;  the  consequence  is  that  patients  have  to 
inhale  rebreathed  air.  To  meet  this  objection  the  compressed  air  bath 
was  invented,  in  which  patients  are  surrounded  with  an  atmosphere  in 
which  they  can  respire  air  at  any  desired  degree  of  pressure  for  hours 
at  a  time,  and  in  some  cases,  as  in  the  St.  Petersburg  establishment,  for 
days  together.  Different  forms  of  the  bath  have  been  devised,  and  the 
size  varies  according  to  the  number  of  occupants.  The  essential  elements 
appear  to  be  (a)  an  air-tight  oval  chamber  of  sufficient  strength  to  resist 
the  variations  of  atmospheric  pressure,  and  (b)  an  efficient  compressing 
apparatus.  The  chamber  may  be  constructed  of  masonry  or  of  iron,  but 
more  generally  it  is  of  wrought  iron  yL  inch  thick,  in  an  irregular  or 
ovoid  form,  and,  if  possible,  with  a  domed  roof  to  resist  pressure,  the 
whole  being  strengthened  by  girders  and  ribs  of  iron.  The  compressing 
apparatus  generally  consists  of  a  steam-engine,  but  in  some  places,  as  in 
M.  Fontaine's  establishment  at  Paris,  hydraulic  power  is  used  which  has 
the  advantage  of  compressing  the  air,  without  materially  increasing  its 
temperature,  and  any  smell  arising  from  contact  with  boilers  is  also 
avoided.  The  advantage  of  steam  is  the  rapidity  with  which  pressure 
can  be  increased  and  steadily  maintained. 

The  annexed  woodcut  of  the  compressed  air  bath  in  use  at  the 
Brompton  Hospital  will  give  some  notion  of  the  details  of  the  appara- 
tus. The  drawing  is  supplied  by  Mr.  Blake,  the  manager  of  Messrs. 
Haden  &  Sons  of  Trowbridge,  the  constructors  of  the  bath. 

The  bath  consistc  of  three  parts  :  the  engine  (A),  the  receiver  (B), 
and  the  air-chamber  (C).  A  includes  a  steam-engine  D,  which,  by  means 
of  a  flywheel  and  crank,  works  a  second  engine  E  in  another  and  sepa- 
rate compartment  F.  E  is  the  air-compressing  engine,  with  a  cylinder 
containing  an  inlet  hole  and  an  outlet  hole,  and  in  this  cylinder  works 
the  piston  H,  the  plate  of  which  is  perforated  by  diaphragm  valves, 
not  here  shown,  which  close  during  the  descent  of  the  piston  and  open 
during  its  ascent.  The  air  from  outside  enters  the  compartment  F 
through  the  inlet  Gr,  and  follows  the  course  indicated  by  the  arrows. 
Entering  the  air-cylinder  it  is  driven  forward  by  the  piston  through  the 


ARTIFICIAL  AERO-THERAPEUTICS 


3" 


pipe  I  into  the  receiver  B,  containing  layers  of  cotton  wool  W,  into  the 
air-chamber.      Both  I  and  J  contain  valves  to  prevent  a  return  current. 


The  air  leaves  the  bath  by  an  outlet  pipe  in  the  roof,  which  is  always 
open,  the  strength  of  the  current  through  it  depending  on  the  rate  at 
which  the  engine  works.    M  is  a  safety  valve  which  opens  wide  and  blows 


312 


SYSTEM  OF  MEDICINE 


a  whistle  when  the  full  pressure  of  10  lbs.  is  reached.  L  is  a  glass  spy- 
hole through  which  the  inmates  can  be  watched.  N  is  an  air-tigiit 
cupboard,  htted  with  double  bolts  to  adjust  the  pressure,  by  which  food 
and  messages,  and,  if  necessary,  medicines,  may  be  passed  in.  Appara- 
tus to  regulate  the  escape  of  air  (K),  which  can  be  worked  both  from 
within  or  outside  the  bath,,  complete  the  chamber,  which  is  lit  from  with- 
out by  stout  plate-glass  windows,  and  fitted  with  a  strong  iron  door. 
The  air  can  be  changed  about  five  times  in  two  hours,  and  must  be  sup- 
plied from  a  pure  source,  such  as  a  garden  or  open  space,  away  from 
machinery  and  drainage  ;  and  in  cities  it  must  be  filtered  through  cotton 
wool  in  the  receiver  B.  The  air  rises  in  temperature  during  compression, 
and  in  summer  it  is  often  necessary,  for  cooling  purposes,  to  pass  it  over 
ice  before  it  enters  the  bath.  The  extra  pressure  used  for  medical  pur- 
poses varies  from  \  to  1^^  atmospheres,  pressures  very  different  from 
those  which  produce  the  well-known  caisson  disease,  and  amount  to 
more  than  4  atmospheres.  For  most  diseases,  and  certainly  for  lung 
affections,  the  added  pressure  does  not  exceed  10  lbs.  (f  of  an  atmos- 
phere) ;  and  9  lbs.  above  the  mean  atmospheric  pressure  is  usually  suf- 
ficient for  aero-therapeutic  purposes. 

The  bath  or  sitting  lasts  two  hours ;  half  an  hour  is  spent  in  increas- 
ing pressure,  which  is  maintained  for  one  hour  at  the  maximum,  and 
half  an  hour  in  reducing  pressure  to  the  normal.  In  sf^me  obstinate  cases 
of  asthma  it  might  be  well  to  maintain  the  pressure  for  long  periods,  and 
thus  enable  the  patient  to  live  in  a  compressed  air  atmosphere  for  days 
together.  This  would  be  quite  possible  by  means  of  the  air-tight  cup- 
board, through  which  supplies  could  be  passed.  The  rate  of  increase  or 
decrease  of  pressure  should  be  about  1  lb.  in  three  minutes. 

As  during  compression  there  is  increase  of  temperature,  so  during 
reduction  there  is  a  slight  fall,  accompanied  by  deposition  of  moisture 
in  the  interior  of  the  chamber.  In  the  management  of  the  bath  the 
chief  points  to  be  borne  in  mind  are  four :  —  1.  To  increase  and  reduce 
the  pressure  as  gradiially  as  possible.  2.  To  keep  the  temperature  below 
65°  F.  3.  While  increasing  or  maintaining  the  pressure,  to  provide  for 
the  escape  of  the  used-up  or  contaminated  air.  The  air  should  be 
pumped  through  the  chamber,  not  merely  into  it ;  and,  as  the  stream  is 
always  flowing,  accumulation  should  only  be  the  result  of  the  outlets 
being  somewhat  smaller  than  the  inlets.  4.  In  case  of  bad  symptoms 
arising  from  increase  or  decrease  of  pressure,  to  reverse  the  process  at 
once. 

A  healthy  person  taking  a  compressed  air  bath  first  experiences,  as  the 
pressure  increases,  an  unpleasant  sensation  in  the  throat,  referred  to  the 
pharynx  immediately  behind  the  tonsil ;  this  is  relieved  by  swallowing 
saliva  or  drinking  water.  Pain  is  also  felt  in  the  membrana  tympani, 
which  is  due  to  the  different  calibres  of  the  external  auditory  meatus  and 
the  Eustachian  tube.  The  latter  being  much  smaller  than  the  former,  the 
column  of  air,  during  increase  of  pressure,  penetrates  with  difliculty  to  the 
internal  surface  of  the  membrana  tympani,  and  changes  of  pressure  are 


ARTIFICIAL   AERO-TBERAPEUTICS  313 

slowly  communicated ;  whereas  through  the  meatus  air  passes  freely,  and 
causes  under  these  circumstances  a  convexity  inwards  of  the  auditory 
membrane.  The  opposite  change  takes  place  when  pressure  is  dimin- 
ished. Hence  the  pain  and  discomfort  in  the  membrane  are  at  the 
beginning  and  end  of  the  bath.  The  voice  becomes  shriller,  and  I  have 
known  singers  gain  a  note  or  two  above  their  average  while  in  the  bath. 
The  arch  of  the  abdominal  wall  is  flattened,  which  has  been  ascribed 
by  Panum  to  compression  of  the  intestinal  gas. 

Experiments  made  by  myself  and  others  in  healthy  individuals  show 
the  following  results  from  compressed  air  :  — 

Respiration.  —  The  patient  breathes  slower,  deeper  and  with  greater 
ease.  The  respiration  rate  falls  from  16  or  15  to  14  or  12  a  minute. 
Von  Vivenot  records  its  falling  to  5  or  even  4  a  minute.  Inspiration 
becomes  easy,  but  expiration  less  so,  and  the  relation  between  the  two 
becomes  changed ;  whereas  at  normal  pressure  the  ratio  between  them 
is  as  4  to  3,  it  becomes  in  compressed  air  as  4  to  6  or  4  to  8.  Von  Vive- 
not tells  of  one  case  where  it  was  as  4  to  11. 


Fig.  20. 

The  annexed  diagram  from  Von  Vivenot  shows  this  as  well  as  the 
depth  of  the  respiration  in  compressed  air  (dotted  line)  compared  with 
that  of  ordinary  breath  (unbroken  line). 

Sjjirometric  observations  show  a  marked  augmentation  of  lung 
capacity  and  chest  measurements,  a  slow  but  considerable  increase  in 
circumference.  It  would  appear  that  breathing  compressed  air '  in- 
creases lung  capacity,  probably  by  opening  up  alveoli  not  previously 
in  use ;  and  the  amplitude  of  each  respiration  makes  up  for  the  smaller 
number. 

Circulation.  —  The  influence  of  compressed  air  on  the  circulation  is 
that  the  pulse  becomes  slower  and  reduced  in  volume ;  but  the  arterial 
pressure  is  raised,  the  superficial  capillaries  are  smaller,  and  the  veins 
less  full  of  blood.  Von  Vivenot's  white  rabbit,  when  placed  in  the  com- 
pressed air  bath,  admirably  exhibited  the  effect  on  the  circulation. 
Under  normal  pressure,  the  rabbit  being  quiet  and  at  liberty,  the  ears 
were  full  of  blood,  the  conjunctival  vessels  injected,  and  the  iris  tinted 
deep  red ;  when  pressure  was  increased,  the  conjunctival  vessels  became 
finer  and  paler,  and  in  one  experiment  they  visibly  filled  and  emptied. 

When  jjressure  was  maintained  at  the  maximum,  the  iris  and  pupils 
became  discoloured,  and  the  ears,  seen  by  transmitted  light,  showed 
empty  vessels;  even  the  larger  vessels  were  scarcely  visible. 

In  man  the  pulse  rate  diminishes  four  to  twenty  beats  a  minute ;  but 


314 


SYSTEM  OF  MEDICINE 


this  depends  very  much  on  the  temperature  of  the  bath ;  for,  though  a 
prolonged  sitting  generally  causes  a  fall  in  the  pulse  rate,  a  hot  atmos- 
phere will  make  the  pulse  rise  at  first.  Sphygmographic  tracings  show 
a  lowering  in  the  height  of  the  tidal  and  dicrotic  waves,  but  this  change 
is  only  maintained  during  the  bath ;  after  it  the  pulse  tracing  returns 
to  its  former  standard.  .  To  the  finger  the  pulse  appears  small  and 


Fig.  21. — Before  bath,  ordinary  pressure. 


Fig.  22.  —  Pressure,  3  lbs. 


Fig.  23. —Pressure,  6  lbs. 


Fig.  24.  —  Pressure,  9  lbs. 


Fig.  25.  —  After  bath,  ordinary  pressure. 

hard.  All  observations  indicate  that  compressed  air  exercises  an  in- 
tropulsive  influence,  affecting  naturally  the  surfaces  most  exposed  to  it, 
such  as  the  skin  and  lungs,  and  drives  the  blood  into  the  organs  pro- 
tected from  air  pressure,  such  as  the  brain,  heart,  liver,  spleen  and 
kidneys.  The  pressure  is  exerted  more  in  the  capillaries  and  superfi- 
cial veins  and  arteries ;  and  its  tendency  must  be  to  reduce  pressure  on 
the  right  side  of  the  heart  and  to  increase  it  on  the  left.  A  proof  of  the 
fulness  of  the  arterial  system  is  to  be  found  (1)  in  the  sphygmographic 
tracings,  and  (2)  in  the  fact  that  when  haemorrhage  occurs  in  the  bath 
the  blood  is  invariably  bright  red  (arterial).  The  slower  pulse  rate, 
according  to  Professor  Burdon-Sanderson,  is  the  effect  of  the  diminished 
pressure  in  the  venous  system,  which  retards  the  filling  of  the  ventricles 
during  the  period  of  relaxation,  and  consequently  lengthens  the  diastolic 
period ;  thus  the  pulse  frequency  is  diminished. 

Again,  the  introduction  of  a  larger  amount  of  oxygen  causes  greater 
absorption  of  this  gas  by  the  lungs,  and  increased  oxidation  and  tissue 
change ;  this  is  proved  by  the  increase  in  the  amount  of  carbonic  acid 
exhaled  from  the  lungs,  and  in  that  of  urea  from  the  kidneys.  Appetite 
is  improved  and  weight  is  generally  gained.  Muscular  power  is  stated 
by  Lange  to  be  increased ;  he  found  men  could  carry  weights  better  after 
the  bath  than  before  it. 

The  internal  temperature  of  the  body  is  slightly  raised,  sometimes 


ARTIFICIAL   AERO-THERAPEUTICS  315 

half  a  degree  in  the  mouth,  that  in  the  axilla  being  diminished;  the 
rectum  temperature  (Stembo)  rises,  as  might  be  expected,  from  the 
intropulsive  action  of  the  bath  on  circulation. 

From  the  preceding  observations  it  will  be  understood  that,  on 
account  of  this  intropulsive  action  on  the  circulation,  the  use  of  the 
compressed  air  bath  is  contra-indicated  in  congestion,  or  inflammation,  or 
haemorrhage  of  any  of  the  organs  which  are  wholly  or  partially  protected 
from  air  pressure  by  bony  cavities,  such  as  the  brain,  spinal  cord,  heart, 
liver,  spleen,  kidneys,  uterus  and  ovaries.  Again  fever,  in  which  there 
is  congestion  of  internal  organs,  is  increased  by  it. 

The  intropulsive  action  is  sometimes  serviceable,  as,  for  example,  in 
long-standing  amenorrh(X.a  ;  for  by  its  effect  on  the  ovaries  the  bath  will 
often  restore  the  menstrual  flow.  Anaemia,  too,  is  greatly  relieved  by 
compressed  air  baths,  probably  on  account  of  the  large  amount  of 
oxygen  supplied.  Certain  it  is  that  under  their  use  pallor  gives  way  to 
the  blush  of  health,  anaemic  murmurs  disappear,  and  the  number  of  red 
corpuscles,  as  noted  by  the  haemocytometer,  largely  increases.  This  has 
been  my  experience  in  all  the  cases  of  anaemia  I  have  treated  in  this 
way. 

The  diseases  in  which  compressed  air  baths  have  been  found  to  do 
most  good  are  bronchial  asthma,  chronic  bronchitis,  and  emphysema. 

Emphysema.  —  In  the  tense  or  large-lunged  form,  which  accom- 
pahies  bronchitis  and  asthma,  and  has  been  so  well  described  by  Dr. 
C.  J.  B.  Williams  and  Sir  William  Jenner,  a  course  of  these  baths  effects 
a  wonderful  change.  The  patient  finds  he  can  breathe  more  freely,  and 
can  ascend  steps  and  hills  with  gi-eater  ease.  His  cough  and  expectoration 
are  reduced.  His  respirations  are  slower  and  deeper,  and  the  pulse  is 
slower  and  firmer.  Physical  examination  shows  the  thoracic  distension 
to  be  diminished.  The  line  of  hepatic  dulness,  long  absent,  reappears  and 
rises  to  the  old  level,  the  area  of  cardiac  dulness  can  again  be  detected, 
and  the  impulse  is  felt,  not  in  the  epigastrium,  but  in  the  normal  posi- 
tion between  the  fifth  and  sixth  ribs,  slightly  to  the  right  of  the  nipple. 
Hyper-resonance  of  the  thorax  gives  place  to  something  more  like 
the  normal  note ;  and  although  there  may  be  prolonged  expiration  with 
occasional  wheezing  sounds,  the  air  is  heard  to  penetrate  into  blocked 
portions  of  the  lung  in  which  breath  sounds  were  previously  absent. 
Cyrtometric  measurements  show  a  reduction  in  the  chest  circumference 
at  different  levels  of  from  \  to  l^-  inches ;  and  the  spirometric  observa- 
tions yield  evidence  of  "increased  vital  capacity." 

These  changes  appear  to  be  due  to  the  removal  of  some  of  the  causes 
of  the  emphysema,  such  as  bronchial  catarrh  and  bronchial  spasm,  thus 
allowing  the  escape  of  some  of  the  distending  air  from  portions  of  the 
lung  in  which  the  emphysema  was  perhaps  temporary. 

Bronchial  Catarrh  and  Bronchitis.  —  The  effect  on  this  class  of  diseases 
is  excellent ;  cough  is  diminished,  expectoration  first  becomes  easier  and 
then  lessened  in  amount,  breathing  is  freer,  and  any  accompanying 
emphysema  is  reduced  considerably.     I  have  used  the  compressed  air 


31 6  SYSTEM  OF  MEDICINE 

bath  in  a  large  number  of  cases  of  bronchitis  and  emphysema,  and.  in 
every  case  there  has  been  relief,  though  it  has  not  always  proved  per- 
manent. Oertel  considers  the  improvement  to  be  due  to  the  increased 
pressure  on  the  larger  tubes,  causing  diminution  of  the  blood  in  the  bron- 
chial system,  and  consequently  less  exudation  of  serum  into  the  coats  of 
the  bronchi,  and  less  pressure  on  the  lymphatic  system. 

Bronchial  Asthma.  —  The  principal  effect  of  the  treatment  on  asthma 
seems  to  be  sedative  to  the  pulmonary  plexuses  and  to  the  pneumo- 
gastric  nerves.  The  attacks  are  rendered  less  severe,  and  after  a  course 
of  twenty  or  thirty  baths  the  intervals  between  the  attacks  become 
much  longer  and  the  spasms  finally  cease.  I  have  several  times  placed 
a  patient  in  the  bath  during  an  asthmatic  attack,  and  always  with  relief 
to  the  spasms.  In  addition  to  the  soothing  influence  on  the  nerve- 
storm,  the  baths  reduce  the  accompanying  emphysema,  and  more  so 
than  in  the  emphysema  of  bronchitis,  probably  because  the  bronchial 
obstructions  are  of  a  more  transitory  character.  The  patient  is  able 
to  breathe  more  freely  and  to  take  deeper  inspirations,  the  chest  dis- 
tension, as  shown  by  the  measurements,  diminishes,  and  the  spirometric 
records  increase  in  amount.  Thus  an  improvement  in  their  general 
condition  ensues.  Exercise  can  be  more  freely  taken,  digestion  and 
assimilation  are  carried  on  with  greater  ease  and  comfort,  and  strength 
and  colour  are  gained. 

Phthisis.  —  I  have  tried  the  treatment  in  a  large  number  of  cases  of 
phthisis,  generally  those  of  limited  lung  tuberculosis ;  and  beyond  the 
facts  that  cough  and  expectoration  slightly  diminish,  and  that  some 
portions  of  the  lung  become  more  expanded,  I  could  see  no  good  result. 
In  several  of  the  cases  haemoptysis  came  on  either  in  the  bath  or  after 
the  treatment,  and  this  constitutes  a  fresh  danger.  In  some  of  the 
patients  there  was  improvement  of  appetite  and  gain  of  weight,  but  it 
cannot  be  said  that  any  lasting  benefit  resulted. 

I  tried  the  treatment  in  cases  of  chronic  pneumonia  and  chronic  lung 
infiltration,  and  also  in  commencing  pleuritic  effusion — in  the  latter  case, 
with  the  view  of  inflating  the  lungs  and  thus  opposing  the  increasing 
fluid  pressure ;  but  in  none  of  these  instances  did  the  bath  do  any  good, 
and  the  progress  of  the  disease  was  unchecked. 

The  number  of  compressed  air  baths  sufficient  to  produce  a  thera^ 
peutic  effect  varies  greatly,  but  in  asthma  or  bronchitis  about  thirty  are 
necessary ;  in  chronic  emphysema  a  larger  number,  sixty  to  seventy,  are 
often  required. 

It  is  a  remarkable  fact  that,  while  there  are  numerous  establish- 
ments for  compressed  air  baths  on  the  Continent  and  elsewhere,  in 
England  there  are  scarcely  any :  those  best  known  are  the  one  at  Ben 
Rhydding  in  Yorkshire,  and  the  admirable  one  of  the  Brompton 
Hospital,  which  is  largely  used,  and  is  now  made  available  for  private 
patients. 

Respiratory  Gymnastics.  —  Dr.  Marcet  (8)  dwells  with  great  force 
on  the  advantage  of  training  the  respiration,  not  only  for  physiological 


ARTIFICIAL   AERO-THERAPEUTICS  317 

exercise,  but  as  an  important  aid  in  the  treatment  of  such  diseases  as 
asthma.  He  showed  that  after  forced  breathing  more  than  double  the 
weight  could  be  lifted  than  after  ordinary  breathing ;  and  he  instances 
the  well-known  fact  of  the  asthmatic  spasm  being  sometimes  momen- 
tarily suspended  by  a  forced  inspiration,  as  a  proof  that  a  deficient 
supply  of  oxygen  to  the  respiratory  centres  bears  a  definite  relation  to 
the  causation  of  asthma. 

Dr.  Marcet  advocates,  as  a  method  of  therapeutics  for  asthma,  the 
practice  of  the  respiratory  movements  required  to  carry  the  air  through 
the  lungs  in  order  to  oxidise  the  blood  and  exhaust  the  carbonic  acid ; 
this  practice,  at  the  same  time,  brings  the  circulation  into  better  co- 
operation with  the  respiratory  function.  A  good  form  of  exercise, 
according  to  this  author,  is  "cycling,  which  increases  the  depth  of 
breathing,  and  this  without  fatigue,  the  inspiratory  movements  being 
automatic ;  at  the  same  time,  it  accustoms  the  rider  instinctively  to 
take  in  at  each  respiration  the  volume  of  air  required  to  aerate  the 
blood,  and  to  eliminate  a  certain  proportion  of  carbonic  acid,  leaving  in 
the  circulation  that  amount  which  is  compatible  with  health." 

C.  Theodore  Williams. 


REFERENCES 

1.  Bert,  Paul.  La  pression  harometrique,  1878.  —  2.  Cohen,  J.  Solis.  Inhala- 
tion in  the  Tt^eatment  of  Disease,  1876.  —  3.  Hassall,  A.  Hill.  The  Inhalation 
Treatment  of  Diseases  of  the  Organs  of  Respiration,  including  ConsumptiQn,  1885.  — 
4.  JuNOD,  Theodore.  Recherches  sur  les  effets  Physiologiques  et  Th^rapeutiques  de  la 
compression  de  I' air,  1835.  —  5.  Lange,  J.  On  Compressed  Air,  its  Physiological 
Effects  and  their  Therapeutic  Importance,  1864.  —  6.  Lee,  Henry.  "Calomel  Baths," 
Lancet,  August  21,  1875.  —  7.  Liebig,  G.  von.  "  The  Exchange  of  Gases  in  the  Lungs 
under  Increase  of  Air  Pressure  in  the  Pneumatic  Chamber,"  Bajer,  Aerztlich-Ititelligenz 
Piatt,  1874.  —  8.  Marcet.  "  Contribution  to  the  History  of  the  Respiration  in  Man," 
Croonian  Lectures.  Brit.  Med.  Journal,  July  1895. — 9.  Oertel,  M.  J.  Handbuch 
der  respiratorischen  Therapie.  English  translation,  1885.  — 10.  Panum,  P.  L.  Fysiologiske 
Undersogelser  over  dem  i  de  pneuinatiske  Helbredel-sesaanstalter,  1866.  — 11.  Bergeon. 
Etudes  experimentales  et  cliniques  sur  la  tuberculose,  1887.  — 12.  Sanderson,  J.  Burdon. 
"  The  Compressed  Air  Batlis  of  Reichenhall,"  Practitioner,  October  1868.  — 13.  Simon- 
OFF.  "On  the  Effects  of  Condensed  Air  on  the  Respiratory  Organs,"  Petersburg, 
Medicin.  Zeitschrift,  1873.  — 14.  Stembo.  Contributions  to  the  Physiological  Influ- 
ence of  Compressed  Mr,  1877.  — 15.  Tabarie  Emile.  "Recherches  Physico-physi- 
ologiques,"  Compt.  Rendus,  1838.  — 16.  Vivenot,  Von.  Therapeutic  uses  of  Compressed 
Air,  1868.  — 17.  Williams,  C.  Theodore.  "  On  the  Value  of  Inhalations  in  the  Treat- 
ment of  Disease,"  Brit.  Med.  Journal,  1888;  "  Lectures  on  the  Compressed  Air  Bath," 
Brit.  Med.  Journal,  1885 ;  Aero-therapeutics,  1894. 

C.  T.  W. 


3i8  SYSTEM  OF  MEDICINE 


BALNEOLOGY  AND  HYDROTHEEAPEUTICS 

A.  —  Balxeo-Therapeutics  ;  or,  Treatment  by  the  Internal  and 
External  Use  of  Mineral  Waters 

Definition.  —  The  name  Mineral  Waters  is  applied  to  those  waters 
which  are  used  in  the  treatment  of  disease,  either  internally  or  in  the 
form  of  baths,  on  account  of  the  saline  or  gaseous  substances  which 
they  contain,  or  on  account  of  their  elevated  temperature. 

The  science  of  the  origin  of  these  waters,  and  of  the  causes  to  which 
they  owe  their  chemical  composition  and  their  temperature,  is  usually 
called  Balneology,  or  in  a  wider  sense  Hydrology ;  and  may  be  regarded 
as  a  part  of  Geology  and  Physical  Geography :  the  art  of  using  them 
in  the  treatment  of  disease  is  Balneotherapy,  and  mineral  waters  are  a 
part  of  Materia  Medica. 

Our  article  is  not  intended  as  a  regular  treatise  on  Balneotherapy, 
but  only  as  a  survey  of  the  uses  of  mineral  waters  in  the  treatment  of 
disease.  The  external  applications  of  mineral  waters  in  the  form  of  baths 
and  douches,  as  practised  at  most  of  the  spas,  are,  with  few  exceptions, 
similar  in  their  effects  to  those  of  ordinary  water  at  more  or  less  elevated 
temperatures.  We  refer,  therefore,  for  their  appreciation  to  section  B 
on  Hydrotherapeutics ;  but  we  may  mention  here  that  at  some  of  the  spas 
various  earthy  matters  are  added  to  the  water,  such  as  peat  earth  or 
moor  earth,  and  are  also  used  in  the  shape  of  local  baths  or  cataplasms. 

We  will  divide  the  present  section  into  two  parts  :  — 

1.  Description  of  mineral  waters  and  their  effects. 

2.  Therapeutic  employment  of  mineral  waters. 


I.   Description  of  Mineral  Waters 

The  principal  constituents  of  mineral  waters  are:  Water,  sodium,, 
magnesium,  calcium,  and  iron;  combined  with  hydrochloric,  sulphuric, 
carbonic,  and  hydrosulphuric  acid.  Other  substances  often  present  are : 
Arsenic,  lithium,  potassium,  manganese,  bromine,  iodine,  alum,  silica, 
argon,  various  organic  matters,  and  other  substances  in  minute  quan- 
tities. The  principal  gases  are :  Oxygen,  nitrogen,  carbonic,  and 
hydrosulphuric  acids. 

These  substances  are  derived  partly  from  the  surface  soil,  partly 
from  the  rocky  strata  through  which  the  water  deposited  from  the 
atmosphere  has  passed.  The  differences  between  the  different  mineral 
waters  are  due  to  the  differences  in  the  superficial  soil  and  the  rocks 
through  which  the  water  has  passed. 

The  mineral  waters  may  be  divided  into  groups  for  more  easy 
survey ;  for  instance,  according  to  their  temperatures,  or  their  chemical 
ingredients,  or  their  physiological  or  their  therapeutical  effects.    Every 


BALNEOLOGY  AND  HYDROTHERAPEUTICS  319 

classification  is  more  or  less  imperfect,  and  an  alphabetical  arrange- 
ment would  be  the  most  easy ;  but  this  would  entail  frequent  repetition 
and  thus  require  more  space.  We  therefore  attempt  a  somewhat  mixed 
arrangement,  based  principally  on  the  chemical  constituents  of  the 
springs.  It  will,  however,  be  evident  that  some  springs  contain  so 
large  an  amount  of  several  ingredients  that  they  can  claim  a  place  in 
different  groups ;  and  that  others  are  named  not  after  the  substance 
which  they  contain  in  the  largest  amount,  but  after  that  which  is  held 
to  be  most  potent.  Those  thermal  waters  which  are  almost  devoid  of 
solid  substances  are  placed  in  a  separate  group.  Thus  we  may  form 
eight  groups :  — 

1.  Simple  Thermal  Waters.  5.  Iron  or  Chalybeate  Waters. 

2.  Common  Salt  or  Muriated  Saline         6.   Arsenic  Waters. 

Waters.  7.   Sulphur  Waters. 

3.  Alkaline  Waters.  8.   Earthy  or  Calcareous 

4.  SuLPHATED  Saline  Waters.  Waters. ^ 

1.  Simple  Thermal  "Waters.  —  (Syn. :  Wildbader,  indifferent  thermal 
waters.)  The  waters  of  this  group  have  a  higher  temperature  than 
ordinary  springs,  varying  between  80°  F.  and  150°  F.  or  more ;  they 
are  transparent,  very  soft,  almost  tasteless,  of  low  specific  gravity,  very 
poor  in  solid  and  also  in  gaseous  substances ;  some  contain  a  little 
more  nitrogen  than  ordinary  water;  others  claim  a  little  more  oxygen. 
It  has  been  stated  that  the  electrical  conditions  of  these  waters  are 
peculiar,  but,  so  far  as  we  know,  there  is  no  proof  of  this. 

Matlock,  in  Derbyshire,  deserves  to  be  mentioned  in  this  place, 
although  the  temperature  of  its  waters  is  only  68°  F.  It  lies  in  a  beauti- 
ful valley,  but  the  climate  of  Matlock  itself  cannot  be  called  bracing. 

Many  other  slightly  mineralised  warm  waters,  whose  principal  action 
is  to  be  attributed  to  the  temperature  of  the  water,  might  be  mentioned 
under  this  head,  such  as  Acqui  in  Italy  and  the  hot  sulphur  waters  of 
the  Pyrenees;  while  some  of  the  spas  mentioned  in  the  preceding 
table,  such  as  Leuk,  Bormio,  Bagneres  de  Bigorre,  Badenweiler,  Bath, 
and  Aix-les-Bains,  may  claim  a  place  in  other  groups. 

The  very  hot  Algerian  baths  near  Biskra,  the  "Fontaine  chaud," 
(Hammam  Salahin,  Bath  of  the  Saints)  of  a  temperature  of  abovit 
112°  F. ;  Mammam  Meskoutin,  with  waters  of  170°  F. ;  Hammam  K'Irha, 
158°  F. ;  and  others,  may  be  regarded  as  belonging  to  this  group. 

The  United  States  of  America  are  rich  in  simple  thermal  springs 
which  are  partly  in  use,  partly  in  course  of  development.  Some  of 
the  most  important  are — the  "Hot  Springs"  in  Virginia,  the  "Hot 
Springs"  in  Arkansas,  the  "Calistoga  Hot  Springs,"  the  "Geysers," 
the  "Pass  Eobles  Hot  Springs"  in  California,  the  "  Idaho  Hot  Springs" 
in  Colorado,  the  "Warm  Springs"  in  North  Carolina,  the  "Warm 
Springs  "  in  Georgia,  the  "  Lebanon  Springs  "  in  Columbia  County,  the 

1  For  all  P^nglish  Spas,  see  The  Climates  and  Baths  of  (heat  Britain,  hy  the  Com- 
mittee of  the  lioy.  Med.  and  Chir.  Society.    London,  Macmillan,  1805. 


320 


SYSTEM   OF  MEDICINE 


"  Warm  Springs  "  and  the  "  Healing  Springs  "  in  Bath  County.  We 
refer  for  the  mineral  waters  of  the  United  States  to  Dr.  Walton's 
work  (New  York,  1883). 

Here  we  ought  to  mention  the  large  cave  of  Monsummano  in  Italy, 
in  which  hot  vapour  is  disengaged  from  numerous  surfaces  of  hot 
water.  The  patient  walks  about  in  it  as  in  a  spacious  steam-bath.  The 
benefit  derived  by  Garibaldi  has  brought  new  fame  to  Monsummano, 
Smaller,  partly  artificial  excavations  in  the  rocks  of  Battaglia,  in  the 
Euganean  Hills  of  Upper  Italy,  are  used  in  a  similar  way. 

Enumeration.  —  We  can  mention  some  of  the  best-known  waters  of 
this  group  in  the  form  of  a  table  showing  at  a  glance  the  two  most 
important  points,  viz.,  the  elevation  above  sea-level  and  the  temperature 
of  the  springs. 


Name  of  Spa. 

Country. 

A  pproxiniative 

elevation  above 

Sea  in  feet. 

Temperature  of 
Springs  In  Fahrenheit. 

Panticosa      . 

Spain  (Pyrenees) 

5000 

77°  to  92° 

Leuk  (L66che-les-Bains) 

Switzerland 

4600 

102°  to  122° 

Bormio 

Italy     . 

4300 

90°  to  104° 

Wildbad.  Gastein  . 

Eastern  Alps 

3300 

95°  to  104-8° 

Pfaeffers 

Switzerland 

2115 

100° 

Johannisbad 

Bohemia 

2000 

86° 

Bagn^res  de  Bigorre     . 

French  Pyrenees. 

1850 

90°  to  95° 

Ragatz 

Switzerland 

1700 

96°  to  98° 

Badenweiler 

Baden . 

1425 

86°  to  90-5° 

Landeck 

Prussian  Silesia  . 

1400 

66°  to  84-2° 

Wildbad 

Wurtemberg 

1323 

95°  to  98-6° 

Plombi^res  . 

France 

1300 

65°  to  156° 

Luxeuil 

France 

1300 

65°  to  163° 

Neuhaus 

Styria  . 

1200 

95° 

Liebenzell     . 

Wurtemberg 

1113 

72°  to  82° 

Warmbrunn 

Prussian  Silesia   . 

1100 

97°  to  104° 

Tobelbad      . 

Styria  . 

1090 

77°  to  82° 

Aix-les-Bains 

Savoy  . 

1060 

86°  to  120° 

Buxton 

England 

1000 

82° 

Schlangenbad 

Nassau 

900 

81-5°  to  86° 

Bomerbad  and  Tuffer  . 

Styria 

700-800 

81-5°  to  86° 

Neris    .... 

France 

800 

114°  to  125° 

Teplitz 

Bohemia 

650 

95°  to  120° 

Lucca  .... 

Italy     . 

500 

100°  to  120° 

Dax      .... 

France 

130 

88°  to  140° 

Bath     .... 

England 

100 

100°  to  120° 

Action. — The  water  of  such  springs,  when  taken  internally,  acts 
probably  like  any  other  pure,  not  hard,  ordinary  warm  water  of  the  same 
temperature.  We  may  refer  for  this  use  to  the  article  on  "  Hydrothera^ 
peutics,"  restricting  ourselves  to  the  remark  that  warm  water  is  more 
rapidly  absorbed  by  the  stomach,  and  makes  less  demand  on  the  body  by 
saving  the  expenditure  of  heat.  We  are  occasionally  told  by  some  patients, 
whose  words  are  in  our  note-books,  that  a  single  tumblerful  of  the  water 
of  Gastein,  or  Wildbad,  or  Buxton,  or  Teplitz,  or  Bath,  has  given  rise  to 
striking  symptoms,  such  as  the  most  severe  headache,  giddiness,  inability 


BALNEOLOGY  AND   HYDROTHERAPEUTICS 


to  walk,  sleeplessness,  etc.,  and,  on  the  other  side,  to  rapid  removal  of 
long-standing  neuralgia,  headache,  sleeplessness,  mental  depression, 
anorexia,  optic  disturbances,  etc.  It  is  not  impossible  that  these 
extraordinary  effects,  good  as  well  as  bad,  which  are  quite  out  of  pro- 
portion to  the  quality  and  quantity  of  the  remedial  agent,  were  due  to 
imagination  or  suggestion. 

Uses.  —  Drinking  courses  of  these  waters  are  useful  in  irritable  con- 
ditions of  the  mucous  membranes  of  the  digestive  and  respiratory  organs, 
in  gastralgia  and  in  some  forms  of  gout  and  rheumatism. 

Bathing  courses  often  act  beneficially  in  allaying  great  sensitiveness 
and  excitability  of  the  nervous  system  in  its  various  spheres,  and  are 
therefore  often  resorted  to  in  cases  of  neuralgia,  hyperaesthesia,  and 
hysteria.  Their  reputation  in  painful  cicatrices  and  rheumatism  in  the 
neighbourhood  of  old  injuries  is  historical.  In  chronic  rheumatism,  in 
sciatica,  and  allied  affections,  in  some  forms  of  gout  and  their  remnants, 
these  waters  often  assist  and  complete  the  cure,  especially,  when  com- 
bined with  Swedish  gymnastics  and  massage. 

In  the  choice  of  the  most  suitable  spa  for  individual  cases  the  situar- 
tion  and  climate  of  the  spa,  the  elevation  above  sea-level,  the  quality  of 
the  bathing  arrangements,  and  the  accommodation,  are  to  be  considered ; 
and  not  less  so  the  skill  of  the  medical  guidance,  and  of  the  persons 
applying  massage  and  Swedish  gymnastics. 

2.  Common  Salt  or  Muriated  Saline  Waters.  —  Although  common 
salt  forms  the  principal  ingredient  of  these  waters,  many  of  them 
contain  iron,  carbonates  of  sodium,  lithium,  magnesium,  and  calcium, 
and  other  chlorides  ;  some  also  sulphates  of  sodium,  magnesia,  and 
lime,  others  sulphides  and  sulphuretted  hydrogen,  and  again  others 
traces  of  bromine  and  iodine  and  other  substances.  In  some  of  these 
waters  the  action  is  no  doubt  modified  by  these  admixtures,  but  as  the 
effect  of  the  chloride  of  sodium  seems  to  predominate,  they  have  been 
placed  in  this  group.  The  difference  of  different  springs  is  great,  not 
only  by  the  amount  of  common  salt  and  other  solid  ingredients  which 
they  contain,  but  also  by  the  presence  of  free  carbonic  acid  in  greater  or 
smaller  amount  in  some  of  them ;  and  further  by  the  temperature,  as 
some  are  more  or  less  hot,  while  the  majority  are  cold.  In  a  larger  work 
it  would  perhaps  be  advantageous  to  make  several  subdivisions  accord- 
ing to  strength,  according  to  temperature,  according  to  the  presence  or 
absence  of  carbonic  acid,  and  according  to  that  of  other  solid  constituents ; 
but  in  this  survey  we  will  only  mention  the  more  important  common  salt 
waters,  dividing  them  according  to  their  situation  in  different  countries. 

Enumeration.  —  The  number  of  common  salt  waters  in  various 
countries  is  very  great.  England  has  the  most  concentrated  salt  waters 
or  l)rines  at  Droitwich,  Nantwich,  Middlewich,  and  Ashby-de-la-Zouche. 
Droitwich,  which  has  satisfactory  arrangements  and  accommodation,  is 
one  of  the  best  places  for  brine-baths.  Moderate  amounts  of  salt  are 
contained  in  the  waters  of  Woodhall,  where  they  are  combined  with 
bromine  and  iodine  in  small  quantities.     Harrogate,  situated  in  a  bracing 

VOL.    I  T 


322  SYSTEM  OF  MEDICINE 


district  of  Yorkshire,  the  most  flourishing  of  spas  in  England  for  drink- 
ing, aiad  to  some  degree  also  for  bathing  courses,  has  springs  of  varying 
strength  in  common  salt,  combined  with  sulphuretted  hydrogen  and 
sulphide  of  sodium.  Llandrindrod  (Wales)  possesses  similar  springs, 
rather  weaker,  but  still  useful.  At  Bridge  of  Allan,  in  Scotland,  situated 
in  a  sheltered  position,  we  have  a  large  admixture  of  chloride  of  lime 
and  sulphate  of  lime.  Melksham  (Wilts)  deserves  a  place  as  well  here 
as  amongst  the  sulphated  waters.  At  Leamington  and  Cheltenham  the 
common  salt  is  combined  with  so  great  a  proportion  of  sulphates  that 
these  springs  may  be  placed  in  the  group  of  sulphated  waters.  England 
has  no  thermal  saline  waters. 

In  Germany  and  Austro-Hungary  we  may  mention  —  Kissingen, 
Homburg,  Soden  (on  Taunus),  Nauheim,  Rehme-Oeynhausen,  Kreuznach, 
Wiesbaden,  Baden-Baden,  Reichenhall,  Ischl,  Hall  in  the  Tyrol,  Hall  in 
Wurtemberg,  Hall  in  Austria,  Kreuth,  Dilrkheim,  Niederbronn  (Alsace), 
Krankenheil,  Salzungen,  Cannstatt,  Cronthal,  Aix-la-Chapelle  (with  sul- 
phur), to  which  many  others  could  be  added.  Germany  does  not  possess 
any  brine-baths  so  concentrated  as  DroitAvich  and  ISTantwich,  but  it  has 
the  advantage  of  several  waters  rich  in  cario«//cac«d,  as  Kissingen,  Hom- 
burg, Soden,  Nauheim,  and  Rehme ;  and  again  some  with  elevated  tem- 
peratures, as  Wiesbaden,  Baden-Baden,  Aix-la-Chapelle,  Nauheim  and 
Rehme. 

France  is  rich  in  salt  springs  of  elevated  temperature  and  strong  to 
medium  mineralisation :  Bourbonne  (Haute-Marne),  Balaruc  (Herult), 
Bourbon  I'Archambault  (Allier),  Bourbon-Lancy  (Saone-et-Loire),  La- 
motte  (Jura)  ;  Uriage  (Isere),  and  St.  Gervais  (Savoie),  with  sulphur ; 
Chatel-Guyon  (Puy-de-Dome),  with  iron.  Amongst  the  cold  salt  springs 
of  France,  Salins  (Jura)  and  Brides  les  Bains  deserve  to  be  mentioned. 

Switzerland  possesses  strong  salt  waters  at  Bex  and  Rheinfelden.  In 
Italy  one  of  the  most  popular  salt  spas  is  Monte  Cattini  in  Tuscany ; 
Castro  Caro  likewise  in  Tuscany,  is  comparatively  rich  in  iodine.  Ischia 
and  Castellamare  were  used  in  ancient  times. 

Spain  has  in  Caldas-de-Montbuy,  in  the  province  of  Barcelona,  a 
strong  thermal  salt  water  of  great  local  reputation,  and  a  weaker  one  in 
Caldas-de-Malavella  in  the  province  of  Girone,  remarkable  for  the  large 
proportion  of  chloride  of  calcium  and  magnesium. 

Caldas  de  Rainha,  in  Portugal,  in  a  beautiful  situation,  is  a  most  useful 
weak  thermal  salt  spring,  impregnated  with  sulphuretted  hydrogen. 

North  America  possesses  St.  Catherine's  Wells,  Michigan  Congress 
Spring,  Spring  Lake  W^ell,  Fruit  Port  Well,  Ballston  Spa,  and  the  much 
frequented  Saratoga  Springs. 

Action.  —  Common  salt  is  an  important  constituent  of  all  our  organs 
and  tissues ;  it  is  an  essential  part  of  food,  and  cannot  be  dispensed  with 
for  any  length  of  time.  It  plays  a  great  part  in  the  nutrition  and  me- 
tabolism of  our  body.  Owing  to  its  easy  diffusibility,  a  large  portion 
of  the  salt  taken  in  natural  waters  is  absorbed  at  once  in  the  stomach, 
while  another  part  passes  into  the  intestines.     It  stimulates  the  secreting 


BALNEOLOGY  AND  HYDROTIIERAPEUTICS  323 

apparatus  of  the  stonaach  and  intestines,  the  peristaltic  action  of  the 
bowels,  and  the  circulation  in  the  portal  vein.  It  seems  to  act  specially 
on  the  mucous  membranes,  and  to  render  their  secretions  less  viscid. 
According  to  Voit  it  increases  the  solubility  and  diff  usibility  of  albumin, 
and  his  experiments  corroborate  those  of  Bischoff  and  Kaupp,  showing 
that  an  increased  supply  of  chloride  of  sodium  causes  an  increase  in  the 
excretion  of  nitrogen  through  the  urine.  As  many  persons  take  at  their 
meals  a  considerable  quantity  of  salt  in  addition  to  that  contained  in  the 
food  itself,  the  extra  amount  taken  in  salt  waters,  say  100  to  300  grains 
at  the  outside,  may  seem  unimportant ;  but  if  we  take  into  account  that 
this  extra,  dissolved  in  water,  is  taken  on  an  empty  stomach  during  half 
an  hour  or  an  hour,  and  that  the  absorption  and  diffusion  is  mostly  aided 
by  gentle  exercise,  it  cannot  be  regarded  as  insignificant. 

Carbonic  add  in  these  waters,  as  in  other  mineral  waters  impregnated 
with  it,  seems  to  alleviate  irritation  of  the  sensitive  nerves  of  the  stom- 
ach, and,  by  stimulating  the  minute  capillaries  and  the  secretion  and 
peristaltic  action  of  the  stomach  and  intestines,  to  accelerate  the  pas- 
sage of  the  waters  from  the  stomach  into  the  intestines,  and  to  promote 
action  of  the  bowels. 

In  the  form  of  baths  chloride  of  sodium  and  the  other  chlorides  act  as 
stimulants  on  the  nerves  and  blood-vessels  of  the  skin,  and  this  stimulus 
seems  to  be  transmitted  to  the  nerve  centres  and  thus  to  influence  the 
function  of  internal  organs.  A  feeling  of  warmth  is  produced  by  a  warm 
salt  bath  greater  than  is  due  to  the  actual  elevation  of  temperature. 
The  presence  of  carbonic  acid  in  the  water  appears  to  heighten  these 
effects.  Actual  absorption  of  chlorides  does  not  occur,  or,  at  all  events, 
the  qiiantity  absorbed  is  so  small  that  it  may  be  left  out  of  consideration. 

Uses.  —  The  common  salt  waters  are  much  used  in  sluggish  action 
of  the  bowels  and  stagnation  in  the  branches  of  the  portal  vein,  with 
the  resulting  troubles  of  dyspepsia,  of  congestion  of  the  pelvic  organs 
and  hemorrhoidal  vessels  and  enlargement  of  the  liver.  They  deserve 
in  such  conditions  to  be  preferred  to  "bitter  waters"  (and  also  to  the 
alkaline  sulphated  waters)  in  spare  persons  where  emaciation  is  to  be 
avoided.  They  are  also  useful  in  catarrh  of  the  stomach  and  intestines, 
and  also  in  catarrhs  of  the  respiratory  organs,  where  they  render  the 
secretion  less  viscid  and  promote  expectoration.  In  chronic  bronchitis 
their  beneficial  effect  is,  no  doubt,  largely  due  to  the  indirect  action  on 
the  right  ventricle  and  to  the  improvement  in  the  contraction  of  the 
whole  heart.  Their  use  (especially  that  of  the  hot  springs)  in  chronic 
rheumatism,  in  sciatica,  and  some  forms  of  peripheric  neuritis,  is  well 
known.  Some  of  them  have  also  long  standing  reputation  in  scrofula, 
as  Creuznach,  Krankenheil,  Woodhall,  and  in  the  removal  of  chronic 
enlargement  of  the  womb  and  remains  of  perimetritis.  Many  judicious 
gynaecologists  maintain  the  good  effects  of  these  spas  in  uterine  fibroids, 
although  this  is  not  generally  admitted. 

3.  Alkaline  "Waters. — Waters  of  this  class  contain  carbonate  of 
sodium  as  a  prominent  constituent,  and,  besides,  a  varying  amount  of 


324  SYSTEM   OF  MEDICINE 

free  carbonic  acid ;  but  many  of  the  waters  contain  chloride  of  sodium, 
and  others  sulphate  of  soda  in  so  large  a  proportion  tliat  we  are  obliged 
to  make  three  subdivisions:  —  (a)  Simple,  Alkaline  Waters;  (b)  Mari- 
ated  Alkaline  Watej^s;  (c)  8ulphatecl  Alkaline  Waters. 

Enumeration  of  the  principal  spas  :  —  (a)  Simple  Akaline  Waters  are 
partly  hot,  partly  cold;  the  hot  springs  are  Vichy  (France),  Neuenahr 
(Germany),  Mont  Dore,  Chaudes  Aigues,  and  I^^eris,  in  France  ;  the  three 
last  are  feebly  mineralised.  Mont  Dore  has  an  appreciable  amount  of 
arsenic,  on  account  of  which  it  will  again  claim  a  place  in  a  later  class. 
The  cold  waters  are  Kohitsch  in  Styria,  Vals  (Depart.  Ardeche),  Obersalz- 
brunn  (Silesia),  Le  Boulou  (Pyrenees),  Evian  (Savoy),  the  Helenenquelle 
at  Wildungen,  Bilin  (Bohemia),  and  a  number  of  feebly  mineralised 
waters  which  are  used  as  table  waters  (Apollinaris,  Gerolstein,  Fachingen, 
Geilnau,  Giesshuebel,  Soulzmatt,  Wilhelmsquelle,  Taunusquelle). 

(b)  Muriated  Akaline  Waters.  — The  principal  Jiot  springs  are  Ems 
(Nassau),  Royat  (Auvergne),  with  some  lithium  and  arsenic ;  La  Bour- 
boule  (Auvergne),  with  arsenic;  Chatel-Guyon  (Puy-de-Dome),  Szczaw- 
nicza  (Galicia).  The  cold  springs  are  Luhatschowitz  (Bohemia),  Elster 
(Saxony),  Gleichenberg  (Styria),  Weilbach  (Nassau),  Toennisstein 
(Rhine)  and  the  table  waters  of  Roisdorf  and  Selters.  In  North  Amer- 
ica the  Congress  Springs  in  California  and  the  St.  Louis  Spring  in  Michi- 
gan belong  to  this  class.  The  California  Seltzer  Springs  contain  a  large 
amount  of  carbonate  of  magnesium. 

(c)  Sidpkated  Akcdine  Waters.  —  The  different  springs  of  Carlsbad 
(Bohemia)  are  all  more  or  less  hot ;  the  weak  springs  of  Bertrich  (Rhen- 
ish Prussia)  are  lukewarm  (87°  F.) ;  Marienbad  (Bohemia),  Franzensbad 
(Bohemia),  Elster  (Saxony),  and  Tarasp  (Switzerland)  are  cold,  as  also 
Rohitsch  (Styria)  and  a  weak  spring  at  Fuered  (Hungary;. 

Action.  —  Like  chloride  of  sodium,  so  also  is  carbonate  of  sodium  an 
important  constituent  of  the  human  body,  and  plays  a  part  in  its  metab- 
olism. Liebig  surmised  that  it  acted  as  vehicle  for  the  carbonic  acid 
from  the  blood  to  the  lungs.  It  has  a  great  share  in  the  secretion  of 
saliva,  bile,  pancreatic  juice,  and  the  digestive  processes.  Introduced 
into  the  stomach,  carbonate  of  soda  neutralises  the  acidity  of  the  ga;Stric 
secretion,  and  acts  as  an  antacid ;  it  increases  the  flow  of  bile  and  renders 
it  more  fluid ;  it  also  renders  the  intestinal  mucus  less  viscid,  and  acts  as 
a  diuretic.  In  large  doses  it  is  apt  to  cause  emaciation ;  in  small  doses 
it  rarely  has  this  effect.  The  combination  with  common  salt  in  the 
muriated  alkaline  waters  further  counteracts  the  emaciating  and  weaken- 
ing tendenc}^  of  the  pure  alkaline  waters,  besides  which  some  of  the  action 
of  common  salt  mentioned  under  that  head  is  brought  about.  A  greatly 
modified  effect  is  exercised  by  the  combination  with  sulphate  of  soda 
in  the  sulphated  alkaline  waters.  The  laxative  effect  of  this  salt  is 
predominant ;  it  may  be  due  to  stimulation  of  the  nerve  ends  in  the 
mucous  membrane,  or  to  increased  exosmosis,  or  both  combined.  The 
increased  movement  in  the  intestinal  walls  leads  to  more  rapid  flow  of 
blood  in  the  branches  of  the  portal  vein  and  in  the  liver  itself,  and 


BALNEOLOGY  AND   ILYDROTLLERAPEUTICS  325 

further  assists  in  the  fluidifying  effects  of  the  alkalies  on  the  bile  and 
intestinal  mucus.  By  easing  the  portal  circulation  the  contractions  of  a 
dilated  heart  are  improved,  and  chronic  pulmonary  catarrh  is  relieved. 

Uses.  —  Alkaline  waters  are  serviceable  in  certain  forms  of  dyspepsia 
where  there  is  a  tendency  to  excessive  formation  of  acid  in  the  stomach, 
and  especially  in  those  cases  where  this  tendency  is  combined  with 
catarrh  of  the  stomach  and  intestines  ;  but  they  are  injurious  in  catarrhal 
conditions  of  the  digestive  organs  with  deficiency  of  acidity,  as  often 
occurs  in  anaemia,  chlorosis,  and  convalescence  from  acute  disease.  The 
muriated  alkaline  waters  act  beneficially  in  chronic  catarrh  of  the  respira- 
tory organs.  The  sulphated  alkaline  waters  are  often  very  helpful  in 
atonic  constipation,  with  all  its  injurious  effects  on  the  blood,  on  the 
circulation  of  the  portal  vein,  and  consequent  passive  congestion  of  the 
liver ;  also  in  tendency  to  gall-stones,  and  to  uric  acid  gravel ;  in  some 
forms  of  gout,  and  in  the  glycosuria  of  gouty  and  corpulent  persons. 

4.  Sulphated  "Waters,  or  Bitter  Waters.  —  We  will  apply  this  name 
to  the  waters  containing  as  their  active  constituent  the  sulphates  of  mag- 
nesium and  sodium.  Some  of  them  contain  sufficient  amounts  of  chloride 
of  sodium  to  produce  an  alteration  in  their  effects.  The  majority  of 
these  waters  are  used  at  home,  not  by  residence  at  the  spas. 

Enumeration.  —  Franz  Joseph,  Hunyadi  Janos,  ^sculap,  and  other 
"Hungarian  Bitter  Waters";  Rubinat  (Spain),  Birmensdorf  (Switzer- 
land), Pullna  (Bohemia),  Sedlitz  (Bohemia),  Saidschutz  (Bohemia),  Mont- 
mirail  (Dep.  Vaucluse),  Friedrich shall  (Saxe-Meiningen),  Mergentheim 
(Wurtemberg),  Melksham  (Wilts),  these  three  with  a  large  proportion 
of  chloride  of  sodium ;  the  Victoria  Spa  (near  Stratford-on-Avon),  Purton 
Spa  (Wilts),  Cherry  Eock  (Gloucester),  Scarborough  (Yorkshire),  Leam- 
ington and  Cheltenham  {vide  Common  Salt  Waters). 

In  this  class  we  may  mention  Brides-les-Bains  in  Savoy,  with  hot 
mixed  sulphated  saline  springs,  containing  the  sulphates  of  sodium  and 
calcium  and  chloride  of  sodium.  These  are  the  only  waters  of  this  class 
which  are  principally  taken  not  at  a  distance,  but  at  the  place  itself 
which  is  situated  in  a  beautiful  valley,  south  of  the  Mont  Blanc  chain. 

Action.  —  In  moderate  doses  these  waters  stimulate  the  mucous  mem- 
brane of  the  digestive  tract,  and  increase  at  the  same  time  the  peristaltic 
actions.  In  larger  doses  they  cause  watery  motions.  Their  action  is  similar 
to  that  of  the  sulphated  alkaline  waters  described  in  the  preceding  class. 

Uses.  —  They  are  used  in  habitual  constipation,  with  sluggish  circula- 
tion in  the  portal  vein  and  its  branches,  in  passive  congestion  of  the  liver, 
and  ii].  excessive  corpulency.  They  have  the  reputation  of  removing  the 
latter  by  an  accelerating  influence  on  the  retrogressive  tissue  change  of 
proteinaceous  substances.  Whether  this  be  so  or  not,  no  doubt  they 
remove  the  alimentary  substances  from  the  intestines  before  all  the 
nutrient  has  been  absorbed;  they  act  therefore  as  abstractors,  and, 
unless  an  increased  amount  of  food  is  taken,  the  weight  must  decrease. 
We  often  hear  that  bitter  waters  are  quite  mild,  certain,  and  easy 
aperients ;  this  is  the  rule  with  many  persons,  but  the  exceptions  to  this 


326  SYSTEM  OF  MEDICINE 

rule  are  rather  frequent.  They  act  injuriously  in  most  cases  of  chronic 
peritonitis  and  of  the  resulting  adhesions,  in  ulcers  of  the  stomach  and 
intestines,  and  in  cancerous  affections  of  these  organs. 

We  have  sometimes  heard  that  it  is  more  simple  to  prescribe  a  certain 
amount  of  sulphates  in  substance  and  administer  them  dissolved  in  hot  or 
cold  water ;  but  in  our  trials  of  this  plan  we  have  frequently  found  that 
a  much  larger  dose  of  the  salts  thus  prescribed  was  required  in  order  to 
produce  the  same  aperient  effect  as  a  dose  of  mineral  water  containing  a 
smaller  quantity  of  bitter  salts.  We  have  noticed  this  especially  in 
using  the  more  composite  waters  such  as  Friedrichshall,  or  Franz  Joseph, 
or  Hunyadi,  or  the  sulphated  alkaline  waters  of  the  preceding  class : 
in  like  manner  a  larger  quantity  of  the  dried  natural  salts  (say  of 
Carlsbad  salts)  seem  to  be  required  than  would  correspond  to  the  active 
quantity  of  the  mineral  waters  at  say  one  of  the  Carlsbad  springs.  It  is 
probable  that  not  all  the  substances  contained  in  the  mineral  water  are 
contained  iM  the  same  conditions  and  combinations  in  the  salts  obtained 
from  it ;  one  point  is  evident,  viz.,  that  the  free  carbonic  acid  is  lost  in 
the  salts.  The  latter  defect  may  often  be  corrected  by  taking  the  salts 
in  one  of  the  natural  acidulated  table  waters,  or  in  "  salutaris  "  or  soda 
water.  Possibly,  also,  the  preparation  of  these  so-called  "  natural  salts  " 
is  not  always  accurate,  and  indeed  may  be  in  some  much  employed  salts 
intentionally  modified,  so  as  to  furnish  transparent  crystallised  instead 
of  opaque  amorphous  salts. 

5.  Iron  or  Chalybeate  Waters.  —  This  term  is  applied  to  those  springs 
in  which  the  proportion  of  iron  to  the  other  ingredients  is  large  enough 
to  produce  a  therapeutic  effect.  A  great  many  of  the  mineral  waters 
enumerated  in  other  classes  contain  iron ;  but  the  amount  of  other  con- 
stituents is  considered  to  predominate  over  the  iron.  The  iron  is  mostly 
contained  in  them  as  a  bicarbonate,  with  free  carbonic  acid,  and  the 
quantity  rarely  exceeds  four-tenths  to  six-tenths  of  a  grain  in  sixteen 
ounces  of  water.  There  are  some  springs  with  sulphate  of  iron  in  rather 
larger  quantity,  but  they  are  rarely  used  therapeutically.  We  may 
divide  the  iron  springs  into  —  (a)  pure  iron  waters  containing  only  a  few 
grains  of  other  substances  in  sixteen  ounces  of  water ;  and  (&)  mixed 
iron  waters  which  contain,  besides  the  iron,  a  larger  but  still  a  small 
amount  of  other  substances,  enough  to  alter  somewhat  the  character 
without  removing  the  predominant  effect  of  iron.  There  is,  however, 
no  strict  line  of  division  between  these  groups. 

Emimerntion.  —  (a)  Pure  or  comparatively  pure  iron  waters.  —  Schwal- 
bach  (Nassau),  Spa  (Belgium),  Ceresole  Reale  in  Piedmont,  Koenigswarth 
(Bohemia),  Orezza  (Corsica),  Schandau  (Saxony),  Alexisbad  (Harz  Moun- 
tains), Brilckenau  (Bavaria),  Flitwick  (Beds),  Tunbridge  Wells  (Kent), 
Charbonnieres  (Rhone,  France).  (6)  Mixed  iron  waters  contain,  in  addi- 
tion to  bicarbonate  of  iron,  bicarbonates  of  sodium,  magnesium  or  calcium, 
as  Arapatak  (Transylvania),  Griesbach  (Baden),  Liebenstein  (Thliringen), 
with  bicarbonate  of  lime;  St.  Moritz  (Oberengadin),  Santa  Catarina 
(Northern  Italy),  Pyrmont  (Waldeck),  Recoaro  (Northern  Italy),  Reinerz 


BALNEOLOGY  AND   HYDROrilERAPEUTLCS  327 

(Silesia),  Sternberg  (Bohemia),  Godesberg  (Rhenish  Prussia),  Booklet 
(Bavaria),  Imnau  (Wlirtemberg),  Cudowa  (Silesia),  Kohlgrub  (Bavarian 
Tyrol),  (jambray  Chalybeate  (Cheltenham). 

Some  possess  an  appreciable  amount  of  sulphate  of  soda,  as  Rippold- 
sau  (Baden)  and  Driburg  (Westphalia),  the  "  Stahlquelle"  and  "  Kalte 
Sprudel "  at  Franzensbad  (Bohemia),  Elster  (Saxony). 

France  possesses  two  thermal  iron  springs  in  Eennes-les-Bains 
(Aude),  and  Sylvanes  (Aveyron). 

A  strong  iron  water  is  that  of  Muskau  (Silesia),  which  contains  both 
carbonate  and  sulphate  of  iron. 

The  arsenic  waters  of  Roncegno  and  Levico,  in  the  Austrian  part 
of  the  Italian  Tyrol,  contain  large  proportions  of  sulphate  of  iron. 

Action. — The  points  accepted  by  the  majority  of  medical  men  as  to 
the  effects  of  iron  waters  are  :  —  Increased  formation  of  blood  globules  ; 
improved  contractility  of  the  circulating  apparatus,  including  the  heart ; 
better  oxidation  and  heat  production;  improvement  in  appetite  and 
general  nutrition.  A.  small  quantity  only  of  iron  is  absorbed  by  the 
stomach,  and  none  by  the  skin.  The  baths  of  the  pure  iron  springs 
seem  to  act  like  ordinary  water-baths  impregnated  with  carbonic  acid. 

Uses.  —  Iron  waters  are,  in  the  minds  of  most  people,  the  best  remedy 
for  anaemia ;  but  their  use  in  this  respect  is  perhaps  overrated.  There 
are  many  cases  of  anaemia  which  are  not  improved,  but  aggravated,  not 
only  by  pharmaceutical  preparations  of  iron,  but  also  by  iron  waters. 
Anaemia  and  chlorosis  are  often  caused  by  constipation  and  poisoning 
by  ptomaines.  In  these  cases  pure  iron  waters  are  mostly  injurious, 
while  some  of  the  common  salt  waters  and  sulphated  waters,  with  or 
without  small  proportions  of  iron,  are  useful.  Many  other  morbid 
conditions  complicated  with  anaemia  —  for  instance,  malarial  cachexia 
and  some  chronic  skin  diseases  — •  are  likewise  rarely  cured  by  pure  iron 
waters,  and  this  reminds  one  forcibly  of  the  prescriptions  of  some  very 
successful  practitioners  who  combine  good  doses  of  sulphate  of  soda  or 
sulphate  of  magnesia  with  iron  whenever  they  prescribed  the  latter. 

There  are,  however,  some  cases  of  pure  anaemia  and  some  complications 
of  neuralgia,  sterility,  impotency,  and  general  debility  complicated  with 
anjemia,  which  are  benefited  by  iron  waters  in  drinking  as  well  as  bathing 
courses.  In  some  cases  of  this  kind  the  compound  iron  and  arsenic 
waters  are  indicated. 

"We  have  mentioned  under  the  head  of  simple  thermal  waters  that  the 
degree  of  elevation  above  sea-level  must  be  regarded  as  an  important 
point  in  the  effects  produced  on  the  invalid.  These  remarks  are 
applicable  to  all  the  different  spas,  but  especially  to  the  chalybeate  class. 
A  course  of  waters,  say  of  a  month,  at  St.  Moritz,  or  Ceresole  Reale,  or 
Santa  C  atari  na,  between  5000  and  6000  feet  above  sea-level,  has  a 
different  effect  on  the  constitution  from  that  of  similarly  constituted 
waters  at  elevations  below  1000  feet. 

6.  Arsenic  "Waters.  —  There  are  no  pure  arsenic  waters,  but  the  waters 
containing  arsenic  in  appreciable  amounts  contain  also  either  iron  or 


328  SYSTEM  OF  MEDICINE 

saline  substances.  Arsenic  is,  liowever,  so  powerful  a  substance  that  we 
venture  to  place  these  waters  together  in  a  small  separate  group,  in  order 
to  direct  more  attention  to  them.  The  group  will  perhaps  be  enlarged 
by  further  discoveries. 

The  strongest  arsenic  waters  used  at  present  are  those  of  Eoncegno 
and  Levico,  which  possess  sulphate  of  iron  combined  with  arsenic ;  they 
are  both  situated  in  the  Southern  Tyrol,  not  far  from  Trento.  They  are 
both  so  strong  that  the  doses  required  are  small,  and  that  they  are  advan- 
tageously diluted  with  warm  water,  or  with  one  of  the  acidulous  table 
waters,  or  with  wine,  and  taken  at  or  after  meals  in  doses  of  one  or  two 
teaspoonfuls,  increasing  gradually  to  two  tablespoonfuls.  It  is  advis- 
able to  commence  with  small  doses,  and  carefully  to  watch  the  effect,  as 
in  some  persons  they  occasionally  cause  digestive  derangements,  such 
as  diarrhoea;  and  in  others  constipation. 

There  are  now  fair  hotels  both  at  Levico  and  Eoncegno,  but  the 
waters  are  more  used  away  from  the  spas  themselves. 

At  Val  Senistra,  in  the  Lower  Engadine,  are  springs  containing 
arsenic  in  smaller  quantity  (one-fifth  of  the  strength  of  Eoncegno  and 
Levico),  combined  with  carbonate  of  iron  and  carbonate  of  soda. 

Ceresole  Eeale,  in  Piedmont,  has,  in  addition  to  bicarbonate  of  iron, 
small  quantities  of  arsenic ;  it  is  situated  in  a  beautiful  and  bracing 
locality,  and  has  good  accommodation. 

Uses.  —  These  arsenical  chalybeate  waters  are  applicable  to  the  same 
ailments  as  are  the  pure  and  mixed  iron  waters,  but  specially  deserve 
a  trial  in  chronic  skin  affections  with  ansemia,  and  in  lymphatic  and 
glandular  diseases,  and  in  malarial  cachexia. 

La  Bourboule,  which  we  have  mentioned  already  amongst  the  warm 
muriated  alkaline  waters,  has  so  appreciable  an  amount  of  arsenic  that 
it  demands  a  preference  over  other  muriated  alkaline  waters  in  chronic 
skin  diseases,  and  may  also  assist  in  the  treatment  of  chronic  phthisis. 

Mont  Dore,  Avith  a  smaller  amoimt  of  arsenic  and  alkaline  substance 
than  La  Bourboule,  has  a  much  greater  reputation  in  the  treatment  of 
asthma.  This  is  probably  due  in  part  to  its  higher  elevation,  and  in 
part  to  the  very  energetic  use  of  inhalations ;  which,  however,  require 
careful  luanagement  in  delicate  persons. 

7.  Sulphur  Waters. — They  contain  either  sulphide  of  sodium,  cal- 
cium, potassium,  or  magnesium,  or  sulphuretted  hydrogen  in  an  appreci- 
able and  fairly  constant  proportion. 

In  some  of  the  springs,  as  at  Aix-les-Bains  and  Landeck,  the  quantity 
of  sulphur  is  so  small  that  they  may  be  placed  amongst  the  simple 
thermal  waters. 

In  other  sulphur  waters  the  amount  of  chloride  of  sodium  and  other 
solid  substances  is  so  large  that  they  find  a  place  in  other  classes  ;  such, 
for  instance,  is  the  case  with  Harrogate,  Llandrindod,  Uriage,  Aix-la^ 
Chapelle,  Caldas  de  Eainha,  Mehadia,  the  Columbia  Springs,  and  the 
Louisville  Artesian  Well  in  the  U.  S.  A.  Many  of  these  springs  are 
thermal,  but  some  are  cold. 


BALNEOLOGY  AND  ILYDLiOTLIERAPEUTICS  329 

Enumeration.  —  The  best  thermal  sulphur  waters  are  those  of  the 
French  Pyrenees  —  Eaux  Bonnes,  Eaux  Chaudes,  Cauterets,  Bareges,  St. 
Sauveur,  Bagneres  de  Luchon,  Le  Vernet,  Amelie-les-Bains  —  which  all 
contain  the  sulphur  as  sulphide  of  sodium,  and  are  situated  at  fair 
elevations. 

Other  hot  sulphur  waters  of  great  reputation  are  —  Baden,  Lavey,  and 
Schinznach  in  Switzerland;  Aix-les-Bains  and  Uriagein  Erance;  Aix-la 
Chapelle  and  Burtscheid  in  Germany;  Landeck  in  Silesia;  Baden  in 
Austria;  Mehadia  and  Fystjan  and  others  in  Hungary;  Battaglia  and 
Acqui  in  Piedmont;  Abano  in  the  Euganean  Mountains  of  jSTorthern 
Italy ;  Panticosa  in  the  Spanish  Pyrenees  ;  Trillo  near  Madrid ;  Caldas 
de  Eainha  in  Portugal;  Helouan  in  the  Arabian  desert  near  Cairo. 
Amongst  the  cold  springs  Harrogate  is  best  known  in  England,  Llan- 
drindod  and  Builth  in  Wales,  Strathpeffer  and  Moffat  in  Scotland, 
Lisdoonvarna  in  Ireland;  Challes,  Enghien,  and  two  springs  at  Ba- 
gneres-de-Bigorre  in  Erance  ;  Eilsen,  Nenndorf,  Weilbach,  Meinberg  in 
Germany;  Alveneu,  Guruigel,  Stachelberg,  and  Heustrich  in  Switzerland. 

Action.  —  Sulphuretted  hydrogen  is  absorbed  by  the  skin  and  by  the 
stomach,  and  we  know  that  larger  quantities  are  poisonous  by  depressing 
the  action  of  the  heart,  and  by  decomposing  the  blood  globules.  It  is, 
however,  difficult  to  account  for  the  alleged  action  of  such  small 
quantities  as  are  taken  up  by  the  system  during  drinking  and  bathing 
courses.  They  are  said  to  act  as  cholagogues,  but  this  is  not  clearly 
demonstrated  by  experiments. 

Uses.  — •  They  are  used  in  chronic  rheumatism  and  gout,  but  hot  baths 
and  hot  water  drinking  are  likewise  beneficial,  and  it  is  not  certain  that 
the  presence  of  small  quantities  of  sulphur  adds  much  to  the  effect  of 
hot  water;  the  same  may  be  said  with  regard  to  some  chronic  skin 
diseases.  Chronic  bronchial,  laryngeal  and  pharyngeal  catarrh  are 
benefited ;  and  often  also  hsemorrhoidal  conditions.  We  have  occasion- 
ally seen  good  effects  in  conditions  of  great  irritability  of  the  heart  with 
palpitation.  The  ancient  reputation  of  their  good  effects  in  poisoning 
with  mercury  or  lead  has  become  doubtful.  Much  has  been  written  about 
the  action  of  these  waters  in  syphilis,  but  we  must  not  forget  that  the 
successful  physicians  at  these  spas  make  most  energetic  use  of  mercury. 

8.  Earthy  or  Calcareous  Waters.  —  Carbonate  and  sidphate  of  lime 
and  carbonate  of  magnesia  are  the  principal  constituents. 

Enumeration.  —  Contrexeville,  Vittel,  Bagneres-de-Bigorre,  Pougues, 
St.  Arnaud,  Cransac  (contains  also  manganese  and  alum)  in  Erance ;  Wil- 
dungen,  Lippspringe  and  Inselbad,  in  Germany  ;  Alzola  and  Eitero, 
the  latter  with  hot  springs,  in  Spain ;  Chianciano,  with  hot  springs,  in 
Central  Italy  ;  Weissenburg  in  Switzerland.  In  North  America  the  best- 
known  earthy  springs  are  —  the  Butterworth  Springs,  Eaton  Eapid 
Wells,  and  Leslie  Well  in  Michigan ;  the  Gettysburg  Spring  in  Penn- 
sylvania, the  Sweet  Springs  in  West  Virginia,  and  the  Alleghany  Springs 
in  Virginia.  The  table  waters,  St.  Galmier,  Couzan  and  Taunus,  may  be 
placed  in  this  class.    Many  of  the  waters  mentioned  in  other  classes  con- 


330  SYSTEM   OF  MEDICINE 

tain  much  calcareous  matter,  as  Bath,  Loeche,  Bormio,  Lucca  and  Ftlred, 
classed  amongst  the  simple  thermal  waters ;  and  Baden  in  Austria,  Baden 
in  Switzerland,  Schinznach,  Battaglia  and  Abano  amongst  the  sulphur 
waters. 

Action.  —  Internally  taken  these  waters  exercise,  through  the  car- 
bonate of  calcium,  an  antacid  and  also  soothing  effect  on  the  mucous 
membranes,  and  are  at  the  same  time  slightly  astringent  and  constipat- 
ing, especially  when  they  contain  much  sulphate  of  lime.  In  bathing 
coui'ses  their  action  is  nearly  the  same  as  that  of  simple  hot  water. 

Uses.  —  They  are  usef id  in  dyspepsia,  with  irritability  of  the  mucous 
membrane,  acidity,  and  diarrhoea.  Some  of  these  waters  possess  a  great 
reputation  in  proclivity  to  gravel  and  stone,  and  to  chronic  catarrh  of  the 
bladder.  They  are  used  also  in  biliary  concretions,  and  in  gouty  condi- 
tions. Their  good  effects  are  probably  due  in  a  great  degree  to  the  cir- 
cumstance that  these  waters  can  be  taken  in  large  quantities,  and  thus 
exercise  a  washing-out  effect.  In  cases  of  actual  stone  in  the  bladder,  or 
in  the  kidney,  the  use  of  these  waters  is  of  doubtful  value ;  the  concre- 
tions may  be  actually  increased  by  fresh  deposits  around  them. 

A  speciality  at  some  springs,  especially  at  Loeche  in  Switzerland,  is 
the  treatment  of  chronic  eczema,  psoriasis,  and  other  chronic  skin  diseases, 
by  hot  baths  prolonged  over  several  hours,  and  this  treatment  is  not  rarely 
successful,  at  all  events  for  a  certain  time ;  but  relapses  are  rather  com- 
mon. 

II.    Therapeutic  Employment  of  Mineral  Waters 

There  is  perhaps  no  section  of  medicine  about  which  the  ideas  of  the 
educated  classes,  including  many  members  of  our  own  profession,  are 
so  vague  as  about  the  effects  of  courses  of  mineral  waters  and  baths, 
especially  at  foreign  spas.  On  the  one  side  we  hear  very  often  that  the 
good  effects  produced  by  spa  treatment  abroad  are  due  not  to  the  waters 
and  baths,  but  only  to  the  concomitant  influences,  such  as  change  of 
locality  and  habits  of  living;  on  the  other,  we  hear  that  the  waters 
alone  are  the  curing  agents,  and  that  they  have,  or  ought  to  have,  the 
same  effect  when  taken  at  home.  Both  views  are,  however,  defective, 
and  based  on  imperfect  observation.  The  error  of  the  former  assertion 
is  due  to  inferences  from  cases  where  the  aberrations  from  health  are 
not  great,  and  are  caused  only  by  fatdts  of  home  life,  such  as  indul- 
gence in  food,  irregular  hours,  social  or  business  worry,  excessive  or 
unsuccessful  work,  acute  or  chronic  mental  shocks,  want  of  exercise,  and 
unhygienic  arrangements.  It  is  not  quite  so  easy  to  show  the  error  of 
the  latter  view,  but  it  is  equally  real  with  regard  to  the  majority  of 
invalids.  It  is  a  great  tax  on  the  system  to  digest  compound  mineral 
waters.  There  are,  it  is  true,  strong  persons  with  imperfect  portal  cir- 
culation, dyspepsia,  hsemorrhoidal  congestion,  and  inactive  liver,  who  are 
able  to  right  themselves  by  good  purgative  waters ;  and  can  take  with 
advantage  even  courses  of  Carlsbad  or  Kissingen  waters  while  continu- 
ing their  usual  diet  and  their  daily  work ;  but  the  majority  of  invalids, 


BALNEOLOGY  AND  HYDROTHERAPEUTLCS  331 

especially  those  with  a  delicate  constitution,  or  with  a  weak  heart,  do  not 
possess  the  amount  of  vital  force  sufficient  for  the  digestion  of  these 
waters,  if  at  the  same  time  their  brain  or  their  mind  is  taxed,  if  they 
have  to  go  into  society,  and  take  long  or  large  meals  in  close  rooms. 
They  often  break  down  utterly  if  they  attempt  to  do  so.  Even  at 
country  houses  many  people  cannot  disengage  their  minds  to  such  a 
degree  as  to  be  able  to  bear  these  waters ;  and  at  the  spas  themselves  it 
often  happens  that  success  is  entirely  spoilt  by  attention  to  letters  from 
home,  especially  about  business  or  family  worries. 

On  the  other  hand,  we  have  to  deal  with  the  opposite  error,  viz.,  the 
belief  of  many  persons  that  the  power  of  foreign  waters  is  so  great  that 
they  think  they  can  remove  large  tumours,  fatty  or  bony,  or  carcino- 
matous ;  that  they  can  unbend  contracted  limbs  ;  that  they  can  restore 
the  muscles  wasted  from  infantile  paralysis,  or  the  functions  lost  from 
senile  decay.  Incredible  as  this  may  appear  to  the  educated  medical 
man,  such  ideas  persist  in  the  high  places  of  society.  It  is,  therefore, 
very  desirable  that  our  profession  should  devote  more  attention  to  this 
important  branch  of  treatment,  and  should  diffuse  general  knowledge  on 
the  subject  amongst  the  public.  Por  this  purpose  a  few  lectures  ought 
to  be  given  regularly  at  our  medical  schools  on  balneo-therapeutics,  and 
also  on  climato-therapeutics,  as  a  part  of  the  course  of  Materia  Medica. 
We  ought  not  to  be  deterred  from  such  a  course  by  the  great  difficulties 
which  beset  the  subject,  to  which  we  can  but  briefly  allude.  While 
in  our  pharmaceutical  remedies  we  have  to  deal  with  more  or  less  fixed 
and  simple  substances,  most  of  the  mineral  waters  are  compound;  and, 
even  if  we  know  to  some  degree  the  action  of  the  constituents  severally, 
we  often  cannot  accurately  calculate  the  share  which  each  of  these  sub- 
stances plays  in  combination  with  the  others,  or  their  mutual  interaction 
—  points  to  which  we  have  already  alluded  in  the  description  of 
the  different  classes  of  mineral  waters.  We  may  call  to  mind  some- 
thing analogous  in  our  ordinary  treatment  when  we  prescribe  compound 
aperient  pills,  or  compound  sedative  draughts.  Another  point  of  some 
uncertainty  is  that  we  prescribe  the  waters  according  to  their  most 
prominent  ingredients,  but  we  cannot  be  perfectly  sure  that  the  sub- 
stances present  in  small  quantities  do  not  play  a  more  important  part 
in  the  action  of  the  whole  water  than  we  generally  concede  to  them. 

We  must  acknowledge  that  we  have,  as  yet,  no  scientific  basis  for 
balneo-therapeutics.  Our  position  is  still  entirely  empirical,  based  on 
the  observation  and  experience  of  physicians  and  patients  as  to  the 
effects  of  certain  waters  and  cures,  either  at  home  or  at  the  spas ;  but 
with  all  the  admissions  as  to  our  exactness  of  knowledge,  we  are 
obliged  to  grant  that  special  bathing  and  drinking  cures  are  most 
efficacious  in  many  chronic  morbid  conditions,  and  cannot  be  replaced 
by  any  other  modes  of  treatment  (.'32). 

We  will  now  endeavour  to  give  a  short  sketch  of  the  main  points 
which  are  to  be  considered  by  the  practitioner  who  is  asked  about 
mineral  waters   and   baths.     We   must   begin  in  every  case  with  the 


332  SVST£A/  OF  MEDICINE 

question,  whether  balneo-therapeutic  treatment  offers  advantages  over 
the  ordinary  medical  treatment;  and  then  consider  whether  this  treat- 
ment ought  to  be  carried  out  at  home  or  abroad,  and  whether  it  is  to 
be  preceded  or  followed  by  pharmaceutical  or  other  treatment,  or  com- 
bined with  it.  When  the  question  is  decided  in  favour  of  balneo- 
therapeutic treatment,  we  have,  to  regard  not  only  the  name  and  nature 
of  disease,  but  have  to  study  all  the  conditions  and  habits  of  the 
individual  before  us,  pecuniary,  physical,  and  psychical ;  his  constitution 
in  general ;  his  power  of  reaction ;  Avhether  the  different  organs  are 
healthy  or  not ;  whether  they  can  take  up  increased  work  in  order  to 
relieve  the  diseased  part ;  whether  they  are  able  or  unable  to  respond  to 
any  unusual  demand.  Thus  we  shall  learn  whether  stronger  thera- 
peutic action  is  permitted ;  whether  rougher  journeys  and  accommoda^ 
tion,  colder  climates  and  seasons  can  be  borne ;  or  whether  gentle 
treatment  is  necessary,  with  easy  journeys,  warm  seasons,  mountain 
climates  of  moderate  elevation,  sheltered  and  sunny  habitations,  and 
delicate  food. 

The  chemical  constitution  of  the  waters  alone  is  not  sufficient  for 
our  selection  of  the  place ;  we  must  know  the  accustomed  jnethods  of 
treatment  at  certain  localities,  the  accommodation,  the  quality  of  food 
and  the  cooking,  the  climate,  the  social  elements  likely  to  be  found,  and 
above  all  the  qualities  of  the  local  physician  to  be  selected  for  the 
treatment  of  the  case. 

It  must  be  evident  from  these  remarks  that  the  same  morbid  con- 
dition may  in  different  persons  require  different  localities  and  even 
different  classes  of  mineral  waters ;  and,  further,  that  diseases  of  different 
nature  may  be  benefited  at  the  same  spa,  by  adapting  the  various 
bathing  procedures,  the  doses  and  temperature  of  water  to  be  drunk  to 
the  individual  case,  and  by  selecting,  when  there  are  different  springs 
at  the  same  place,  the  most  suitable  one.  Often  the  treatment  must  be 
at  first  of  a  tentative  nature,  requiring  the  most  careful  watching  by  the 
local  physician,  and  perhaps  frequent  alterations.  In  many  cases  it  is 
impossible  to  attack  the  principal  complaint,  and  our  efforts  must  be 
directed  towards  improving  the  general  condition,  by  which  means  very 
often  the  diseased  portion  of  the  organism  is  drawn  into  the  stream  of 
general  improvement. 

Taking  the  different  points  just  alluded  to  into  consideration,  every 
one  will  see  how  much  depends  on  the  local  physician ;  and  that  it  is  not 
in  the  interest  of  the  patient  to  prescribe  the  course  of  treatment,  either 
directly  or  indirectly :  though  it  is  often  advisable  for  the  home  practi- 
tioner to  make  suggestions  based  on  previous  experience. 

We  will  now  sketch  the  applicability  of  waters  to  some  morbid  con- 
ditions, but  must  limit  ourselves  for  want  of  space  to  a  few  states  only. 

1.  Tardy  or  imperfect  convalescence  is  the  condition  of  many 
persons  inquiring  about  waters,  and  the  nature  of  these  cases  varies  con- 
siderably. All  have  this  in  common,  that  they  are  in  a  state  of  insta- 
bility ;  their  balance  is  easily  upset.     Any  increased  demand  on  their 


BALNEOLOGY  AND  LIVDROTHERAPEUTLCS  3.33 

nerve  power,  or  on  their  digestive  functions,  may  lead  to  illness ;  the 
nerves  and  blood-vessels  of  the  skin  are  weak ;  and  comparatively  slight 
exposure  leads  to  chill  and  to  more  or  less  grave  results.  In  advising 
we  must  therefore  be  careful  to  warn  against  fatiguing  joiTrneys, 
irregular  or  heavy  meals,  long  cold  drives,  and  so  forth.  The  majority 
do  not  require  spa  treatment;  when  they  do,  spas  not  too  distant, 
with  gentle  treatment  and  good  accommodation,  in  sheltered  positions 
at  medium  elevations,  are  to  be  recommended ;  or  change  of  air  alone 
without  spa  treatment  at  the  beginning.  Later,  iron  Avaters  or  common 
salt  waters  are  often  useful.  If  there  be  still  remains  of  disease,  each 
such  case  will  require  special  consideration. 

In  the  exudations  of  perimetritis,  for  instance,  after  miscarriage  or 
confinement,  the  common  salt  waters,  such  as  Kreuznach,  Kissingen, 
Woodhall  are  useful. 

If  after  rheumatic  fever  the  skin  remains  weak,  the  joints  painful, 
the  heart  dilated,  with  or  without  some  valvular  complication,  the 
thermal  gaseous  saline  waters  of  Nauheim  and  Relime  are  of  great 
value,  sometimes  assisted  by  Schott's  movements  with  resistance. 

If  tendency  to  diarrhoea  be  a  prominent  symptom,  Plombieres  is 
often  useful ;  if  much  neuralgia  without  organic  cause,  Schlangenbad ; 
if  chronic  bronchial  catarrh,  the  muriated  or  muriated  alkaline  Avaters 
of  Soden,  of  Gleicheiiberg,  of  La  Bourboule,  or  of  Baden-Baden. 

2.  Abdominal  venosity  is  a  prominent  feature  of  many  chronic 
ailments,  not  only  of  the  abdominal,  but  also  of  the  circulatory  and 
respiratory  organs  —  of  obesity,  of  drowsiness,  of  anaemia,  of  glycosuria, 
etc.  The  term  used  by  the  old  German  authors.  Abdominal  plethora, 
is  very  significant.  It  is  often  the  cause  of  piles,  of  the  enlargement 
of  the  liver,  of  chronic  pulmonary  catarrh,  and  so  on ;  and  is  generally 
part  of  a  weak  organic  fibre  in  the  whole  system,  of  the  heart  and  all 
the  blood-vessels,  especially  of  the  capillaries  and  veins,  but  also  of  the 
intestines  and  of  the  mucous  membranes.  Dietetic  and  hygienic  man- 
agement, the  various  forms  of  active  and  passive  exercise,  are  pre- 
eminently useful,  but  these  are  greatly  assisted  and  must  sometimes  be 
preceded  by  waters  :  here  the  alkaline  sulphated,  the  "  bitter  waters," 
the  common  salt  waters  are  most  useful,  for  an  account  of  which  we 
refer  to  the  first  part  of  this  contribution. 

3.  Diseases  of  the  Respiratory  Organs.  —  Climato-theraiseutic  treat- 
ment is,  in  the  majority  of  cases,  more  important  than  waters,  but  the 
latter  in  many  conditions  may  be  a  great  help,  and  in  others  deserve  the 
first  place. 

In  chronic  catarrh  of  the  bronchial  tubes  the  alkaline  and  muriatic 
alkaline  waters  and  the  sulphur  waters  are  beneficial ;  and  when  it  owes 
its  origin  to  abdominal  venosity,  the  recommendations  of  the  previous 
section  find  a  place.  When  the  dilatation  of  the  heart  is  the  prominent 
feature,  the  waters  and  baths  of  Nauheim,  assisted  by  the  movements 
with  resistance,  are  required. 

Emphysema  comes  more  or  less  under  the  same  head.     Climatically 


334  SYSTEM   OF  MEDICINE 

the  saps  of  Gleiclienberg  in  Styria  and  of  the  Pyrenees  are  well  adapted, 
to  these  cases,  and  so  is  Ems  in  the  earlier  or  later  summer. 

Chronic  naso-pharyngitis,  if  it  be  not  connected  with  adenoid 
growths,  requires  likewise  alkaline  muriated  or  sulphur  waters,  or  the 
arsenical  waters  of  Mont  Dore  with  inhalations. 

Imperfect  resolution  of  pneumonia  needs  climatic  and  careful  hygienic 
management,  and  sulphur  and  alkaline  muriated  waters,  but  with  careful 
avoidance  of  exposure  to  the  raw  morning  air  while  taking  the  early 
draughts. 

Asthma  depends  on  various  causes,  and  accordingly  requires  various 
modes  of  treatment  by  drugs  and  Avater  and  climate,  or  is  not  amenable 
to  any.  The  catarrhal  form  in  fairly  robust  persons  is  often  greatly 
relieved  by  the  treatment  at  Mont  Dore. 

4.  Diseases  of  the  Heart.  —  We  restrict  ourselves  to  a  few  remarks. 
Many  cases  are  not  suited  to  long  journeys  and  treatment  by  waters. 

Fatty  hearts  or  weak  hearts  in  fat  persons  are  mostly  benefited  by 
diet,  combined  with  active  and  passive  exercise  and  with  sulphated 
alkaline  and  bitter  waters.  For  dilated  hearts  associated  with  abdominal 
venosity,  see  sub-section  2. 

In  valvular  affections  with  great  aneemia  iron  waters  are  often  useful ; 
but  in  many  cases  aperient  Avaters  or  pharmaceutical  preparations,  and 
Swedish  gymnastics,  must  be  combined  with  chalybeate  waters. 

In  weak  and  moderately  dilated  hearts  graduated  exercise  (Oertl) 
is  better  than  baths ;  but  if  the  dilatation  be  great,  whether  with  or 
without  valvular  disease,  the  cautious  use  of  the  baths  of  Nauheim, 
assisted  by  movements  with  resistance,  must  precede  the  voluntary  move- 
ment Avith  climbing.  In  some  cases  treatment  at  home  on  the  Nauheim 
plan  must  precede  the  journey  abroad ;  and  sometimes  we  must  not  be 
deterred  from  such  measures  by  seemingly  advanced  symptoms. 

Recent  valvular  affections  resulting  from  rheumatic  fever  we  have 
already  mentioned  in  sub-section  1. 

5.  In  Anaemia  we  have  to  consider  whether  it  is  caused —  (a)  by  direct 
loss  of  blood  or  albuminous  and  mucous  discharges ;  (6)  by  constipation 
and  impeded  abdominal  circulation  ;  (c)  by  inability  to  take  food,  sleep- 
lessness, mental  shocks  and  worry,  neuralgia,  etc. ;  (d)  by  diseases  of  the 
lymphatic  glands ;  or  (e)  by  malarious  affections  and  consequent  affec- 
tion of  the  spleen  and  liver.  The  more  a  case  belongs  to  (a)  the  more 
likely  is  the  effect  of  iron  to  be  beneficial ;  and  the  physician  has  to 
decide  whether  chalybeate  spa  treatment  offers  advantages  over  pharma- 
ceutical preparations.  In  the  group  (6)  chloride  of  sodium  waters  are 
mostly  preferable  at  first  to  pure  steel  waters ;  and  a  course  of  the  latter, 
or  of  climatic  treatment,  or  of  both  combined,  may  in  many  cases  follow 
with  advantage.  In  (c)  climatic  change  alone  is  often  more  important 
than  waters.  In  (cZ)  the  use  of  muriated  saline  and  of  arsenic  waters 
may  be  tried ;  but  they  often  fail,  and  ought  at  all  events  to  be  followed 
by  long  sea-side  residence  or  sea-voyages.  In  (e)  the  muriated  or  sul- 
phated saline  waters  at  mountain  localities  ought  to  be  combined  with 


BALNEOLOGY  AND  HYDROTHERAPEUTICS  335 

iron  or  arsenic,  and  followed  by  long  residence  at  high  elevations  or 
occasionally  sea-side  places. 

6.  Gravel  and  Stone.  —  In  the  nric  acid  varieties  the  alkaline  waters 
are  generally  prescribed,  but  great  care  is  necessary  not  to  allow  the 
urine  to  become  too  alkaline,  since  this  may  lead  to  deposition  of  phos- 
phates around  a  small  uric  acid  stone.  A  better  plan,  in  general,  is  to 
order  the  sulphated  alkaline  waters,  especially  the  hot  waters  of  Carls- 
bad, in  the  numerous  cases  where  a  certain  amount  of  abdominal  venosity 
and  sluggish  circulation  of  the  liver  are  among  the  causes  of  gravel. 

We  have  already  mentioned  that  it  is  difficult  to  explain  the  great 
reputation  of  earthy  waters  in  gravel,  and  that  their  effect  is  probably 
due  to  the  administration  of  such  waters  in  large  quantities,  so  as  to  pro- 
duce a  washing  out  effect,  which  probably  would  be  obtained  quite  as 
well  by  the  systematic  drinking  of  large  amounts  of  hot  water  on  an 
empty  stomach. 

7.  Gout  occurs  in  widely-differing  constitutions,  varies  widely  in  de- 
gree, and  may  or  may  not  be  complicated  with  many  other  morbid  affec- 
tions. If  we  have  to  deal  with  persons  of  so-called  "  full  habit "  —  with 
portal  venosity,  sluggish  liver,  and  a  urine  of  rather  high  specific  grav- 
ity, loaded  with  urates  and  uric  acid — the  sulphated  alkaline  or  mild 
bitter  waters  are  indicated,  especially  Carlsbad,  Marienbad,  Tarasp, 
Franzensbad,  Elster,  Brides-les-Bains.  All  courses  of  the  stronger  waters 
ought  to  be  followed  by  a  long  rest  with  careful  diet  in  good  air  before 
returning  to  the  daily  life ;  and  this  is  pre-eminently  the  case  with  the 
courses  just  mentioned.  If  such  a  long  rest  be  impossible,  a  less  search- 
ing course  ought  to  be  recommended,  such  as,  according  to  the  nature  of 
the  case,  Homburg,  Kissingen,  Harrogate,  Leamington,  Royat,  Contrexe- 
ville.  La  Bourboule,  Wiesbaden,  Baden-Baden,  Aix-la-Chapelle,  Uriage, 
Aix-les-Bains,  Bagneres  de  Luchon.  A  shorter  rest  is  usually  sufficient 
after  these  waters.  In  many  delicate  persons,  especially  if  time  be  lim- 
ited, the  simple  thermal  waters  are  preferable  —  Buxton,  Bath,  Wildbad, 
Ragatz,  Schlangenbad,  Teplitz,  Gastein.  Numerous  cases  of  gout,  how- 
ever, are  not  suitable  for  mineral  water  treatment,  and  will  be  found 
more  amenable  to  pharmaceutical  remedies,  diet,  and  climate. 

8.  Chronic  Rheumatism.  —  In  cases  associated  with  exudation  round 
the  joints,  the  hot  thermal  treatment  is  very  useful ;  and  it  must 
frequently  be  combined  with  various  forms  of  massage  and  Swedish 
gymnastics.  The  simple  thermal  waters,  the  hot  sulphur  waters,  the 
muriated  saline  waters,  can  be  employed  Avith  success.  Chronic  mus- 
cular rheumatism  is  amenable  to  similar  treatment.  In  cases  com- 
bined with  affection  of  the  heart,  especially  with  dilatation,  the  tepid 
gaseous  saline  waters  of  Nauheim  are  preferable,  associated  with  Schott's 
modification  of  Ling's  system.  Many  cases  are  well  suited  to  simple 
hydrotherapeutic  treatment. 

9.  Diabetes  and  Glycosuria.  —  It  is  not  long  since  some  alkaline  and 
sulphated  alkaline  watei's,  especially  Vichy,  Carlsbad,  and  Neuenahr,  were 
tliought  to  exercise  a  specific  influence  on  these  complaints  ;  but  reason 


336  SYSTEM  OF  MEDICINE 

and  experience  have  proved  this  view  to  be  erroneous.  It  is  quite 
true  that  in  the  milder  forms  of  glycosuria  courses  of  treatment  at  these 
spas  improve  the  general  health,  and  greatly  diminish  or  temporarily 
remove  the  sugar  from  the  urine.  This,  however,  is  due  in  the  first 
place  to  the  arrangement  of  diet,  in  the  second  to  improvement  of  the 
digestive  organs  and  functions  by  the  use  of  the  waters,  and,  thirdly,  to 
the  removal  of  the  patients  from  the  worries  of  life  at  home.  In  the 
frequent  cases  of  chronic  glycosuria  in  fat  and  gouty  persons,  sulphated 
alkaline  waters  are  beneficial,  and  the  more  bracing  the  climate  the 
better. 

10.  Diseases  of  the  Nervous  System.  —  Spa  treatment  is,  as  a  rule, 
not  applicable  to  mental  diseases,  although  milder  forms  of  hypochondri- 
asis and  melancholia,  if  they  depend  on  chronic  constipation  or  abdominal 
venosity,  may  be  favourably  influenced  by  the  waters  mentioned  under 
that  head.  Epilepsy  is  likewise  to  be  excluded,  and  also  locomotor  at- 
axy, unless  they  depend  on  syphilis,  which  will  be  presently  discussed. 

Nerve  exhaustion  and  neurasthenia  in  their  various  forms  and  degree 
may,  according  to  the  nature  of  the  cases,  be  treated  at  chalybeate, 
or  thermal  muriated  saline,  or  simple  tepid  spas ;  but  such  treatment 
can  only  take  a  small  share  in  the  judicious  general  management,  which 
must  be  pursued  during  a  long  period  of  time. 

Neuralgic  affections  are  often  relieved  by  spa  treatment,  if  they  can 
be  referred  to  gout,  to  anaemia,  or  to  nerve  exhaustion ;  and  the  selec- 
tion of  the  spa  must  depend  on  these  considerations. 

11.  Affections  of  the  Female  Sexual  Organs  are  frequently  treated 
at  spas,  although  such  treatment  is  not  always  required.  Chronic  con- 
gestion of  the  womb,  especially  in  consequence  of  confinements  and 
miscarriages,  can  be  greatly  benefited  by  the  muriated  saline,  by  the 
alkaline,  and  also  by  the  simple  and  the  sulphurous  thermal  waters.  The 
deposits  round  the  pelvic  organs  from  perimetritis  are  often  removed  by 
the  careful  use  of  the  muriated  saline  Avaters.  Many  gynaecologists,  both 
in  this  country  and  abroad,  have  great  faith  in  the  effect  of  these  waters 
(especially  those  of  Creuznach)  in  fibrous  tumours  of  the  uterus. 

12.  Syphilis  is  regarded  by  many  persons  as  one  of  the  diseases 
which  can  be  cured  by  the  use  of  mineral  waters ;  but  all  that  can  be 
said  is  that  the  use  of  other  remedies  may  be  assisted  by  them.  It  often 
happens  that  the  energetic  use  of  hydrargyrum  cannot  be  carried  out 
under  the  usual  circumstances  of  home  life,  and  that  it  is  facilitated  by 
the  methodic  employment  of  hot  baths  and  vapour  baths,  and  the  careful 
management  of  the  manner  of  living,  so  as  to  avoid  chills,  and  other  injuri- 
ous influences.  Thus  certain  spas,  like  Aix-la-Chapelle,  have  acquired  a 
great  reputation  in  the  treatment  of  syphilitic  affections,  especially  those 
of  secondary  and  tertiary  phases.  In  this  way  many  cases  of  affections 
of  the  skin,  of  the  mucous  membranes,  of  the  muscles  and  organs  of 
circulation,  of  the  brain  and  spinal  marrow,  epilepsy  and  locomotor  ataxy, 
on  a  syphilitic  basis,  are  cured  or  benefited  more  or  less  permanently,  or 
again  it  may  be  but  transitorily,  by  treatment  at  spas ;   but  generally 


BALNEOLOGY  AND   HYDROTHERAPEUTICS  337 

not  by  mere  spa  treatment.  This  applies  as  well  to  acquired  as  to 
inherited  syphilitic  affections.  As  in  home  treatment,  so  also  at  spas,  it 
is  often  found  that  serious  affections  on  a  syphilitic  basis  are  no  longer 
amenable  to  anti-syphilitic  treatment,  and  that  the  latter  does  more  harm 
than  good.  In  such  cases  the  means  for  the  improvement  of  the  general 
health  are  all  that  remain  to  us,  and  herein  climate  and  spas  may  take 
again  their  humble  share  according  to  the  nature  of  the  cases. 

We  might  mention  a  number  of  other  morbid  conditions  which  can 
be  relieved  by  spa  treatment,  but  for  a  mere  survey  the  preceding  classes 
of  affections  are  probably  sufi&cient.  We  can  also  dispense  with  sugges- 
tions about  diet  and  manner  of  living,  as  each  individual  case  ought  to 
be  considered  in  itself  by  the  local  physician,  whose  assistance,  as  we 
have  already  urged,  is  indispensable. 

Seasons  for  Spa  Treatment.  —  A  few  words  as  to  the  times  of  the 
year  to  be  selected  are  perhaps  not  out  of  place.  Climate  and  weather 
are  important  agents  in  spa  treatment.  Most  delicate  persons  are  better 
in  summer  than  in  winter ;  spa  treatment  has,  therefore,  a  greater  chance 
of  doing  good  in  summer.  Extreme  heat,  however,  is  to  be  avoided  in 
most  cases,  and  spas  which  are  very  hot  in  the  middle  of  summer,  such 
as  Wiesbaden,  Ems,  Aix-les-Bains,  Vichy,  Baden-Baden,  Bath,  ought 
therefore,  as  a  rule,  not  to  be  visited  in  July  and  the  beginning  of  August, 
but  in  the  earlier  and  later  parts  of  the  summer.  On  the  other  hand, 
spas  at  high  elevations,  such  as  St.  Moritz  and  Tarasp,  ought  to  be 
recommended  only  between  the  middle  of  June  and  September.  Few 
resorts  are  open  earlier  than  May  or  later  than  September ;  but  some 
of  the  hot  springs,  as  Bath,  Aix-la-Chapelle,  Wiesbaden,  Baden-Baden, 
Amelie-les-Bains,  and  Dax,  are  available  during  the  whole  of  the  year. 
It  must  be  borne  in  mind,  however,  that  Tiiuch  greater  care  is  required 
in  the  hot  baths  during  the  colder  months,  and  that  the  exhilarating 
influence  of  fine  weather  is  mostly  wanting. 

Duration  of  Courses  of  Spa  Treatment.  —  Formerly  it  was  the  custom 
to  have  fixed  periods  for  the  treatment  at  different  spas,  say  three,  four, 
or  five  weeks ;  but  in  the  light  of  increased  knowledge,  we  have  learnt 
that  it  is  in  many  instances  impossible  to  fix  at  the  outset  the  length 
of  the  course  —  just  as  it  is  often  impossible  to  say,  on  prescribing  iron 
or  arsenic,  that  it  is  to  be  continued  for  two  or  three  weeks  and  not  longer. 
Much  must  depend  on  the  effect  which  a  course  of  spa  treatment  has  on 
the  individual  case,  and  the  local  physician  must  decide  not  only  on  the 
doses,  but  also  on  the  duration  of  the  course.  There  are  cases  in  which 
it  is  wise  to  give  small  doses  for  a  long  period  of  time,  and  others  in 
which  it  is  more  advantageous  to  give  large  doses  for  short  periods  only. 
In  some  instances  two  courses  are  required  in  the  same  year,  with  a 
longer  or  shorter  rest  between  them.  Again  it  frequently  occurs  that 
two  courses  of  different  waters  ought  to  follow  one  another ;  for  instance, 
in  a  case  of  antemia  with  a  sluggish  portal  system  and  passive  congestion 
of  the  liver,  it  may  be  necessary  to  begin  by  a  course  of  saline  waters  to 
unload  the  portal  system,  and  afterwards  to  use  chalybeate  waters. 


338  SYSTEM  OF  MEDICINE 

After-management.  —  The  success  of  courses  of  mineral  waters  often 
depends  entirely  on  the  way  in  which  the  first  three  or  six  weeks  follow- 
ing the  treatment  are  employed.  In  almost  all  cases  it  is  necessary  to 
spend  some  time  away  from  home  at  a  good  climatic  resort,  with  careful 
diet  and  with  open-air  life,  but  without  mental  or  bodily  fatigue.  It 
seems  dif&cult  for  many  people  to  see  this,  but  we  cannot  too  strongly 
advise  our  professional  brethren  to  insist  upon  it.  Some  waters,  like 
the  simple  thermal  or  thermal-sulphur  waters,  especially  when  taken 
at  bracing  localities,  require  a  shorter  after-treatment  than  the  more 
complicated  and  searching  waters  of  Carlsbad,  Marienbad  or  Tarasp. 

Every  one  who  is  acquainted  with  the  "  Weir  Mitchell  treatment " 
will  admit  that  its  author  is  correct  in  demanding  after  the  termination 
of  the  treatment  proper  a  further  absence  of  six  or  eight  weeks  from 
the  excitement  and  worry  of  home  life  ;  and  some  of  us  must  have  found 
that  the  neglect  of  this  demand  often  destroys  the  good  effect  of  the 
previous  treatment.  Similarly,  after  a  serious  course  of  waters  the  whole 
system  is  in  many  persons  in  an  abnormal  state  of  sensitiveness  or 
unstableness,  especially  as  regards  the  organs  of  digestion,  circulation, 
and,  not  least,  the  nervous  system.  Injurious  influences,  however  slight, 
such  as  a  chill,  mental  or  bodily  fatigue  or  excitement,  a  mistake  in  diet, 
are  apt  to  cause  a  new  break  down.  We  ought  not  to  be  influenced  in 
our  directions  by  the  fact  that  some  strong  persons  can  do  everything, 
even  at  or  after  Carlsbad,  with  impunity.  Such  cases  form  rare  excep- 
tions, not  the  rule. 

Hermann  Weber. 

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Bromo-Iodiue  Waters  and  its  Salts,"  Brit.  Med.  Journ.  1873.  — 15.  Cormack,  C.  E. 
The  Mineral  Waters  of  Vichy,  1887.  — 16.  Diruf,  O.,  Sen.  Kissingen,  its  Baths  and 
Minval  Springs,  1887.  — 17.  Debout-d'Estrees.  A  Lecture  on  C'ontrexeville,  1891. — 
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Fardel  and  Le  Bret.  Dictionn  d''s  Eaux  Min^rahs,  1862. — 20.  Durand-Fardel. 
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Carlsbaden  Miihlbrunuens  bei  Diabetes  Mellitus,"  Berl.  klin.  Wochensch.  1880. — 29. 
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Lersch,  B.  M,  Biz  phys.  u.  thzrapeut.  Fundamente  der  pract.  Balneologie,  1868.  —  35, 
Macpherson,  J.  The  Baths  and  Wells  of  Europe,  3rd  ed.  1888.  —36.  Macpherson,  J. 
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therapie  und  Balneotherapie,  1889. — 43.  Reumont.  "  Suli^hur  Wells"  in  Valentiner's 
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die  Zuckerausscheiduug,"  Berl.  klin.  Wochensch.  1877. — 45.  Robertson,  W.  H.  "The 
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H.  W. 

B.  —  Hydrotherapeutics 

Under  the  term  "  Hydrotherapeutics  "  the  therapeutic  use  of  water 
is  considered,  especially  in  its  external  application  to  the  body.  The 
internal  and  external  uses  of  natural  mineral  waters  are  dealt  with  in 
the  article  on  "  Balneo-therapeutics." 

History.  —  Hydrotherapeutics  was  known  to  the  ancient  Greeks  and 
Eomans,  and  regular  bathing  of  the  body  and  keeping  of  the  skin  in  a 
healthy  condition  were,  like  the  athletic  training  of  the  body,  held  by 
them  in  high  esteem.  It  is  possible  that  a  reaction  from  the  excessive 
luxury  of  later  Eome  partly  helped  to  bring  baths  into  the  neglect  into 
which  they  fell  amongst  the  early  ascetic  Christians. 

In  Italy  and  France  hydrotherapeutics  made  a  start  in  the  fifteenth 
and  early  sixteenth  centuries,  and  were  even  applied  in  mental  diseases, 
as  narrated  in  one  of  Poggio's  tales.  In  the  seventeenth  century 
Floyer  and  T.  Smith  wrote  on  hydrotherapeutics  in  England,  and  in 
the  early  eighteenth  century  F.  Hoffmann  wrote  on  the  subject  in  Ger- 
many. About  the  middle  of  the  eighteenth  century  J.  G.  and  J.  S. 
Hahn  treated  febrile  diseases  with  cold  sponging,  and  one  of  them,  when 
attacked  with  typhoid  fever,  had  himself  treated  by  this  method,  modifi- 
cations of  which  have  been  so  widely  adopted  in  modern  times.  In  the 
latter  part  of  the  eighteenth  century,  in  spite  of  the  results  by  W. 
Wright,  James  Currie  and  W.  Jackson,  and  in  Germany  by  Reuss, 
Frohlich,  Brandis  and  Horn,  hydrotherapeutical  treatment  was  again 
falling  into  disuse,  when,  soon  after  1820,  Vincent  Priessnitz,  originally 
a  small  farmer  of  Graefenberg  in  Silesia,  began  to  treat  every  kind  of 


340  SYSTEM   OF  MEDICINE 

ailment,  chronic  as  well  as  acute,  by  hydrotlierapeutic  means.  He 
added  to  the  external  applications  the  abundant  internal  use  of  water,  and 
with  this  treatment  he  combined  active  exercise,  and  a  very  simple  diet, 
and  prohibited  tea,  coffee  and  all  alcoholic  beverages.  Priessnitz  at 
different  periods  made  considerable  alterations  in  his  hydrotherapeutic 
measures.  Originally  he  packed  patients  for  several  hours  in  dry  woollen 
blankets,  covered  with  feather  beds,  before  applying  cold  affusions ;  later 
he  substituted  packing  in  wet  linen  sheets  for  several  hours,  followed 
by  a  full  bath  or  a  douche  ;  still  later  he  frequently  employed  a  cold  wet 
pack  of  fifteen  or  twenty  minutes'  duration,  repeated  several  times  in 
the  same  day.  He  introduced  the  method  of  rubbing  the  whole  body 
with  a  cold  wet  slieet  instead  of  the  full  bath ;  and  made  extensive  use  of 
partial  baths  for  the  hips,  the  hands,  the  arms,  or  the  feet,  of  wet  abdomi- 
nal belts,  and  of  wet  applications  on  different  parts  of  the  body.  The 
success  of  his  measures,  combined  as  they  were  with  a  simple  diet  and 
exercise  in  a  healthy,  mountainous  country,  was  in  many  cases  consider- 
able; but  the  indiscriminate,  too  energetic,  and  protracted  use  of  his 
methods  often  led  to  unfavourable  results.  The  system  was  beginning 
to  be  regarded  as  a  sort  of  quackery,  when,  about  the  year  1850,  estab- 
lishments were  placed  under  the  superintendence  of  regularly-educated 
physicians,  who  studied  the  physiological  effects  of  the  different  methods, 
and  modified  them  according  to  the  requirements  of  individual  cases : 
they  also  added  pharuiaceutical  remedies  when  required.  To  the  more 
modern  works,  by  Winternitz,  Ha^-em,  Scheuer,  etc.,  the  writers  of  the 
present  article  are  largely  indebted. 

Although  England  has  taken  such  a  proininent  position  in  the  use  of 
baths  in  health,  especially  the  daily  morning  "  tub,"  it  is  remarkable  that, 
as  compared  with  French  and  German  hospitals,  the  London  hospitals 
are  still  very  badly  furnished  with  douches,  and  other  means  of  hydro- 
therapeutic  treatment. 

Modes  of  Application.  —  Amongst  these  are  the  ordinary  full  bath 
at  different  temperatures,  hip-baths,  shower  or  rain  baths,  wrapping  in 
wet  towels,  affusions,  douches  of  various  kinds,  and  many  forms  of  local 
applications.  The  temperature  may  sometimes  be  varied  during  the 
application  (alternating  douche,  Scotch  douche).  Among  the  many 
forms  of  medicated  baths  only  a  few  can  be  mentioned  here.  Brine- 
baths,  to  imitate  sea-baths,  can  be  made  by  adding  about  10  lb.  of  sea 
salt  to  thirty  gallons  of  water.  Alkaline  baths  of  thirty  gallons  contain 
about  six  ounces  of  carbonate  of  sodium  or  three  ounces  of  carbonate  of 
potassium.  Acid  baths  can  be  made  by  adding  about  twelve  ounces  of 
diluted  nitro-muriatic  acid  to  thirty  gallons  of  water.  The  common  bran 
and  mustard  baths  need  not  be  described.  Aromatic  and  pine  baths  are 
made  by  adding  a  decoction  of  aromatic  plants,  such  as  lavender  or  fresh 
pine  leaflets,  or  an  extract  or  essence  of  pine  leaflets  to  warm  water. 
Mercurial  baths  belong  to  the  treatment  of  syphilis,  and  electrical  baths 
will  be  described  under  "  Electro-therapeutics."  Baths  can  also  be  made 
to  imitate  those  of  natural  mineral  Avaters. 


BALNEOLOGY  AND  HYDROTILERAPEUTICS  341 

The  varieties  of  hydrotherapeutic  application  are  very  numerous,  but 
most  ends  which  can  be  attained  in  the  present  state  of  our  knowledge  can 
be  arrived  at  by  the  judicious  use  of  a  very  small  number  of  appliances. 

The  internal  use  of  plain  water  as  a  therapeutic  agent,  much 
employed  in  the  old  "  water  cure,"  is  now  generally  but  an  adjuvant  to 
other  methods  of  treatment.  Vapour  and  hot  air  baths  may  conveniently 
be  classed  with  hydrotherapeutic  appliances.  In  the  Turkish  and 
Russian  baths  the  patient  is  placed  in  a  chamber  heated  with  watery 
vapour ;  but  a  vapour-bath  may  be  taken  in  a  box  not  including  the 
head.  In  the  Roman  bath  the  hottest  chamber,  the  "  Calidarium  "  or 
"  Sudatorium,"  is  heated  b}^  dry  air  to  a  temperature  of  133°  to  140°  F., 
and  perspiration  is  more  free  than  in  vapour  baths.  These  baths  may 
be  followed  by  soaping,  rubbing,  douching,  and  a  plunge  into  cold  water. 

Treatment  by  hydrotherapeutic  means  depends  chiefly  on  the  reaction 
of  the  organism  to  cold  and  heat;  but  a  mechanical  stimulation  is  added 
to  the  purely  hydrothera.peutic  effect  by  the  impetus  of  the  water  in 
douches,  and  to  some  extent  by  the  bubbles  of  carbon  dioxide  in  the  waters 
of  Schwalbach,  Nauheim,  etc. ;  the  addition  of  a  little  mustard  has  a 
chemically  stimulating  effect,  and  a  bran-bath  diminishes  the  irritability 
of  the  skin ;  stimulation  of  the  skin  may  also  be  increased  by  friction 
and  massage.  Care  must,  however,  be  taken  that  stimulation  does  not 
exceed  the  powers  of  the  organism,  and  supervision  by  a  medical  man  is 
necessary  for  the  proper  regulation  of  the  treatment  in  every  case.  Each 
case  must  be  individually  considered,  and  hydrotherapeutic  treatment 
may  be  associated,  according  to  requirements,  with  change  in  diet,  air, 
and  the  surroundings  of  the  patient ;  or  with  a  course  of  mineral  waters 
or  internal  medication. 

Action  and  Physiological  Effects.  —  What  has  been  called  the  *' hydro- 
therapeutic reaction  "  is  the  natural  reaction  of  the  organism  to  cold  or 
heat ;  the  organism  thus  endeavours  to  defend  itself  against  the  action 
of  these  agents.  In  human  beings,  the  skin  of  the  body,  unprotected 
by  any  natural  covering,  reacts  the  more  readily  to  cold  and  heat ;  in 
most  races  this  sensitiveness  is  increased  by  the  habitual  use  of  clothes  : 
the  clothes  form  a  sort  of  zone  around  the  body,  in  which  the  temperature 
stands,  with  tolerable  regularity  (according  to  Winternitz)  at  about  90°  F. 
In  order,  therefore,  to  obtain  the  "hydrotherapeutic  reaction"  it  is 
necessary  that  the  water  should  have  a  temperature  some  degrees  above 
or  below  90°  F.  It  is  obvious,  also,  that  on  account  of  its  greater 
speciiic  heat  and  greater  coeiRcient  of  heat  conductivity,  water  is  much 
more  active  than  air  of  the  same  temperature  in  inducing  the  reaction. 
On  the  proper  bringing  about  of  this  reaction  the  result  of  hydrothera- 
peutic treatment  largely  depends. 

Cold  "Water  Treatment.  —  When  a  healthy  man  jumps  into  a  cold 
bath,  or  has  a  cold  douche  applied  over  the  whole  or  a  considerable  area 
of  his  body,  he  receives  an  impression  of  cold,  shivers,  and,  after 
an  almost  involuntary  pause  in  breathing,  takes  a  very  deep  inspira- 
tion.    The  skin  is  pale,  and  owing  to  the  contraction  of  the  unstriped 


342  SYSTEM  OF  MEDICINE 

muscle  fibres,  presents  the  appearance  called  "goose  skin."  When  the 
man  gets  out  of  the  bath,  or  sometimes  even  whilst  he  still  remains  in  it, 
these  first  eli'ects  give  place  to  the  phenomena  of  the  "  reaction."  The 
skin  then  becomes  slightly  reddened,  and  an  agreeable  subjective  sensa- 
tion of  warmth  is  experienced.  He  breathes  more  easily,  and  has  a 
general  feeling  of  comfort  and  capability  for  exertion.  This  is  the 
''  hydrotherapeutic  reaction  "  to  cold ;  it  depends  in  degree  and  rapidity 
on  the  temperature  of  the  water,  the  length  of  the  application,  and,  in 
the  case  of  a  douche,  on  the  force  with  which  it  is  applied.  The  reac- 
tion is  assisted  by  voluntary  movements  and  friction  of  the  skin,  and 
varies  much  with  the  health  and  strength  of  the  individual  and  with  his 
previous  habits  in  respect  of  cold  bathing.  To  those  already  accustomed 
to  cold  baths  the  initial  shock  is  not  unpleasant,  and  the  reaction  sets 
in  much  more  easily. 

Many  physiological  experiments  have  been  made  to  explain  scientifi- 
cally what  takes  place  when  the  whole  body  is  exposed  to  cold.  The 
pallor  of  the  skin  during  the  initial  shock  is  due  to  the  contraction  of 
the  superficial  blood-vessels,  which  sets  up  a  corresponding  dilatation  of 
the  internal  vessels  of  the  body.  As  the  blood  is  the  great  distributor 
of  heat  in  the  body,  the  central  temperature,  measured  by  a  thermometer 
in  the  rectum,  may  rise  slightly  at  first.  The  contraction  of  the  super- 
ficial blood-vessels  of  the  body  must  prevent  excessive  loss  of  heat 
until  heat  production  is  increased.  Owing  to  this  contraction  of  the 
superficial  blood-vessels  the  general  blood  pressure  rises  and  the  heart's 
action  is  increased. 

When  the  reaction  sets  in,  the  superficial  vessels  dilate,  the  flow  of 
blood  through  the  skin  is  much  increased,  and  affects  the  sensory  nerve 
terminations  so  as  to  give  rise  to  a  sense  of  warmth  in  the  skin.  Ac- 
companying the  reaction  a  thermometer  in  the  rectum  shows  a  slight 
lowering  of  the  central  temperature,  which  then  gradually  regains  its 
initial  level  or  slightly  surpasses  it. 

The  vascular  phenomena  consequent  on  the  hydrotherapeutic  appli- 
cation are  clearly  proved  to  be  due  mainly,  if  not  entirely,  to  nervous 
vaso-motor  action ;  for,  although  the  muscular  walls  of  the  arterioles, 
like  other  unstriped  muscle,  can  certainly  react  to  direct  stimuli,  the 
phenomena  follow  a  stimulus  too  fleeting  to  act  directly  on  the  muscle 
fibres  (Hayem).  The  phenomena  are  not,  to  any  considerable  extent  at 
least,  due  to  the  peripheral  nervous  mechanism,  but  to  a  reflex  mechanism 
including  the  central  nervous  system :  in  animals  they  are  absent  from 
parts  in  Avhich  the  nerves  have  been  experimentally  cut ;  and  in  the  case 
of  men  the  phenomena  may  be  diminished  or  absent  in  paralysed  and 
anaesthetic  limbs.  An  attempt  to  trace  out  the  "  reflex  arcs  "  concerned 
in  the  hydrotherapeutic  reaction  would  take  us  too  far  away  from 
practical  medicine. 

The  respiratory  phenomena  observed  after  the  application  of  cold 
water  to  the  skin  are  also  due  to  a  nervous  (reflex)  action ;  they  have 
been  produced  in  animals  rendered  insensible  'by  chloral  (Roehrig). 


BALNEOLOGY  AND   IIYDROTHERAPEUTICS  343 


These  phenomena  consist  in  increased  amplitude  of  the  respiratory- 
movements,  with  increased  liberation  of  carbon  dioxide  and  absorp- 
tion of  oxygen  by  the  blood  circulating  through  the  pulmonary  capil- 
laries. 

Increased  combustion  in  the  tissues  is  due  to  the  need  for  increased 
heat,  production  to  compensate  the  heat  given  up  to  the  cold  water. 
iShivering  must  be  regarded  as  part  of  the  means  whereby  nature  causes 
increased  heat  production.  As  is  the  case  during  muscular  exercise,  this 
increased  combustion  is  shown  by  the  increase  of  carbon  dioxide  given 
off  by  the  lungs.  Increase  of  urea  and  diminution  of  uric  acid  are  some- 
times observed  in  the  urine  of  patients  under  hydrotherapeutic  treat- 
ment ;  and,  when  observed,  show  that  the  nitrogenous  catabolism  in  the 
body  is  more  extensive.  When,  owing  to  the  continued  application  of 
cold,  the  muscular  layer  of  the  body  becomes  cooled  catabolism  is 
diminished,  but  it  is  again  increased  when  the  reaction  takes  place 
after  the  application. 

The  flow  of  urine  is  increased  and  the  action  of  the  bowels  promoted, 
the  latter  probably  being  due  partly  to  increased  peristaltic  action, 
partly  to  increased  intestinal  secretion.  The  appetite  is  stimulated,  the 
digestion  of  food  aided,  and  the  tonic  effects  on  the  nervous  and  mus- 
cular systems  increase  the  desire  for  physical  exertion  and  make  work 
feel  lighter. 

If  the  cold  application  (douche  or  bath)  instead  of  being  general,  be 
local,  and  especially  if  it  be  limited  to  an  extremity,  the  general  effects 
are  less  marked.  Local  applications  have  been  shown,  however,  to  cause 
certain  distant  reactions.  Thus,  when  iced  water  is  applied  to  one 
hand  both  become  colder,  and  both  show  a  diminution  in  volume  as 
measured  by  the  plethysmograph.  These  phenomena  are  doubtless  due 
to  the  diminution  in  the  amount  of  their  blood,  caused  by  contraction 
of  their  blood-vessels.  Inverse  phenomena  are  observed  to  take  place 
at  a  level  of  the  body  remote  to  that  affected  by  the  cold  application ; 
thus,  during  the  application  of  a  cold  hip-bath,  Winternitz  has  found 
that  an  augmentation  in  the  volume  of  the  arm  takes  place.  These  dis- 
tant reactions  following  on  local  applications  form  an  additional  argu- 
ment in  favour  of  the  reflex  nature  of  the  general  "hydrotherapeutic 
reaction."  If  an  antiphlogistic  action  be  desired,  it  is  important  that 
the  local  application  of  cold  be  continuous :  Leiter's  tubes  are  less 
easily  displaced  than  icebags. 

Warm  Water  Treatment.  —  Whereas  the  chief  ultimate  effect  of  cold 
stimuli  to  the  skin  is  tonic,  that  of  warm  stimuli  is  sedative.  The  effect 
of  the  warm  treatment  is  not,  however,  exactly  the  opposite  of  that  of 
the  cold ;  indeed,  all  cutaneous  stimuli  whether  mechanical  (by  friction 
or  massage),  electrical  (by  faradic  shocks),  chemical  (by  counter-irri- 
tants), or  thermic  (cold  or  hot),  show  certain  points  of  analogy. 

Like  cold  applications  hot  ones  probably  produce  an  initial  vaso- 
coritraction ;  this,  however,  passes  off  quickly  and  gives  place  to  vaso- 
riilatation,  which  lasts  during  the  rest  of  the  application,  and  then  slowly 


344  SYSTEM   OF  MEDICINE 


passes  off.  This  dilatation  of  the  superficial  vessels,  with  the  subjective 
feeling  of  warmth,  is  the  characteristic  effect  of  hot  applications.  The 
superficial  vaso-dilatation  is  associated  with  increase  in  the  secretion  of 
sweat  and  in  the  frequency  of  the  respiratory  movements.  The  whole 
constitutes  the  reaction  of  the  body  to  heat,  and  thus  the  animal  mech- 
anism increases  the  loss  of  heat  to  counteract  the  heating  effects  of  the 
application.  Owing  to  superficial  vaso-dilatation  more  heat  radiates 
from  the  body ;  by  increased  sweating  the  loss  of  heat  by  evaporation 
is  augmented;  and  by  increased  respiratory  movements  more  heat  is 
given  off  in  the  air  and  watery  vapour  expired. 

In  addition  to  the  local  sedative  action  of  hot  applications  on  the 
sensory  nerves,  as  seen  in  the  application  of  poultices  and  hot  fomenta- 
tions, there  is  a  general  sedative  action  exercised  by  heat,  when  the 
application  is  general  and  sufiiciently  prolonged.  This  general  sedative 
action  is  shown  by  diminished  desire  for  exertion,  and  is  probably  ex- 
plained by  the  partial  emptying  of  the  deeper  blood-vessels  and  slowing 
of  the  blood-streams  which  accompany  the  dilatation  of  the  superficial 
vessels,  and  cause  a  certain  anaemia  of  the  viscera  and  brain. 

If  the  loss  of  heat  be  partly  prevented  by  immersing  the  whole  body 
in  a  bath  of  hot  water,  the  central  temperature,  as  measured  by  a  ther- 
mometer in  the  rectum,  rises  somewhat;  but  doubtless  in  such  cases 
diminution  of  the  heat  production  in  the  body  assists  the  loss  of  heat  by 
respiration  to  prevent  undue  rise  of  the  body's  temperature. 

Hot  applications  tend  to  constipation.  This  may,  perhaps,  be  due  to 
diminished  peristalsis,  perhaps  to  a  diminution  in  the  intestinal  secretion 
on  the  increased  excretion  of  sweat. 

The  local  applications  of  hot  water,  like  local  cold  applications  but 
to  a  lesser  degree,  iiave  been  found  to  cause  certain  distant  reactions. 
Thus  when  one  lower  limb  was  heated,  vaso-dilatation,  increase  in 
volume,  and  sweating  were  observed  in  the  other  lower  limb. 

Hot  air  and  vapour  baths  differ  from  hot  water  baths  chiefly  in  their 
action  on  the  skin ;  the  greatest  amount  of  perspiration  is  obtained  by 
hot  air  baths. 

The  Internal  Use  of  Water.  —  Plentiful  drinking  of  water  leads  to 
increase  in  the  watery  secretions ;  besides  the  urine,  the  bile,  saliva, 
pancreatic  juice  and  sweat  appear  to  be  increased ;  though  if  increased 
secretion  of  sweat  be  desired,  it  is  generally  stimulated  by  heat  or  bodily 
exercise.  This  increase  in  the  watery  constituents  of  the  secretions  is 
accompanied,  for  a  time  at  least,  by  increased  excretion  of  the  waste  pro- 
ducts of  tissue  metabolism,  which  are  "  washed  out "  from  the  tissues 
and  the  blood  itself.  The  effects  of  plain  water  taken  internally  form 
a  considerable  part  of  the  results  obtained  from  courses  of  mineral 
waters  (see  article  on  ''  Balneo-therapeutics  "),  and  the  treatment  may 
exercise  a  good  influence  in  some  cases  of  gout,  urinary  gravel,  imper- 
fect secretion  of  bile,  and  constipation  from  sluggish  peristaltic  action. 
Excessive  water-drinking,  on  Priessnitz's  original  plan,  may  however 
lead  to  dyspepsia. 


BALNEOLOGY  AND  IIYDROTHERAPEUriCS  345 


Diseases  and  Morbid  Conditions  Suitable  for  Hydrotherapeutic  Treatment 

Digestive  Derangements.  —  Habitual  constipation  from  atony  of  the 
bowels,  often  associated  with  a  tendency  to  haemorrhoids  and  "abdominal 
venosity,"  may  sometimes  be  treated  with  cold  baths  and  other  stimulat- 
ing methods,  which  increase  the  general  nutrition  of  the  tissues  and  the 
physical  and  psychical  energy  of  the  nervous  system.  In  cases  of 
chronic  dyspepsia  with  catarrh  of  the  stomach  the  common  salt  waters 
and  alkaline  sulphated  waters  (as  at  Carlsbad)  are  more  frequently  used 
and  often  preferable ;  but  hydrotherapeutic  treatment  may  be  employed 
for  the  tonic  after-treatment,  or  it  may  be  employed  with  due  care  from 
the  beginning  as  an  adjuvant  to  the  other  treatment. 

Muscular  Pains  and  "Muscular  Rheumatism." — Some  of  thsse  cases 
may  be  treated  with  cold,  some  Avith  hot  baths,  or  with  hot  air  or  vapoiir 
baths,  according  to  the  patient's  power  of  reaction ;  they  are  often  treated 
by  warm  or  hot  baths  followed  by  a  cold  shower  bath.  The  diaphoretic 
methods  by  packing  with  woollen  blankets  or  wet  sheets  are  often  found 
to  be  useful,  but  they  sometimes  fail.  In  this  class  of  cases  the  original 
supporters  of  hydrotherapeutic  treatment  considered  their  methods  in- 
fallible, but  this  is  by  no  means  the  case.  Invalids  of  this  class  should 
not  be  exposed  to  all  weathers  during  the  cure,  and  the  access  of  cold  air 
to  the  wet  body  should  not  be  risked.  The  course  of  treatment  should 
not  be  too  prolonged  at  one  time,  but  may  be  repeated  again  after  an 
interval  of  some  months:  the  interval  may  advantageously  be  spent  at 
sheltered  sea-side  localities,  at  moderate  elevations,  or  at  one  of  the 
gaseous  thermal  saline  spas. 

Sciatica  and  Neuralgias.  —  Some  patients  may  be  treated  by  hot 
baths,  but  they  are  more  often  sent  to  natural  thermal  spas,  such  as 
Schlangenbad,  Wildbad,  etc. 

Hepatic  and  Nephritic  Colics,  etc.  —  Hot  baths  may  be  of  great 
service  in  hepatic  and  nephritic  colics,  probably  by  the  relaxing  action 
on  un striped  muscle,  and  in  helping  the  action  of  opiates.  They  may 
sometimes  be  of  service  in  severe  flatulent  colic,  in  tenesmus,  in  reten- 
tion of  urine,  etc. 

Rheumatism  and  Gout. — In  chronic  rheumatic  joint  affections  the 
patient  is  often  too  enfeebled  for  cold  hydrotherapeutic  treatment,  but  a 
hot  bath  (with  the  help,  if  necessary,  of  a  chair  to  lower  the  patient  into 
the  bath),  may  be  useful  in  the  treatment  of  such  cases.  Mild  cases  of 
gout  may  derive  benefit  from  the  usual  hydrotherapeutic  treatment,  in 
so  far  as  it  aims  at  invigorating  the  nervous  system,  and  producing  more 
complete  oxidation  of  the  downward  products  of  tissue  metabolism ;  the 
treatment  should  be  associated  with  moderation  in  the  amount  of  food, 
and  especially  in  the  use  of  .stimulants.  Local  packing  may  cause  fits  of 
gout,  and  indeed  the  hot  mustard  foot-bath  has  been  used  for  this  purpose 
in  supposed  cases  of  "suppressed  gout."    The  more  severe  forms  of  gout 


346  SYSTEM   OF  MEDICINE 

are  too  much  complicated  with  general  constitutional  defects  to  encour- 
age us  in  recommending  cold  water  treatment. 

Catarrhal  Attacks. — Weakness  or  over-sensitiveness  of  the  skin,  or 
nerve  terminations  in  the  skin,  may  be  the  cause  of  frequently  recurring 
attacks  of  diarrhoea,  or  of  tendency  to  catarrh  of  the  respiratory  mucous 
membrane;  at  all  events,  when  this  over-sensitiveness  is  present,  cold 
is  more  likely  to  induce  such  attacks.  Hydrotherapeatic  methods, 
mildly  stimulating  at  first,  with  gradually  increasing  energy,  are  here 
useful;  unless,  as  in  impeded  convalescence,  the  reactive  power  is  so 
reduced  that  gaseous  thermal  salt  baths  and  mountain  air  are  prefer- 
able.    In  some  cases  sea-air  and  sea-baths  are  most  useful. 

Chron"c  Affections  of  the  Skin.  —  In  local  perspirations,  some  cases  of 
prurigo,  and  chronic  affections  of  the  skin,  hydrotherapeutic  treatment 
in  a  modified  form  may  be  useful ;  it  may  also  be  used  as  an  adjuvant  in 
the  treatment  of  syphilis.  In  some  affections  of  the  skin  alkaline  baths 
are  of  service,  and  bran-baths  are  used  to  allay  cutaneous  irritability. 
Psoriasis  has  been  successfully  treated  by  prolonged  cold  baths. 

Chronic  Metallic  Poisoning.  —  In  some  cases  of  this  sort,  if  there  is 
sufficient  reactive  power,  cold  water  treatment  may  be  of  as  much  good 
as  the  thermal  sulphur  treatment.  The  treatment  will  be  aided  by  the 
abundant  internal  use  of  water,  and  if  necessary  by  the  administration  of 
iodide  of  potassium,  which  is  commonly  supposed  to  assist  in  the  removal 
of  the  poison  from  the  tissues. 

Hysteria,  etc.  —  Cold  Avater  treatment,  pine-baths,  and  aromatic-baths 
may  sometimes  be  found  useful  in  the  treatment  of  hysteria  and 
functional  nervous  affections,  and  in  some  cases  of  "diabetes  insipidus." 
In  organic  nervous  diseases  they  are  not  to  be  recommended,  unless  it 
be  to  relieve  the  lightning  pains  of  tabes. 

Catamenial  Irregularities.  —  These  are  frequently  treated  at  hydro- 
therapeutic  establishments.  Profuse  menstruation  may  often  be  checked 
by  the  regular  use  of  the  cold  hip-bath  for  three  to  five  minutes.  In 
cases  where  the  menses  are  insufficient,  warm  hip-baths  of  ten  to  fifteen 
minutes'  duration,  combined  in  some  cases  with  wrapping  in  a  wet  sheet, 
may  often  be  found  useful ;  dysmenorrhoea  is  likewise  occasionally  treated 
with  advantage  by  the  partial  wet  sheet  or  hot  baths. 

Anaemia.  —  Scheuer  recommends  the  treatment  of  some  anaemic  con- 
ditions by  hydrotherapeutic  measures.  Under  general  cold  applications 
an  increase  in  the  haemoglobin  and  number  of  the  red  blood  corpuscles 
has  been  observed.  Of  course  special  care  must  be  observed  in  the 
treatment  by  cold  water  of  anaemic  and  feeble  persons.  According  to 
Scheuer  the  loss  of  heat  can  be  counteracted  by  rest  in  bed,  by  wrapping 
up  after  the  application  of  cold,  by  preliminary  moderate  exercise,  or  by 
previously  over-heating  the  body  in  the  hot  air  chamber,  or  by  hot  water, 
as  in  the  Scotch  douche. 

Rickets.  —  In  some  rickety,  scrofulous,  and  other  ill-nourished  chil- 
dren regular  bathing  in  rather  cold  salt  or  sea  water  may  form  a  part  of 
the  treatment,  provided  that  great  care  be  taken  to  avoid  a  chill. 


BALNEOLOGY  AND   LIYDROTHERAPEUTLCS  yi^ 

Infantile  Convulsions,  etc.  —  Hot  baths  of  short  duration,  with  or 

without  the  addition  of  mustard,  are  often  employed  for  the  immediate 
treatment  of  laryngismus  stridulus  and  general  convulsions  in  children. 
Hot  baths  also  are  sometimes  used  for  adults  in  cases  of  puerperal 
eclampsia  and  uraemic  convulsions,  but  in  these  cases  some  benefit  is 
expected  from  their  diaphoretic  action  as  well  as  from  their  sedative 
influence  on  the  cerebrum.  Cold  douches,  or  the  continuous  application 
of  cold  (by  some  form  of  "  cap  "),  to  the  head  are  often  of  the  utmost 
value  in  acute  delirium ;  as  for  example  in  the  course  of  the  infectious 
fevers.  Delirium  and  screaming  are  sometimes  arrested  almost  at  once 
by  holding  the  patient's  head  over  a  pail  at  the  bedside  and  pouring 
cold  water  over  the  head,  beginning  near  it  and  slowly  raising  the  can 
higher  and  higher. 

Nephritis  and  Uraemia.  —  The  wet  pack,  hot  water,  hot  air,  or  vapour 
baths  are  sometimes  of  service  by  producing  diaphoresis.  When  the 
patient  has  to  remain  in  bed  the  application  of  the  two  latter  baths 
requires  especial  care. 

Enteric  Fever  and  other  Acute  Infectious  Diseases.  —  Of  acute 
febrile  diseases  enteric  fever  is  the  one  in  which  cold  baths  have  been, 
most  practised.  Brand's  direction  for  the  use  of  the  cold  bath  is  in  gen- 
eral to  take  the  rectal  temperature  every  three  hours ;  if  it  be  102-2°  F. 
or  more,  the  patient  is  to  be  placed  in  a  cold  bath  of  64-4°  F.  to  68°  F., 
and  to  be  kept  there  until  a  slight  shivering  is  observed,  probably 
about  a  quarter  of  an  hour.  There  are,  however,  many  varieties  of  this 
treatment ;  English  physicians,  following  von  Zierassen,  prefer  to  place 
the  patient  in  Avater  at  about  90°  F.,  and  to  cool  the  bath  gradually  by 
the  addition  of  cold  water  until  the  fever  is  reduced  to  about  101°  F. 
Von  Ziemssen's  method  is  within  fifteen  minutes  to  cool  the  bath  down 
from  about  95°  to  68°  F. ;  the  skin  is  lightly  rubbed,  and  in  ^O-SO 
minutes,  or  when  shivering  commences,  the  patient  should  be  put  back 
to  bed.  His  temperature  usually  falls  one  or  two  more  degrees  after 
removal  to  bed,  which  should  be  warm  and  contain  a  hot  bottle  for  the 
feet.  Cold  affusions,  cold  sponging,  the  application  of  ice  to  the  body, 
or  the  suspension  of  ice  in  vessels  in  a  "cradle"  within  the  bedclothes, 
have  been  used  in  milder  cases  for  a  similar  purpose.  Persistent  fever 
in  children  may  be  conveniently  reduced  by  filling  wide-mouthed  pickle- 
bottles  with  ice,  wrapping  each  in  flannel,  and  placing  more  or  fewer 
of  them  about  the  patient  —  in  the  axillse,  against  the  flanks,  or  between 
the  legs.  Bottles  may  be  added  or  removed  from  time  to  time  as  the 
thermometer  may  indicate.  The  temperature  should  not  only  be  taken 
soon  after  the  bath,  but  also  after  an  interval  of  fifteen  mimites;  the 
temperature  then  indicates  whether  the  bath  was  sufficiently  cold ;  this 
indication  is  of  use  in  regulating  the  next  bath.  A  little  alcohol  may 
be  administered  before  or  whilst  the  patient  is  in  the  bath,  and  friction 
may  be  applied  to  prevent  the  too  sudden  contraction  of  the  cutaneous 
vessels.  The  use  of  cold  baths  in  enteric  fever  was  introduced  by 
F.   GMnard   in   1871    from   Germany  into   France,  and  was   adopted 


348  SYSTEM  OF  MEDICINE 

especially  in  Lyons.  Dr.  Osier,  in  the  report  on  typhoid  fever  (Johns 
Hopkins  Hospital  Reports,  vol.  iv.  1894),  speaks  in  favour  of  the  bath 
method  of  treatment,  which  indeed  has  been  widely  practised  in  most 
countries,  and  is  very  efficacious,  not  only  as  regards  the  pyrexia,  but  in 
low  delirium,  subsultus  tendinum,  tympanites  and  like  "  typhoid"  states. 
Similar  methods  have  been  used  for  acute  infectious  diseases  other  than 
enteric — in  the  typhoid  symptoms  sometimes  occurring  during  the  course 
of  pneumonia,  small-pox,  erysipelas,  scarlatina,  etc.  On  account  of  the 
tonic  and  diuretic  action  of  the  baths,  it  is  said  that  they  may  be  em- 
ployed also  with  advantage  in  some  cases  of  infectious  fevers,  where, 
although  the  temperature  is  not  much  more  than  100°  F.,  a  condition 
of  prostration  and  tendency  to  stupor  is  found.  Further  details  will  be 
found  in  the  elaborate  account  by  Dr.  H.  Faure-Miller  {Les  Bains  Froids 
dans  les  Formes  Typho'ides  des  .Maladies  Infectieuses,  1893). 

Hyperpyrexia.  —  In  cases  of  hyperpyrexia,  occurring  in  the  course  of 
acute  rheumatism  and  other  acute  diseases,  the  advantage  of  the  cold 
water  treatment  over  the  internal  use  of  antipyretic  drugs  is  now  gen- 
erally admitted,  and  the  methods  of  its  use  are  well  understood. 

Burns,  Phlegmons,  etc.  —  The  use  of  baths  for  these  cases  comes 
under  the  head  of  surgery. 

Contra-Indications.  —  For  the  successful  results  of  cold  water  treat- 
ment it  is  essential  that  the  organism  be  able  to  stand  a  certain  amount 
of  abstraction  of  heat;  that  it  be  capable  of  more  or  less  energetic 
reaction,  and  that  the  digestive  and  assimilative  organs  be  able  to  take 
up  a  fair  amount  of  nourishing  material  to  compensate  increased  catabo- 
lism.  In  cases  of  great  debility  after  illness  special  care  must  be  observed, 
and  cold  water  treatment  is  still  more  hazardous  Avhen,  to  the  debility 
of  illness,  the  weakness  of  childhood  or  old  age  is  added.  When  cold 
water  treatment  causes  diarrhoea,  urticaria,  or  hsemoglobinuria,  it  must 
be  discontinued;  and  in  chronic  nephritis  and  any  great  degree  of 
arterio-sclerosis  it  is  contra-indicated ;  so  also  is  it  certainly  in  cases  of 
aneurysm,  in  those  who  have  had  one  attack  of  cerebral  haemorrhage,  or 
appear  threatened  with  cerebral  haemorrhage,  and  in  all  cases  of  heart 
disease,  except  in  slight  and  well-compensated  mitral  valvular  affections. 
The  abundant  use  of  liquids  internally  is  injurious  to  patients  with  old 
valvular  heart  disease  and  a  tendency  to  loss  of  compensation ;  it  is  to 
be  avoided  likewise  by  many  obese  persons  with  weakly  acting  hearts. 

Hermann  Weber. 
F.  Parkes  Weber. 

REFERENCES 

1.  Beni-Barde.  Manuel  mMical  d'Hj/droth^rapie,  2me  edition.  Paris,  1883.  — 2. 
BoTTEY,  F.  Traite  d'Hydrothirapie.  Paris,  1895.— 3.  Brand,  Ernst.  Die  Wasser- 
b-handbing  der  typhos'en  Fieber,  2nd  edition.  Tiibingen,  1877.— 4.  Delmas,  P. 
Phyxiologie  nouveile  de  I'hydrotMrapie,  d'apres  des  recherches  ricentes  sw  Vaction 
du  froid  et  de  la  chaleur  sur  Vorgavume.  Paris,  1880.  —  5.  Fauee-Miller,  H. 
Lzs  Bains  Froids  dans  les  formes  typhoides  des  Maladies  Infectieuses.     Paris,  1893.  — 


THE  MEDICAL   APPLICATIONS    OF  ELECTRICITY  349 

6.  Fleury,  L.  Trait6  th^rapeittique  et  clinique  d'hydrotherapie.  Paris,  1875.  —  7. 
Hayem,  G.    Le<;ons  de  Therapeutique.    Les  Agents  Physiques  et  Naturels.    Paris,  1894. 

—  8.  HoppE,  F.  "  Ueber  d.  Einliuss  des  Warmeverlustes  auf  die  Eij^entemperat.  warm- 
bliit.  Thiere,"  Virch.  Arch.  1857,  xi.  —  9.  Juegensex,  TheodoPv.  "  Zur  Lelire  von 
der  Behandlung  fieberhafter  Kranklieiten  mittelst  des  kalten  Wassers,"  iJeut.  Arch.f. 
klin.  Med.  1868,  vol.  iv.  pp.  110  et  seq.  — 10.  Labadie-Lagkave.  Du  Froid  en  Thera- 
peutique. Paris,  1878. —  11.  Lehmann,  L.  "Ueber  die  Wirkung  kalter  Sitzbiider," 
Archivfdr  ivlssensch.  Heilkunde,  1854.  — 12.  Lepine,  R.  and  Flavard.  "  Note  relative 
a  Paction  du  bain  a  temperature  excessivement  basse,  sur  la  comijosition  de  Purine," 
Societe  de  Biologie,  Comptes  Rendus,  1880,  p.  80.  — 13.  Liebermeister.  "  Phys.  Unters. 
iiber  die  quautit.  Veriiuderung  d.  Wiirmeproduct,"  Reichert  und  Du  Bois  Raymond's 
Arch.  1860,  1861.  — 14.  Liebermeister  and  Hagenbach.  Beohachtungen  und'Vesuche 
iiber  Anioendung  des  kalten  Wassers  bei  fieberhaften  Krankheiten,  1868.  — 15.  Lieber- 
meister and  Gildemeister.  Ueber  die  Kohlensdurerepi-oduction  bei  Anwendung  v. 
kalten  Biid.  Bale,  1870.  —  16.  Liebig,  G.  von.  "  Ueber  d.  Vera-uder.  d.  Puis,  im  lauen 
Bade,"  Centralblatt  f'dr  d.  med.  Wissensch.  1878,  49.  —  17.  Mosler.  "  Untersuch.  iiber 
d.  Einfl.  V.  Trinkwasser  aul  d.  Stoffwechsel,"  Arch.  f.  wiss.  Heilkunde,  1857,  iii.  3. — 
18.  Paalzow.  "  Ueber  d.  Einti.  d.  Hautreiz.,  auf  d.  Stoffwechsel,"  Pfliiger's  Arch.  vol. 
iv.  1871.  — 19.  Petri.     "  Hydro therapie."     Yalentiner's  Handb.  d.  Balneotherapie,  1873. 

—  20.  RiCHTER.  Das  Wasserbuch,  etc.  BevWn,  l^^ii. — 21.  Riegel,  Franz.  "  Ueber  d. 
Beziehung  d.  Gefassnerv.  z.  Korpertemp,"  Pjli'ujer's  Arch.  v.  1872.  —22.  Riegel,  Franz. 
"Ueber  Hydrotherapie  und  locale  Warmeentziehungen,"  Deut.  Arch.f.  klin.  Med.  1872, 
X.  6.  —  23.  Roehrig.  Die  Physiologic  der  Uaut  expei-imentell  und  kritisch  bearbeitet. 
Berlin,  1876.  —  24.  Rosenthal.  "Die  Physiologic  der  thierischen  Warme,"  in  Her- 
mann's Handb.  der  Phi/siologie.  Leipzig,  1882.  — 25.  Runge,  F.  "  Ueber  die  Bedeutung 
der  Wasserkuren  in  chrouischen  Krankheiten,"  Dent.  Arch,  fdr  klin.  Med.,  vol.  xii. 
1873-1874,  pp.  207-232.  —  26.  Scheuer,  V.  Essai  sur  Vaction  physiologique  et  thera- 
peutique de  I' Hydrotherapie.  Paris,  1888.-27.  Senator.  "  Unters.  iiber  d.  Warmebild. 
und  d.  Stoffwechsel,"  Reichert  und  Du  Bois  Reymond's  Arch.  1871. — 28.  Stolnikow. 
"  Ueber  d.  Verand.  d.  Hautsensibilitat  durch  kalte  und  warme  Bader,"  Petersburg  med. 
Wochenschr.  1878,  25,  26.  —  29.  Thermes.  De  I'influence  immediate  et  mediate  de 
V hydrotherapie  sur  le  nombre  des  globules  rouge  du  sang.  Paris,  1878.  —  30.  Virchow. 
"  Ueber  d.  Baden,"  Virchoiv's  Arch.  1859,  xv.  Heft  1  and  2.  —  31.  Virchow.  "  Wirkung, 
d.  kalten  Bades.  und  Warmeregulirung,"  Virchow's  Arch.  1872,  ii.  133. — 32.  Weber, 
Hermann.  Article  on  Hydrotherapeutics  in  Quain's  Dictionary  of  Medicine,  2nd  ed. 
London,  1894.  —  33.  Winternitz,  W.  "Hydrotherapie,"  in  H.  v.  Ziemssen's  Hand- 
buch  der  allgetneinen  Therapie.  Leipzig,  1881.  This  contains  a  long  bibliography  up 
to  1880,  including  Winternitz's  earlier  works  on  the  subject.  English  translation  by 
F.  W.  Eisner,  London,  1886. —  34.  Wundt.  "Ueber  d.  Einfl.  hydrotherap.  Einwickl. 
auf  d.  Stoffwechsel,"  Arch,  des  Vereins  fiir  gemeins.  Arbeit,  iii.  1856.  —  35.  Ziemssen,  H. 
"  Die  zweckmassigste  Methode  der  Kaltwasser  behandlung  des  Typhus  "  in  Cent,  fur  die 
med.  Wissenschaften,  1866,  p.  642.  —  36.  Ziemssen  and  Immermann.  Die  Kaltivasser 
behandlung  des  Typhus  abdominalis.    Leipzig,  1870. 

H.  W. 

F.  P.  W. 


THE  MEDICAL   APPLICATIONS   OF  ELECTRICITY 

Although  a  large  number  of  books  have  been  written  upon  medical 
electricity  its  use  makes  slow  progress  among  medical  men.  The  appai-- 
ent  reasons  for  this  are  that  the  apparatus  is  expensive,  its  management 
troublesome,  and  the  time  required  to  carry  out  the  treatment  more 
than  a  busy  practitioner  can  spare;  these  objections  would  probably 
vanish  quickly  if  the  fact  could  once  be  grasped  that  electrical  treat- 
ment is  of  real  value  in  a  considerable  variety  of  cases.     The  true 


3SO  SYSTEM  OF  MEDICINE 

reason  for  the  slow  advance  of  medical  electricity  is  that  the  medical 
profession  have  not  yet  become  fully  aware  of  its  advantages. 

There  is  no  manner  of  doubt  that  electrical  currents  produce  definite 
physiological  effects  5  from  a  consideration  of  these  it  is  possible  to  arrive 
at  an  estimate  of  the  value  of  electricity  in  the  treatment  of  disease, 
and  medical  electricity  may  be  defined  as  the  application  of  our  knoAvl- 
edge  of  these  physiological  actions  to  the  study  and  treatment  of  disease. 

The  most  obvious  ph3^siological  action  of  electricity  is  its  power  of 
stimulating  living  tissues.  This  is  apparent  enough  when  the  current  is 
applied  to  nerves  or  muscles,  for  it  can  be  felt  and  seen  :  but  the  stimulat- 
ing effect  is  not  confined  to  nerves  and  muscles ;  it  can  also  be  observed 
in  unicellular  organisms,  and  its  results  noted  in  several  ways  in  man 
and  animals.  The  metabolic  activity  of  the  tissues  can  be  considerably 
increased  by  electricity,  as  Gautier  and  Larat  have  shown  in  their 
experiments  upon  the  elimination  of  carbonic  acid  gas  and  urea  under 
electrical  treatment,  when  it  was  found  that  an  increase  of  40  or  50  per 
cent  could  be  produced  by  general  electrification.  This  trophic  action 
of  electricity  has  valuable  applications  in  medical  treatment.  It  is 
surprising  to  see  the  great  improvement  in  general  health  shown  by 
children  during  a  course  of  electrical  treatment  for  infantile  paralysis ; 
and  in  rickety  children  the  most  encouraging  results  have  been  obtained. 
The  same  beneficial  trophic  effects  are  commonly  seen  in  adults ;  and 
the  most  suitable  methods  of  treatment  will  be  considered  below  under 
the  head  of  general  electrification.  In  addition  to  the  other  methods 
of  improving  nutrition  —  such  as  change  of  air,  exercise  and  gym- 
nastics, massage,  or  the  administration  of  cod  liver  oil  and  certain 
other  drugs  —  we  have  in  electricity  a  most  direct  and  useful  means  to 
the  same  end,  and  one  which  sometimes  offers  advantages  over  all  the 
others. 

When  the  question  is  one  of  localisation  of  the  stimula,ting  effect, 
then  the  advantages  of  electricity  are  conspicuous,  as  is  clearly  shown 
by  the  almost  exclusive  use  of  electrical  methods  by  physiologists  when 
local  stimulation  is  required  for  purposes  of  experiment.  The  power 
of  exercising  and  of  stimulating  to  contraction  any  paralysed  muscle  or 
group  of  muscles  is  a  most  valuable  one. 

The  electrotonic  effects  of  currents  can  also  be  a,pplied  to  purposes 
of  treatment.  By  electrotonus  is  meant  the  changed  condition  of  a 
nerve  during  the  passage  of  a  steady  current  through  it ;  that  is,  an 
increase  of  irritability  in  the  region  of  the  negative  pole,  and  a  decrease 
round  the  positive  pole.  Physiological  principles  suggest  the  use  of  the 
anode  (or  positive  pole)  for  conditions  of  exalted  irritability,  such  as 
neuralgia  or  spasm ;  and  the  use  of  the  kathode  for  paralytic  or  paretic 
states :  thus  we  are  often  enabled  to  obtain  favourable  results.  In 
patients  with  injuries  to  nerves  and  impaired  cutaneous  sensibility  the 
electrotonic  effects  of  the  current  are  often  plain  enough ;  the  application 
of  the  anode  to  the  affected  region  with  a  moderate  current  may  be  able 
to  abolish  all  sensibility  for  the  time,  while  the  use  of  the  kathode  will 


THE  MEDICAL   APPLICATIONS   OF  ELECTRICITY  351 

restore  it  in  an  increased  degree.  So  too  it  is  common  for  a  trigeminal 
neuralgia  to  fade  away  completely  during  the  application  of  the  anode 
over  the  affected  region,  and  it  often  happens  that  a  neuralgic  pain  thus 
dissipated  does  not  return. 

Another  effect  of  the  current  is  electrolysis,  which  is  made  use  of  in 
surgery  when  destructive  effects  are  desired ;  as,  for  example,  in  the 
treatment  of  nsevus.  In  medical  treatment  these  destructive  electro- 
lytic effects  at  the  surface  of  the  electrodes  have  to  be  remembered 
in  order  to  be  avoided ;  but  the  electrolytic  process  implies  not 
merely  the  dissociation  of  chemical  compounds  at  the  poles,  but  also 
a  rearrangement  of  the  molecules  composing  the  electrolyte  which  lies 
between  the  poles  —  i.e.  in  the  case  of  the  body,  the  juices  and  tissues : 
and  it  is  not  impossible  that  some  of  the  results  of  electrical  treatment 
may  be  due  to  interpolar  electrolytic  actions  in  the  tissues  traversed 
by  the  current.  It  is  difficult  at  present  to  estimate  the  exact  impor- 
tance of  these  molecular  changes,  but  they  may  be  considered  for  the 
present  as  ''  alterative  "  effects. 

Sometimes  it  is  possible  to  make  use  of  a  peculiar  property  of  elec- 
tric currents  as  a  means  of  introducing  drugs  into  the  system  through 
the  skin ;  the  process  of  electric  osmosis  or  cataphoresis  causes  the  pas- 
sage of  solutions  from  the  positive  to  the  negative  pole,  and  many 
applications  of  it  have  been  suggested,  such  as  the  direct  introduction 
of  iodide  of  potassium  into  a  syphilitic  node  or  gumma,  or  the  elimina- 
tion of  metallic  poisons  from  the  system.  Its  chief  value,  however, 
may  consist  in  the  production  of  local  anaesthesia  of  the  unbroken  skin 
by  cocaine  :  this  can  readily  be  done  by  placing  on  the  skin  a  few  thick- 
nesses of  blotting  paper  wet  with  10  per  cent  cocaine  solution  and 
applying  the  positive  pole  over  it,  the  circuit  being  completed  through 
the  body  to  the  negative  pole  placed  on  some  remote  part.  With  a 
moderately  strong  current  of  five  to  ten  milliamperes  the  skin  can  be 
rendered  anaesthetic  in  five  minutes. 

The  phenomena  of  electrotonus,  of  electrolysis,  and  of  electric- 
osmosis  are  peculiar  to  the  direct  current ;  the  stimulating  and  trophic 
effects  belong  both  to  direct  and  to  alternating  currents,  though  they 
are  more  apparent  with  the  latter. 

In  medicine  both  the  direct  and  the  alternating  current  are  in  daily 
use ;  the  consideration  of  what  has  just  been  written  will  serve  as  a 
guide  in  the  choice  of  one  or  the  other  for  the  treatment  of  particular 
cases.  Fashion  has  had  no  little  influence  in  deciding  the  preference  of 
one  or  other  of  these  electrical  methods. 

The  apparatus  required  for  electrical  treatment  and  diagnosis  is  in 
reality  a  simple  matter,  although  the  elaborate  catalogues  of  the  instru- 
ment makers  are  apt  to  give  the  idea  that  it  is  rather  complicated. 
The  words  Franklinism,  Galvanism,  and  Faradism  will  not  be  used  in 
this  article;  but  in  their  place  I  shall  speak  of  electrostatic  methods, 
of  treatment  by  the  battery  current,  and  of  treatment  by  the  induction 


352  SYSTEM   OF  MEDICINE 


coil  current.  Electro-static  treatment  consists  in  the  use  of  charges  from 
an  electrical  machine  of  higli  potential,  with  sparks,  the  brusli  discharge, 
or  the  discharges  of  Leydeu  jars.  These  electro-static  methods  were 
applied  to  medicine  almost  on  their  discovery ;  and  tlie  early  writers 
on  medical  electricity  enumerated  long  lists  of  cures  effected  by  their 
means ;  these  old  records,  however,  hardly  repay  a  study,  partly  because 
many  of  the  patients  seem  to  have  been  hysterical,  while  the  others  are 
so  described  as  to  make  it  difficult  to  diagnose  the  respective  diseases. 
After  the  discovery  of  the  voltaic  pile  the  use  of  the  electrical  machine 
gradually  fell  into  disuse;  but  it  is  now  being  revived  with  modern 
apparatus  and  a  better  knowledge  of  the  subject.  In  France  especially 
these  methods  have  been  much  in  vogue  during  the  last  few  years,  and 
a  certain  amount  of  scientific  work  has  been  devoted  to  them,  so  that 
we  are  beginning  to  gather  some  little  trustworthy  knowledge  of  the 
physiological  effects  of  high  potential  electrification.  There  seems  to 
be  no  doubt  that  in  this  way  certain  general  nutritive  changes  can  be 
brought  about ;  the  effect  on  healthy  persons  probably  being  to  increase 
the  metabolic  activity  of  the  tissues,  and  in  some  cases  to  such  an  extent 
as  to  do  harm.  Thus,  in  some  careful  experiments  iipon  himself,  Truchot 
found  that  as  a  result  of  a  course  of  electro-static  treatment  a  feverish 
state  of  body  was  produced,  with  accelerated  pulse,  raised  temperature, 
and  increased  elimination  of  nitrogen.  In  certain  morbid  states  this 
increase  of  activity  seems  to  be  useful,  notably  in  people  of  a  torpid 
condition  of  bod}',  in  the  anaemic,  the  debilitated  and  the  convalescent. 
These  effects  have  been  noticed  from  the  simple  electro-static  charge. 
When  sparks  are  combined  with  this  certain  local  effects  may  be  super- 
added, and  with  Ley  den  jars  forcible  muscular  contractions  also  occur. 
The  whole  of  this  branch  of  medical  electricity  requires  fresh  investiga- 
tion on  physiological  lines,  and  much  which  was  written  by  the  older 
writers  requires  to  be  forgotten.  The  clinical  gains  have  been  in  the 
treatment  of  some  skin  diseases,  especially  eczema  and  eczematous  ulcers ; 
the  removal  of  certain  states  of  abnormal  obesity ;  the  relief  of  neuralgia, 
and  so  on.  Moreover,  electro-static  methods  have  above  all  the  power  of 
combating  many  hysterical  manifestations,  such  as  pains,  anaesthesias, 
contractures  and  paralyses :  these  last,  however,  depend  rather  upon 
the  psychological  than  on  the  physiological  effects  of  electricity.  In 
this  country,  unfortunately,  electro-static  methods  of  treatment  have 
not  yet  received  proper  study,  and  are  generally  regarded  as  having  no 
effects  except  through  the  mental  impressions  produced  by  the  treat- 
ment ;  but  there  is  probably  more  of  value  in  them  than  is  yet  believed. 

The  best  type  of  electro-static  machine  is  the  Wimshurst  machine ; 
and  it  is  advantageous  to  use  one  with  eight  or  twelve  plates,  each 
having  a  diameter  of  twenty  inches,  and  to  enclose  the  whole  machine 
in  a  roomy  glass  case  to  protect  it  from  the  dust  which  is  abundantly 
attracted  by  the  machine  when  in  action.  Details  of  management  must 
be  looked  for  in  the  special  handbooks. 

For  carrying  out  the  methods  in  ordinary  use  with  battery  and 


THE  MEDICAL  APPLICATIONS   OF  ELECTRICITY  353 

induction  coil,  it  is  perhaps  best  at  the  beginning  to  procure  a  portable 
combined  battery  from  a  good  maker.  This  can  be  used  either  in  the 
consulting  room  or  in  the  patient's  home,  and  is  therefore  superior  to 
a  fixed  installation.  It  is  unwise  to  multiply  batteries ;  they  gradually 
deteriorate  with  keeping,  whether  used  or  not,  and  it  is  easier  to  bear  the 
expense  of  maintenance  of  one  battery  than  of  two  or  more.  The  com- 
bined battery  should  consist  of  twenty-five  or  thirty  small  size  Leclanche 
or  "dry"  cells,  with  a  current  collector  or  switch  for  progressively  tak- 
ing cells  up  into  circuit  one  by  one;  a  galvanometer  graduated  in  milli- 
amperes ;  a  commutator  for  reversing  the  direction  of  the  current  in  the 
external  circuit ;  a  pair  of  binding  screws  for  the  attachment  of  the  con- 
ducting wires  ;  an  induction  coil  with  one  or  two  separate  and  larger  sized 
cells  to  drive  it,  and  a  key  for  switching  on  either  the  induction  coil  cur- 
rent or  the  battery  current  to  the  terminal  binding  screws  at  will.  Some 
mode  of  regulating  the  strength  of  the  induction  coil  is  necessary. 

Such  an  apparatus  can  be  had  at  prices  varying  from  eight  to  fifteen 
pounds,  and  is  the  most  convenient  arrangement  for  all  medical  purposes 
of  testing  and  treatment,  though  it  is  not  suitable  for  the  large  currents 
needed  for  galvano-cautery  or  for  instruments  with  electric  lamps.  A 
pair  of  flexible  conductors  of  insulated  wire  and  a  few  electrodes  make 
up  the  outfit.  It  is  best  to  procure  any  special  electrodes  as  occasion 
arises :  those  wanted  for  general  purposes  are  of  two  kinds,  —  one  a  flat 
pad  of  metal,  oval,  four  inches  long,  covered  with  wash-leather  or  ama- 
dou, and  fitted  with  a  binding  screw ;  and  the  other,  a  handle  to  which 
metal  discs  ranging  from  half  an  inch  to  two  inches  in  diameter  can  be 
attached.  The  former  is  called  the  indifferent  electrode ;  during  treat- 
ment it  is  applied  to  some  indifferent  part  of  the  patient's  body,  where 
the  pressure  of  the  clothes  usually  suffices  to  keep  it  in  place  —  on  the 
back  of  the  neck,  for  example,  on  the  sternum,  or  the  sacrum.  The  other 
or  active  electrode  is  manipulated  over  the  region  affected.  For  testing 
the  nerves  and  muscles  it  is  convenient  to  have  a  special  electrode  fitted 
with  a  key  for  closing  the  circuit  at  will. 

A  sheath  for  the  indifferent  electrode  with  one  side  Avaterproof  is  con- 
venient, as  it  protects  the  patient's  clothing  from  being  Avetted.  It  is 
important  to  have  clean  coverings  for  the  electrodes ;  and  so  far  as  pos- 
sible to  provide  each  patient  with  a  separate  electrode  and  sheath ;  a 
handy  form  of  electrode  is  made  in  which  the  wash-leather  covering  can 
be  changed  in  a  few  moments.  Salt  water  is  not  necessary  for  the 
moistening  of  the  electrodes,  and,  as  it  corrodes  them  more  rapidly  than 
plain  warm  water,  the  latter  is  to  be  preferred.  The  silk  covered  con- 
ducting cords  should  be  light  and  flexible,  four  or  five  feet  long,  and  of 
two  colours,  to  distinguish  their  attachments  the  more  easily. 

Units  of  Measurement.  —  It  is  impossible  to  have  clear  ideas  upon 
medical  electricity  unless  the  meaning  of  the  words  Volt,  Ohm  and 
Ampere  are  understood.  These  terms  stand  for  the  units  in  which  elec- 
trical quantities  are  expressed,  and  are  as  necessary  to  the  subject  as 
are  the  better  known  imits  of  measurement,  such  as  the  inch,  the  pound 

VOL.  I  2  a 


354  SYSTEM  OF  MEDICINE 

and  tlie  pint,  to  matters  of  everyday  life.     The  volt  is  the  practical  unit 

of  electro-motive  force,  or  electrical  pressure;  and  the  electro-motive 

force  of  a  battery  expresses  the  tendency  of  such  a  battery  to  produce 

an  electric  discharge,  just  as  the  pressure  in  a  steam-boiler  signifies  the 

tendency  of  the  boiler  to  emit  steam ;  in  the  former  case  the  closure  of 

a  conducting  circuit,  and  in  the  latter  the  opening  of  a  valve  is  necessary 

to  cause  the  discharge. 

The  olim  is  the  practical  unit  of  resistance,  and  is  necessary  because 

electrical  conductors  differ  from  one  another  in  their  specific  conductivity ; 

those  which  conduct  well  are  said  to  have  a  low  specific  resistance,  and 

those  which  conduct  badly  are  said  to  have  a  high  resistance.    Metals  are 

good  conductors ;  and  of  metals  silver  and  copper  have  the  least  resistance. 

The  resistance  of  a  wire  or  rod  or  other  mass  of  any  substance  depends 

upon  the  specific  resistance  of  the  substance,  and  varies  directly  as  its 

length,  and  inversely  as  its  sectional  area  or  thickness :  thus  a  long  or 

a  thin  wire  of  copper  will  have  a  greater  resistance  than  a  short  or  thick 

one.     The  ampere  is  the  unit  of  current,  and  the  three  units  are  so  related 

to  one  another  that  an  electro-motive  force  of  one  volt  acting  upon  a 

conductor  with  a  resistance  of  one  ohm  will  set  up  in  that  conductor  a 

current  of  one  ampere.     This  relation,  known  as  Ohm's  law,  can  be 

E 
expressed,  in  symbols,  by  C  =  — ,  where  C  stands  for  current,  E  for  electro- 

motive  force,  and  E.  for  resistance :  if  two  of  the  three  quantities  are 
known  the  third  can  be  calculated  from  them ;  thus  when  an  electro-motive 

Tf  -1 2 

force  of  12  volts  act  upon  a  resistance  of  8  ohms,  C  =  — ,  or  C  =  — ,  or 

rv  o 

C  =  1"5  amperes,  which  is  the  resulting  current. 

As  a  current  of  one  ampere  is  never  applied  to  patients  in  medical 
treatment,  the  thousandth  of  an  ampere  (-001  ampere)  or  milliampere 
forms  a  more  convenient  unit,  and  medical  currents  are  usually  expressed 
in  milliamperes ;  thus  five  milliamperes  is  a  common  magnitude  of  cur- 
rent, and  it  is  more  easily  expressed  in  that  way  than  by  the  fraction 
•005  ampere. 

The  resistance  of  the  body  is  high,  very  much  higher  than  that  of  a 
metal;  and  it  varies  considerably  with  the  moisture  or  dryness  of  the 
skin :  under  conditions  of  medical  treatment  with  Avetted  electrodes,  it 
may  be  taken  as  ranging  between  1000  and  5000  ohms.  It  is  worth  while 
to  calculate  the  electro-motive  force  necessary  to  send  a  current  of  five 
milliamperes  through  such  a  resistance.    First,  in  the  case  of  1000  ohms — 

C  =  ^     .-.      RC  =  E 
R 

R  =  1000  C  =  005.         E  =  1000  X  -005  =  5  volts. 
Secondly,  in  the  case  of  5000  ohms  — 

E  =  RC  =  5000  X  -005  =  25  volts. 


THE  MEDICAL  APPLICATIONS   OF  ELECTRICII  Y  355 

A  medical  battery  must  therefore  have  an  electro-motive  force  of 
twenty-five  volts  if  it  is  to  drive  a  current  of  five  milliamperes  through 
a  body  whose  resistance  is  5000  ohms. 

The  Leclanche  cells  usually  supplied  in  portable  batteries  have  an 
electro-motive  force  of  1-5  volts  per  cell;  thirty  cells  (a  usual  number) 
properly  connected  together  have  a  combined  electro-motive  force  of 
forty-five  volts :  this  gives  an  ample  margin,  and  would  send  a  current 
of  fifteen  milliamperes  through  a  resistance  of  3000  ohms.  As  this  cur- 
rent is  very  rarely  exceeded,  and  as,  by  thoroughly  moistening  the  skin, 
the  body  resistance  can  usually  be  brought  well  within  3000  ohms,  this 
number  of  cells  is  sufficient.  Beyond  this  the  weight  and  cost  of  the 
battery  increases  out  of  proportion  to  its  efficiency.  The  current  from 
the  cells  of  the  battery  flows  through  the  circuit  in  one  direction  from 
the  positive  to  the  negative  terminal,  and,  so  long  as  the  circuit  is  closed, 
with  almost  unvarying  strength ;  when  it  is  broken,  by  removing  the  elec- 
trodes from  the  patient  or  by  opening  a  key  in  the  circuit,  the  current 
ceases  abruptly.  If  the  electrode  be  caused  to  slide  over  the  surface 
of  the  body  there  will  be  variations  in  the  lines  of  flow  in  the  neigh- 
bourhood of  the  moving  electrode ;  and  the  point  of  entry  of  the  cur- 
rent, or  point  of  greatest  density  of  flow,  will  vary  in  position,  even 
though  the  total  current  flowing  in  the  circuit,  as  indicated  by  the 
galvanometer,  be  steady  and  uniform. 

The  current  from  the  induction  coil  is  of  a  different  kind,  inasmuch 
as  its  strength  is  continually  varying  with  the  electro-motive  force  of  the 
coil  which  rises  and  falls  in  the  form  of  a  wave  with  each  vibration  of 
the  moving  contact  breaker ;  each  rise  and  fall  of  electro-motive  force 
means  a  rise  and  fall  of  the  current  through  the  circuit.  If  the  primary 
coil  of  the  induction  apparatus  be  used  the  consecutive  waves  of  current 
are  all  in  one  direction ;  if  the  secondary  coil  be  used  they  change  or 
alternate  in  direction.  In  medical  coils  the  current  of  the  primary  cir- 
cuit is  not  always  adapted  for  use,  and  it  has  no  therapeutic  advantages 
over  that  of  the  secondary  coil ;  the  secondary  current  is  a  current  alter- 
nating in  direction  about  fifty  times  per  second  and  wave-like  in  char- 
acter ;  that  is  to  say,  it  rises  from  zero  to  a  positive  maximum,  then 
falls  away  again  to  zero,  rises  to  a  negative  maximum,  and  again  returns 
to  zero ;  each  electrode  is  thus  alternately  positive  and  negative.  There 
are  several  ways  of  regulating  the  strength  of  the  secondary  coil :  one 
of  the  best  is  by  winding  it  on  a  separate  bobbin  which  can  be  made  to 
slide  between  guides  so  as  to  vary  its  position  in  the  magnetic  field  of 
the  primary  coil ;  as  the  secondary  is  withdrawn  from  the  primary  the 
current  becomes  weaker,  and  vice  versa. 

The  measurement  of  the  alternating  currents  of  the  induction  coil 
(which  do  not  affect  an  ordinary  galvanometer  needle)  has  been  for  a  long 
time  a  serious  difficulty,  and,  in  electrical  testing,  comparisons  have  been 
usually  made  by  the  aid  of  an  arbitrary  scale  marked  along  the  slide  of 
the  roil ;  this  does  indeed  enable  the  relative  positions  of  primary  and 
secondary  coils  to  be  reproduced  at  will,  but  is  of  very  little  use  in  com- 


356  SYSTEM  OF  MEDICINE 


paring  the  results  obtained  with  two  coils  which  may  differ.  Now  at 
length  an  instrument  is  made  which  gives  readings  of  the  induction  coil 
currents  in  milliamperes,  and  as  soon  as  its  use  becomes  general  our 
knowledge  of  the  actions  of  the  induction  coil  current  will  be  placed  upon 
a  surer  basis.  Different  instruments  differ  much  in  the  painfulne&s  of  the 
sensation  to  which  they  give  rise.  In  few  of  them  are  the  successive  dis- 
charges sufficiently  equal  to  produce  a  smooth  sensation.  In  the  choice 
of  a  coil  this  point  should  be  attended  to,  and  pains  should  be  taken  to 
obtain  one  which  has  a  contact  breaker  working  smoothly  and  evenly. 

The  least  painful  rate  of  vibration  is  from  sixty  to  a  hundred  impulses 
per  second. 

The  properties  of  the  discharges  of  the  induction  coil  are  modified  by 
the  number  of  turns  of  wire  in  the  secondary  windings.  A  coil  of  few 
turns  (two  or  three  hundred)  has  a  lower  electro-motive  force  and  a  lower 
resistance  than  a  coil  of  many  turns  (two  or  three  thousand)  ;  and  besides 
its  resistance  there  is  another  factor  which  increases  with  the  number  of 
turns,  and  is  known  as  its  self-induction  :  this  retards  the  rate  of  rise  and 
fall  of  current  in  the  coil,  and  diminishes  the  magnitude  of  the  current 
which  can  be  taken  from  it.  Thus  a  coil  of  many  windings  has  a  high 
electro-motive  force  so  long  as  very  small  currents  are  taken  from  it,  but 
this  falls  rapidly  when  the  resistance  of  the  external  circuit  is  low ;  a 
short  coil  has  a  lower  electro-motive  force,  but  is  capable  of  giving  a  pro- 
portionately larger  current  without  fall  in  its  electro-motive  force.  For 
treatment  with  moistened  skin  and  wet  electrodes  a  long  coil  is  not 
needed,  but  for  the  stimulation  of  the  superficial  cutaneous  nerve  end- 
ings with  a  dry  skin  and  a  wire  brush  —  a  method  sometimes  adopted 
—  a  long  coil  is  needed,  as  the  dry  skin  has  a  very  high  resistance,  and 
requires  a  high  electro-motive  force  to  drive  through  it  even  the  small 
current  required  in  this  mode  of  treatment.  Some  medical  coils  are 
therefore  provided  with  two  interchangeable  secondary  coils ;  but  the 
same  advantage  can  be  had  from  one  coil,  if  its  windings  can  be  tapped 
so  as  to  use  either  a  part  or  the  whole  of  it  at  will. 

Too  much  has  been  made  of  the  various  qualities  supposed  to  be 
obtained  by  varying  the  thickness  of  the  wire  and  the  numbers  of  turns 
in  the  winding ;  the  rise  and  fall  of  the  wave  of  current  is  rather  more 
gradual  from  a  long  than  from  a  short  coil;  this  difference  and  the  point; 
mentioned  above  —  that  a  long,  fine  wire  is  the  best  for  stimulating  the 
dry  skin  —  give  the  pith  of  the  matter.  Recently  very  rapidly  vibrating 
contact  breakers  have  been  advocated,  because  of  a  peculiar  benumbing 
effect  upon  the  cutaneous  nerves  which  is  produced  by  them.  These, 
however,  are  not  often  useful. 

Nerve  and  Muscle  Reactions.  — There  is  a  marked  difference  in  the  way 
in  which  nerve  and  muscle  respond  to  the  battery  current  and  the  coil 
curreiit  respectively ;  and  this  has  been  made  the  basis  of  the  elec- 
trical testing  of  nerve  and  muscle.  In  health  the  battery  current  pro- 
duces a  single  twitch  of  a  muscle  when  the  circuit  is  closed,  and  another 
when  the  circuit  is  opened.     In  the  interval  between  closure  and  opening 


THE  MEDICAL   APPLICATIONS   OF  ELECTRICITY 


357 


the  muscle  is  quiescent,  although  the  muscle  or  its  motor  nerve  is  being 
traversed  by  the  current;  the  minimal  current  necessary  to  produce  the 
contraction  when  the  negative  electrode  is  most  favourably  placed  over  a 
superficial  nerve  trunk  is  about  one  milliampere.     With  the  positive  pole 


K.  frontalis, 

Vppsr  Tiramh  of  facial, 

M.  oomg.  enpcicil. 

M.  orbio.  palpebr. 
JTasal  muscles  | 

M.  zygomatic! 

M.  orbicnl.  oris  | 

ISUMe  iraneh  of  facial 

H,  masseter. 

IL  levator  menti 

M.  qtiadr,  mcnti 

2i.  triang.  menti 

Hypoglossal  n. 

Xaicer  brarujt  of  facial 

M.  platysma  myoid. 

Hyoid  mnsdes  \ 

HL  omobyoidcns 


Ant,  Ihoracti  n. 
CU.fectoxBl-^ 


Eeglon  of  Srd  frontal 
conv.  and  island 
of  Reii  (ceatze  tat 
speecli) 

M.  temporalis 


Facial  n,  (tmni) 
Post.  auricidoTJU 
Middle  branch  offaeiaZ 
Lotcer  branch  of  facial 
M.  splenioa 
M  BtemocleidO" 

mastoideus 
Spinal  accessory  n, 
IL  levator  anguli  acapul 
K.  cncullariA 
BorsaJii  scapukB 


Axillary  n. 


,J*hrenicru   Bupmclavicular  point.      Brachial  plexus 
(Erb's  point.  M.  deltoid., 
biceps,  bracliialis  intern, 
and  sapin.  long.) 

Fig.  26.  —The  Motor  points.     The  Head  and  Neck. 


a  current  of  about  twice  the  strength  is  needed,  and  in  both  cases  the 
contractions  are  more  easily  produced  by  closure  than  by  opening  of  the 
circuit.     Thus  there  are  four  possible  ways  of  causing  a  contraction:  — 

1.  Closure  with  Kathode  on  the  nerve  or  muscle,  KCC,  Kathodal 

closure  contraction. 

2.  Closure  with  Anode  ,,  ,,  ,,         ACC,  Anodal 

closure  contraction. 

3.  Opening  with  Anode  ,,  ,,  ,,         AOC,  Anodal 

opening  contraction. 

4.  Opening  with  Kathode       ,,  ,,  ,,        KOC,  Kathodal 

opening  contraction. 

These  are  arranged  in  the  order  of  their  appearance  in  health.  In  disease 
the  order  may  be  modified. 

When  the  currents  are  stronger  the  muscle  is  not  quiescent  during 
the  steady  passage  of  the  current,  but  is  in  a  state  of  imperfect  tetanus, 
which  is  called  closure  tetanus. 

With  the  induction  coil  current  the  muscle  passes  into  a  state  of 
tetanus,  and  remains  so  during  the  passage  of  the  current.     This  is  what 


358 


SYSTEM   OF  MEDICINE 


one  would  expect  from  the  continual  change  of  strength  of  the  induction 
coil  current,  which  acts  as  a  rapid  succession  of  separate  stimuli. 

These  muscular  contractions  are  obtained  either  by  stimulating  the 
motor  nerve  trunk  at  any  part  of  its  course,  or  by  stimulating  the 
muscle  by  placing  the  electrode  directly  over  it.     But  even  in  this  latter 


M.  supinator  long. 
M.  radial,  ert.  long. 
M.  radial,  est.  brev. 


H.  triceps  (caput 
Ion  gum) 


)  M.  triceps  CcaintS 
>        extern.) 


K.  ulnar.  extcTB. 
U.  snpinat.  brer. 


M.  estens.  digit!  minim. 
M.  eztens.  indicia 


M.  eztens.  poIL  lon^. 


M.  abduct,  digit,  mln. 


I  U.  intcross.  dorsoL 
J        ULetlV. 


SI.  extensor  digit, 
communis 

U.  extensor  indicia 

M.  nbdnctor  pollic.  long. 
SL  extensor  pollic.  brev. 


VL  izkteross.  doraol.  I. 
etXL 


Fig.  27.  —  The  Motor  points.    The  Extensor  Aspect  of  the  Upper  Limb. 


case  the  stimulus  is  still  distributed  through  the  muscle  by  means  of  the 
ramifications  of  its  motor  nerves,  which  convey  the  stimulus  more  rapidly 
than  the  muscle  fibres  could  do  it. 

In  certain  forms  of  paralysis  the  reactions  become  altered  and  the 
following  condition  is  found:  the  motor  nerve  responds  neither  to  the 
induction  coil  nor  to  the  battery  current;  the  muscle  does  not  respond 
to  the  direct  application  of  the  induction  coil  current,  and  to  the  battery 
current  it  responds  in  an  altered  Avay,  viz.,  the  contractions  at  closing 
and  opening  the  circuit  produce  a  slow,  sluggish  contraction  instead  of 
the  sudden  twitch  seen  in  health ;  often,  too,  the  anodal  closure  proves  a 


THE  MEDICAL  APPLICATIONS   OF  ELECTRICITY 


359 


more  effective  stimulus  than  tlie  kathodal.  These  contractions  (slug- 
gish) may  be  produced  by  very  small  currents,  or,  on  the  contrary, 
strong  currents  maybe  needed  to  produce  them.  The  irritability  of  the 
muscle  to  battery  currents  (galvanic  irritability;  is  said  to  be  increased 


Si.  ttloetis  Qxmz  bead) 

IL  tdcepa  (iimer  head) 
Vlnar  n.  \ 


It.  flexor  carpi  nlnaris 


IL  flex,  digitor.  commi 
profund. 


M,  flex,  digitor.  rablim, 
(digiti  II.  et  UL) 


M.  flex,  digit.  BUbl.  (digit 
indicia  et  zoimtui) 


IL  palmaris  brev. 

M.  abductor  digiti  ruin. 

M.  flexor  digit.  rruD 

IL  opponens  digit.  Tnin. 


twtti  lozobricales  \ 


M.  deltoid, 
(anteiior  h&lf) 


euCan£0U4  n, 

M.  biceps  biachli 

JI.  brach. 
intemoB 

Median  n. 

M.  supinator  longus 

IL  pronator  teres 
M.  flex,  carpi  radiolis 

IL  flex,  digitor.  snbllm. 

M.  flex.  poUicis  lODgos 
Median  n. 

M.  abductor  pollic.  brer. 
^  opponena  pollicis 

IL  flex.  poll.  brer. 

M.  adductor  poUi&  bror. 


Fro.  28.  —  The  Motor  points.     The  Flexor  Aspect  of  the  Upper  Limb. 

or  decreased  accordingly;  the  irritability  to  induction  coil  currents 
(faradic  irritability)  being  abolished  both  in  the  nerve  and  the  muscle. 
This  condition  is  known  as  the  reaction  of  degeneration,  and  is  found  in 
oases  of  serious  injury  or  disease  in  the  motor  nuclei  of  the  anterior 
cornua,  or  in  the  nerve  trunks. 

The  iiriportance  of  the  reaction  of  degeneration  lies  in  the  valuable 
help  afforded  by  it  for  localising  the  seat  of  disease. 


36o 


SYSTEM  OF  MEDICINE 


Other  modifications  of  tlie  normal  reactions  are  a  general  increase  of 
irritability  to  coil  and  battery,  a  corresponding  general  decrease  of  irritability, 
and  a  partial  reactioii  of  degeneration,  whose  essential  features  are  the 
presence  of  sluggish  contractions  when  the  muscle  is  stimulated  directly 
by  a  batter}''  current,  and  a  partial  retention  of  the  excitability  of  the 
nerve  and  muscles  to  the  induction  coil  current.  This  pai-tial  reaction 
of  degeneration  most  usually  occurs  as  a  transient  phase  in  a  paralysis 
which  is  becoming  either  worse  or  better ;  and  it  may  be  seen  in  other 
cases  where  the  damage  is  not  sufficient  to  produce  a  complete  reaction 
of  degeneration. 

Practical  Electrical  Testing.  —  This  should  be  carried  out  as  follows  : 


U.  adductor  magnns 
li.  adduct.  longos 


U.  tensor  {asoiffi  latra 


M.  quadrioepg  f  emorls 
(commou  point) 

M.  lectoB  f  emoris 


Ua  vastas.estenuu 


W.  Toetoa  intoxnus  -l 


Fig.  29.  —The  Motor  points.     The  Front  of  the  Thigh. 

Place  the  indifferent  electrode  in  a  suitable  position  on  the  patient, 
and  take  the  limb  to  be  tested  in  the  left  hand,  holding  in  the  right 
the  testing  electrode  with  one  inch  disc  which  should  have  a  key  in  the 
handle  for  closing  the  circuit.  Moisten  the  skin  thoroughly  over  the 
muscles  to  be  tested,  and  set  the  induction  coil  in  action  at  a  weak 
strength ;  then  apply  the  testing  electrode  to  the  hand  which  holds  the 
patient's  limb,  in  order  to  estimate  the  strength  of  current.  This  should 
invariably  be  done  before  the  electrode  is  allowed  to  touch  the  patient, 
as  the  protection  afforded  to  him  by  this  procedure  is  obviously  very 
great.  When  thus  the  strength  of  the  current  is  found  suitable,  apply 
the  electrode  to  the  motor  points  of  the  muscles  in  order,  noting  whether 
they  contract.     A  finger  placed  lightly  upon  the  tendons  will  often  help 


THE  MEDICAL  APPLICATIONS   OF  ELECTRICITY 


361 


us  to  decide  whether  they  contract  or  not,  and  will  obviate  the  use  of 
very  strong  currents.  The  limb  should  also  be  disposed  in  such  a  way 
as  to  exhibit  the  action  of  the  contracting  muscles.  If  the  opposite  limb 
be  sound  a  comparison  should  be  made  of  the  two  sides  in  order  to 
discover  whether  there  be  any  changes  in  the  contractility  to  the  induc- 
tion coil.  A  rough  comparison  can  be  made  by  the  help  of  the  graduated 
slide  of  the  induction  coil  or  by  a  suitable  galvanometer,  if  such  a  one 
be  at  hand. 

If  the  muscles  all  react  satisfactorily  to  the  coil  test  the  case  cannot 


ML  biceps,  f  em.  (cap. 
long.) 


U.  biceps  fern,  (cap, 
bier.) 


liL  gastroonem.  (cap.  /    O 

eztei]i.> 


yUflexor  liallnols  longns 


M,  glateufl  mAximnB 


H.  adduotOT  magnaa 
"M".  semiiendiQosns 
M.  somimembrauosos 


U.  gastroonem.  (oap.  Int.) 


M.  flexor  digltot.  comm. 
locgiu 


Fig. 


-  The  Motor  points.     The  Posterior  Aspect  of  the  Lower  Limb. 


be  one  of  the  complete  reaction  of  degeneration.  This  should  always 
be  confirmed  by  going  over  them  again  with  the  battery  current,  noting 
whether  the  contraction  is  quick  or  sluggish,  whether  the  anodal  or 
kathodal  closure  is  the  more  effective ;  and  noting  also  the  current  in 
milliamperes  required  to  produce  contractions.  If  the  electrode  be  ever 
so  little  off  the  motor  point  the  minimal  contraction  will  require  a 
stronger  current  than  when  it  is  rightly  placed.  Tables  of  motor  points 
are  given  in  most  books  upon  medical  electricity,  but  the  best  way  to 
learn  them  is  by  careful  practice  upon  one's  own  muscles.  The  nerve 
trunks  of  the  limb  should  also  be  tried  with  both  forms  of  current,  and 


362 


SYSTEM   OF  MEDICINE 


their  responses  should  tally  with  those  obtained  from  the  muscles  them- 
selves. 

A  knowledge  of  the  positions  and  actions  of  the  muscles,  and  of  their 
nerve-supply,  is  quickly  gained  by  the  practice  of  electrical  testing ;  and 
from  the  data  obtained  valuable  opinions  as  to  the  seat  and  extent  of 
the  injury  or  disease  can  be  formed. 

Sensibility  can  also  be  tested  electrically ;  the  coil  is  to  be  used  and 
the  electrode  applied  to  the  surfaces  of  the  skin,  noting  the  position  of 
the  secondary  coil  at  which  a  sensation  is  first  felt.  If  the  active 
electrode  be  applied  to  the  operator,  and  the  fingers  of  his  own  hand  be 


TS.  tdUaL  antic. 


IL  eztens.  digit,  comm. 
Jong. 


II.  peionen9  bievis 


JS.  extensor  ImUucis 
Jong. 


3Im.iliteiossei  donees  | 


Fermealn. 


M.  gastrocnem.  erfenu 
U.  peioueus longos 


M.  flezoi  Iiallacis  long. 


K.  eztens.  digit,  comm. 
■brevis 


M.  abdactor  afgiOjaia. 


Fig.  31.  —  The  Motor  points.     The  Leg  and  Foot,  outer  side. 

used  as  the  electrode  to  convey  the  current  to  the  patient,  the  sensibility 
of  the  patient's  skin  can  be  directly  estimated;  in  this  way  the  presence 
or  absence  of  anaesthesia  can  be  gauged  with  great  nicety.  In  cases 
where  tactile  and  common  sensation  are  unequally  affected,  the  electrical 
test  determines  analgesia  rather  than  anaesthesia.  Thus  a  patient  with 
analgesia  may  be  able  to  feel  the  touch  of  the  electrode,  though  uncon- 
scious of  the  strong  current  which  it  is  conveying  into  the  skin. 

Electrical  Treatment.  —  This  may  be  locally  applied  for  the  sake  of 
influencing  a  particular  part,  or  it  may  be  applied  generally.  The  appli- 
cation of  localised  electrification  to  cases  of  nervous  disease  has  had  the 
effect  of  diverting  attention  from  the  treatment  of  general  morbid  con- 
ditions by  general  electrification ;  but  the  value  of  the  latter  treatment  is 


THE  MEDICAL  APPLICATIONS  OF  ELECTRICITY  363 

now  becoming  more  fully  recognised.  General  electrification  is  very 
useful  as  a  stimulating  method  of  treatment  in  states  of  malnutrition  or 
debility  ;  for  example,  during  convalescence  after  exhausting  illness,  in 
rickety  children,  in  anaemic  people,  in  the  earlier  stages  of  rheumatoid 
arthritis,  and  in  some  other  conditions,  such  as  general  neuritis  and 
neurasthenia.  The  best  mode  by  far  of  obtaining  the  eifects  of  general 
electrification  is  through  the  medium  of  the  electric  hath.  For  this  an 
earthenware  or  wooden  bath-tub  is  to  be  used,  which  is  fitted  with  large 
metal  electrodes  at  the  head  and  foot.  The  patient  is  jjut  into  the  bath 
with  the  water  at  a  temperature  of  99°,  and  the  current  is  passed  through 
it.  The  water  carries  off  a  large  part  of  the  current,  but  the  patient's 
body  is  traversed  by  about  one-eighth  part  of  the  total. 

The  induction  coil  current  is  the  most  effective,  and  the  most  gen- 
erally useful  in  the  electric  bath.  The  patients  make  good  progress 
under  this  mode  of  treatment  and  gain  in  weight ;  a  large  number  of 
patients  receive  electric  baths  every  year  at  the  electrical  department 
in  St.  Bartholomew's  Hospital,  and  the  value  of  the  treatment  is  un- 
doubted. Rheumatoid  arthritis,  if  'not  too  far  advanced,  is  relieved. 
The  use  of  a  small  bath  as  a  means  of  carrying  out  electrical  treatment 
for  children  is  very  convenient;  it  is  well  borne  by  them,  and  they  like 
it ;  the  action  of  the  current  is  also  more  uniform  and  thorough  than 
when  treatment  with  the  ordinary  moistened  electrode  is  used.  The 
electric  bath  may  also  be  used  as  a  means  of  applying  local  treatment  if 
the  parts  involved  be  of  considerable  extent ;  by  so  doing  the  risk  of 
chill  is  diminished,  and  the  currents  affect  the  cutaneous  nerves  less 
painfully  because  of  the  good  moistening  of  the  skin.  Thus  children 
with  infantile  paralysis  of  the  lower  limbs  improve  more  quickly  when 
their  treatment  is  applied  through  the  medium  of  a  small  warm  bath; 
and  if  one  leg  only  be  affected,  the  sound  leg  can  be  drawn  up,  and 
the  current  diverted  into  the  paralysed  limb.  I  have  been  extremely 
pleased  with  the  results  obtained  in  this  way.  The  electric  bath  un- 
fortunately has  suffered  much  in  repute  from  the  abuses  connected  with 
it ;  but  there  is  no  doubt  whatever  that,  when  properly  applied,  it  is 
a  most  valuable  means,  and  its  uses  will  in  time  be  more  fully  recognised. 
The  deplorable  quackery  which  has  degraded  medical  electricity  of  late 
years  has  had  the  effect  of  destroying  the  confidence  of  the  medical 
profession  in  the  treatment;  but  this  attitude  tends  to  perpetuate 
the  evil,  which  should  rather  be  dealt  with  by  medical  men  themselves 
taking  up  the  study  and  practice  of  medical  electricity,  and  withdraw- 
ing their  support  entirely  from  all  unqualified  ''  medical  electricians," 
who  are  uniformly  to  be  regarded  with  suspicion.  It  may  be  assumed 
that  all  such  persons  are  likely  sooner  or  later  to  abuse  the  confidence 
placed  in  them,  and  to  yield  to  the  temptations  of  treating  patients  on 
their  own  account,  either  by  selling  them  "electric"  or  "magnetic 
appliances,"  or  by  promising  impossible  cures. 

Gene)-al  electrification  })y  means  of  an  electro-static  machine  has 
already  been  referred  to.     It  has  the  advantage  that  it  does  not  require 


364  SYSTEM   OF  MEDICINE 

the  patient  to  undress,  and  it  appears  to  be  of  some  value  in  certain 
cases ;  the  use  of  electro-static  treatment  for  cutaneous  affections,  and 
especially  for  pruritus  and  for  chronic  varicose  ulcers,  deserves  a  trial, 
as  it  has  been  found  to  be  of  great  value  by  certain  French  observers. 
The  methods  of  application  will  be  found  in  the  special  handbooks. 

Localised  electrification  for  local  affections  has  been  tried  in  a  vast 
number  of  diseases ;  indeed  there  are  few  morbid  conditions  for  which 
electricity  has  not  at  one  time  or  another  been  recommended.  The  modes 
of  application  are  simple.  The  indifferent  electrode  is  applied  to  the 
body  in  such  a  way  that  the  path  of  the  current  from  it  to  the  active 
electrode  shall  follow  as  closely  as  possible  the  line  of  the  nerves  of  the 
part  to  be  treated.  An  active  electrode  of  suitable  size  and  shape  is  then 
moved  over  the  affected  region  (labile  application),  or  held  firmly  over 
one  part  (stabile  method),  the  skin  and  the  electrode  being  well  mois- 
tened ;  ten  minutes  is  a  suitable  length  of  time.  The  treatment  should 
be  repeated  two  or  three  times  a  week,  the  choice  of  current  —  whether 
of  induction  coil  or  of  constant  current  —  will  depend  upon  the  effects 
desired ;  for  the  stimulating  and  trophic  effects  which  form  so  large  a 
part  of  ordinary  electrical  treatment  the  induction  coil  is  the  best  as 
a  rule. 

The  properties  of  the  current  can  be  represented  by  the  accompany- 
ing table :  — 

Effects  desired. 

A.  Stimulating       \      (1)    Induction    coil.       (2)    Battery  current   with 

and  trophic   J  variations,  interruptions,  and  reversals. 

B.  Anodyne .  .       Battery  current.      Positive  pole  without  interrup- 

tions or  sudden  variations. 

S'    ^^^'^*^°!^'*^"^       I  Battery  current,  without  reversals.      C.  Peripolar 

U.    Alterative  and  v  ^^^^^^     ^   Interpolar  effect. 

vasomotor     J  ^ 

E.    Osmotic   .          .  Battery  current.     Positive  pole. 

The  striking  effect  of  electrical  currents  in  causing  contractions  in 
paralysed  muscles  has  naturally  attracted  attention  from  the  first  as  a 
possible  therapeutic  method.  In  certain  kinds  of  paralysis  electricity 
affords  a  very  useful  means  of  treatment.  In  Hemiplegia  from  organic 
disease  it  cannot  indeed  be  expected  to  restore  parts  which  have  been 
destroyed ;  but  a  short  course  of  treatment  during  the  period  of  recovery 
does  help  materially  in  the  restoration  of  power  to  those  which  are  not 
too  severely  damaged.  It  appears  that  the  paralysis  which  follows  a 
hemiplegic  attack  is  often  more  extensive  than  is  warranted  by  the 
actual  destruction  of  fibres  in  the  brain,  and  the  electrical  treatment 
favours  the  return  of  functional  activity  in  those  parts  which  have  been 
disused,  or  impaired  though  not  destroyed  by  the  cerebral  lesion.  I 
have  seen  few  cases  of  hemiplegia  which  have  not  gained  something  from 
a  month's  treatment  by  electricity.  The  application  of  a  fairly  strong 
induction  coil  current  to  the  affected  limbs,  so  as  to  produce  lively  con- 


THE  MEDICAL   APPLICATIONS   OF  ELECTRICITY  365 

tractions  of  the  muscles,  is  the  proper  method ;  it  should  be  done  twice 
or  thrice  a  week  for  ten  minutes  at  a  time,  and  this  treatment  carried 
out  for  a  month.  By  the  end  of  that  time  the  patient  will  have 
■  derived  whatever  benefit  he  is  likely  to  obtain.  It  is  important  not  to 
begin  electrical  treatment  until  from  four  to  six  weeks  after  a  seizure. 

Infantile  Paralysis.  —  In  this  disease  electrical  treatment  is  of  great 
value,  but  demands  much  perseverance  on  the  part  of  all  concerned. 
After  the  close  of  the  febrile  attack  which  usually  accompanies  the  onset 
of  the  disease,  the  damaged  muscles  rapidly  waste  to  a  greater  or  less 
degree,  and  the  reaction  of  degeneration  may  be  well  marked  in  some 
of  the  muscles  within  a  week  of  the  onset.  At  the  end  of  three  weeks 
the  muscles  may  be  tested,  and  the  extent  of  the  damage  estimated ; 
electrical  treatment  should  then  be  begun.  It  is  customary  to  use  the 
induction  coil  if  the  muscles  react  to  it;  if  they  do  not,  to  use  the 
battery  current  instead :  in  either  case  the  active  electrode  is  moved 
over  the  surface  of  the  paralysed  parts.  It  is  at  present  by  far  too  com- 
mon a  practice  to  leave  cases  of  infantile  paralysis  to  themselves,  in  the 
belief  that  the  muscles  will  recover  spontaneously  if  the  motor  cells  in 
the  cord  are  not  destroyed ;  or  will  remain  incurably  atrophied  if  these 
cells  are  destroyed.  This,  however,  by  no  means  represents  the  true 
state  of  the  case.  From  a  fairly  wide  experience  of  electrical  testing 
and  treatment  in  infantile  paralysis,  I  may  definitely  assert  that  there 
are  many  cases  of  children  in  which  weak  and  damaged  muscles  remain 
inefficient  during  years  of  such  "  expectant  treatment,"  although  they 
present  no  reaction  of  degeneration.  These  are  cases  which  Avill  at  once 
begin  to  improve  with  electricity,  and  will  continue  to  improve  if  the 
electrical  treatment  be  continued.  There  are  also  many  cases  where 
muscles,  atrophied  and  degenerated  for  two  or  three  years,  and  giving 
no  response  to  any  form  of  electrical  stimulation,  may  be  made  to  grow 
and  recover  normal  reactions  by  patient  electrical  treatment.  The 
secret  is  that  infantile  paralysis  does  not  of  necessity  destroy  the  whole 
of  an  affected  muscle ;  this  is  the  exception  rather  than  the  rule.  A 
few  normal  fibres  and  a  few  of  their  ganglion  cells  very  often  survive, 
and  by  the  persevering  treatment  of  these  a  new  muscle  can  be  slowly 
cultivated.  Thus  in  one  case  a  new  and  useful  calf  gradually  grew 
where  there  had  been  complete  atrophy,  the  new  muscle  consisting 
almost  wholly  of  a  highly-developed  outer  head  of  the  gastrocnemius ; 
the  inner  head  of  the  same  muscle  and  the  soleus  remained  atrophied. 
If,  by  treatment,  a  certain  degree  of  development  can  be  gained,  so  as 
to  enable  the  muscle  to  be  of  service,  then  the  voluntary  use  of  it  con- 
tinues the  process  of  repair.  Exercises  are  therefore  an  important 
adjunct  to  the  electrical  treatment. 

In  brief,  the  treatment  of  infantile  paralysis  is  most  encouraging, 
and  should  by  no  means  be  neglected  in  children.  No  case  should  be 
regarded  as  hopeless,  for  however  bad  it  may  be,  some  gain  from  a 
course  of  treatment  is  certain  ;  the  gain  may  be  but  trifling,  or  it  may 
be  great;  but  there  is  no  better  treatment ;  and  the  parents  should  be 


366  SYSTEM  OF  MEDICINE 

encouraged  to  continue  it  for  years  if  necessary.  I  have  had  several 
cases  under  treatment  for  three  years  or  more.  When  the  disease  is  of 
several  years'  standing  the  prospects  are  less  favourable,  but  even  these 
will  make  some  progress  under  careful  treatment.  The  method  of 
treatment  to  be  followed  may  be  with  one  electrode  applied  to  the  nape 
of  the  neck  in  the  case  of  paralysis  of  an  upper  limb,  or  to  the  dorsal 
or  lumbar  region  for  the  lower;  the  active  electrode  is  to  be  moved 
over  the  affected  muscles  for  ten  minutes  three  times  a  week  or  oftener. 
The  induction  coil  is  to  be  used  for  all  the  cases  ;  and  for  those  showing 
altered  reactions  the  constant  current  also,  five  minutes  with  each.  The 
strength  of  current  must  be  regulated  by  the  feelings  of  the  patient, 
some  children  being  more  timid  than  others ;  but  as  a  general  rule  the 
current  should  be  as  strong  as  they  are  able  to  bear  Avithout  discomfort 
or  distress.  The  skin  should  be  well  soaked  in  hot  water  to  diminish  its 
resistance.  Two-inch  electrodes  should  be  used  and  kept  in  movement 
over  the  affected  muscles  all  the  time.  In  this  way  children  may  bear 
the  passage  of  three,  four  or  five  milliamperes ;  but  if  not,  then  smaller 
currents  must  suffice.  Although  the  constant  current  has  the  reputation 
of  being  the  best  for  these  cases,  the  grounds  for  its  preference  are  more 
theoretical  than  real,  and  an  induction  coil  apparatus  will  give  good 
results.  When  the  parents  or  the  nurse  are  to  carry  out  the  treatment 
for  a  year  or  more  the  coil  is  the  best  apparatus,  as  it  is  simpler  and 
cheaper,  and  any  failure  in  its  action  is  easier  to  detect  by  the  cessation 
of  the  audible  vibration  of  the  contact-breaker.  There  is  also  no  risk 
of  damaging  the  patient's  skin  by  electrolytic  action. 

The  best  way  of  treating  these  cases  when  the  paralysis  affects  the 
lower  limbs,  as  it  so  commonly  does,  is  to  arrange  two  metallic  plate 
electrodes  at  the  ends  of  an  ordinary  foot-bath  of  wood  or  earthenware 
filled  with  warm  water.  The  child  can  be  put  into  the  bath  in  a  sitting 
posture  with  legs  extended,  and  the  coil  current  passed  through  the  bath ; 
tlie  strength  of  the  current  can  be  gauged  by  putting  the  hands  into  the 
water,  one  close  by  each  of  the  electrodes.  The  bath  can  be  given  daily 
in  the  evening ;  after  it  the  limbs  are  to  be  well  rubbed,  and  the  child  put 
to  bed.  A  little  warm  jacket  can  easily  be  contrived  to  cover  the  arms 
and  trunk  during  the  bath.  Eubbing  and  manipulation  of  the  affected 
limb,  with  some  suitable  gymnastic  exercises,  are  of  great  advantage  as 
auxiliaries  in  the  treatment  of  this  disease.  The  only  way  of  ensuring 
proper  treatment  for  these  children  is  to  entrust  it  to  the  mother  or  to 
a  good  nurse,  to  teach  them  carefully  how  to  do  it,  and  to  have  it  done 
every  day.  It  is  useless  to  leave  it  to  the  visits  of  a  medical  man.  The 
treatment  must  be  made  a  part  of  the  child's  daily  life ;  but  the  medical 
man  must  see  it  done  now  and  then,  and  must  test  and  measure  the 
limbs  from  time  to  time  to  estimate  the  progress  of  the  case.  For  this 
reason  a  simple  apparatus  is  essential,  and  such  an  one  has  been  contrived 
by  myself  for  the  express  purpose  of  enabling  the  parents  to  manage  the 
daily  treatment  for  themselves  without  the  possibility  of  going  wrong. 

Injuries  of  Nerves. —  The  different  forms  of  paralysis,  due  to  contusion, 


THE  MEDICAL  APPLICATIONS   OF  ELECTRICITY  367 

compression,  or  other  injury  of  nerve-trunks,  improve  rapidly  under  treat- 
ment if  the  nerve-trunk  be  not  actually  divided  or  torn  across.  When 
this  is  the  case,  an  operation  to  unite  the  ends  must  be  performed  before 
electricity  can  be  of  service.  When  a  nerve-trunk  is  involved  in  scar  tis- 
sue the  cases  are  likely  to  be  tedious ;  but  even  here  perseverance  with 
the  treatment  will  do  much.  There  are  few  forms  of  paralysis  more 
likely  to  improve  under  electrical  treatment  than  those  of  damaged 
nerve-trunks,  but  the  prognosis  should  be  a  guarded  one  until  the  actual 
severity  of  the  injury  can  be  gauged.  If  the  electrical  reactions  be  not 
altered,  and  if  the  reactions  to  the  induction  coil  be  present,  the  case  may 
be  expected  to  recover  within  four  weeks  ;  often  it  will  get  well  in  a 
shorter  time.  In  neglected  cases  electricity  will  often  start  an  immediate 
improvement.  The  exciting  cause  of  the  mischief,  if  still  present,  must 
be  removed ;  this  applies,  of  course,  chiefly  to  cratch  palsy.  When  there 
is  a  marked  reaction  of  degeneration  the  case  may  be  a  longer  one ;  the 
progress  of  the  case  during  the  early  days  of  treatment  must  be  watched, 
and  the  prognosis  based  on  the  state  of  atrophy  and  the  amount  of  vol- 
untary power  and  sensation  present.  Often  it  happens  that  improved 
nutrition  and  voluntary  power  begin  to  return  before  any  change  in  the 
electrical  reactions  can  be  detected  ;  in  fact,  this  is  the  rule.  In  every 
case  perseverance  with  the  electricity,  aided  by  rubbing  and  shampoo- 
ing, is  to  be  insisted  on ;  in  electrical  treatment  of  these  cases  one  need 
never  despair  except  when  the  wasting  and  paralysis  grow  worse  in 
spite  of  all  that  is  being  done :  in  such  cases  the  nerve-trunk  has  prob- 
ably been  torn,  and  a  surgical  operation,  to  explore  and,  if  necessary,  to 
reunite  the  nerve,  should  be  considered.  When  the  reaction  of  degen- 
eration becomes  more  and  more  difficult  to  elicit,  requiring  stronger  cur- 
rents than  it  did  before,  the  prospects  are  unfavourable.  The  site  of  the 
lesion  in  the  nerve-trunk  can  be  localised  very  closely  by  electrical  test- 
ing and  examination  of  the  affected  muscles.  The  commonest  types  of 
paralysis  from  injury  to  nerves  are  sleep  palsy,  crutch  palsy  (musculo- 
spiral  nerve),  paralysis  from  blows  about  the  shoulder  (circumflex 
nerve,  supra-scapular  nerve,  and  nerve  to  serratus  magnus),  and  median 
or  ulnar  paralysis  from  fractures  and  wounds  of  arm  and  forearm  or 
from  tight  bandaging  or  badly-applied  splints.  These  last  two  causes 
are  not  very  uncommon,  and  they  should  be  borne  in  mind.  In  the  lower 
limb  paralysis  from  injuries  to  the  nerve-trunks  is  less  frequently  seen. 
Facial  Palsy.  —  Facial  paralysis  in  most  cases  also  belongs  to  the  same 
group :  its  symptoms  need  not  be  described  here.  It  is  important  to 
remember  that  the  electrical  examination  of  the  muscles  of  the  face  must 
be  carried  out  with  very  weak  currents ;  the  skin  is  very  sensitive,  and 
as  the  muscles  lie  close  beneath  the  surface  they  are  readily  thrown  into 
contraction.  Care  must  therefore  be  taken  not  to  alarm  the  patient  by 
the  use  of  strong  currents  on  the  first  visit.  If  the  electrical  reactions 
be  normal  the  prognosis  is  good,  and  the  patient  may  be  expected  to 
recover  in  from  three  to  four  weeks.  If  there  be  a  reaction  of  degener- 
ation, partial  or  complete,  a  longer  time  must  be  allowed.     As  a  rule, 


368  SYS  TEAT  OF  MEDICINE 

cases  of  facial  paralysis  recover  unless  some  progressive  disease  in  the 
course  of  the  nerve  be  the  cause  of  it.  The  cases  which  come  on  spon- 
taneously and  are  usually  ascribed  to  cold  may  be  expected  to  recover. 
Too  confident  a  prognosis  must  not  be  given,  as  now  and  then  an 
apparently  simple  case  resists  treatment  obstinately.  Cases  of  long 
standing  and  those  in  elderly  people  are  as  a  rule  less  favourable ;  but 
treatment  must  be  persevered  with,  as  improvement  may  begin  to  show 
itself  as  late  as  three  months  after  the  onset. 

Electrical  treatment  will  often  start  improvement  in  cases  which  are 
stationary ;  and  it  is  desirable  to  begin  electrical  treatment  early,  and 
not  to  neglect  it  until  a  late  stage  of  the  complaint.  Many  cases  of 
facial  palsy  recover  without  electrical  treatment ;  but  it  is  not  wise  to 
leave  the  cases  untreated.  The  induction  coil  is  best  for  those  with 
normal  reactions ;  if  the  reaction  of  degeneration  be  present,  it  should 
be  supplemented  by  the  constant  current,  negative  pole.  The  indiffer- 
ent electrode  should  be  applied  to  the  back  of  the  neck,  and  the  active 
electrode  moved  over  the  face,  following  approximately  the  lines  of  the 
main  branches  of  the  facial  nerve.  The  skin  must  be  very  thoroughly 
moistened  to  diminish  the  unpleasantness  of  the  current.  The  electrode 
should  be  kept  away  from  the  points  of  emergence  of  the  main  branches 
of  the  fifth  nerve,  as  these  are  very  sensitive. 

Neuritis.  —  In  the  various  forms  of  paralysis  due  to  general  or  mul- 
tiple neuritis,  the  best  treatment  by  far  is  by  the  electric  bath;  the 
induction  coil  and  fairly  strong  currents  are  to  be  used,  and  the  same 
treatment  should  be  adopted  in  paralysis  following  specific  fevers,  of 
which  diphtheritic  paralysis  is  the  type.  Failing  the  electric  bath,  the 
induction  coil  may  be  used  with  large  sponge  electrodes.  The  patient 
must  be  guarded  from  the  risks  of  chill  by  using  hot  water  and  a  well- 
warmed  room,  and  it  is  often  most  convenient  to  apply  the  treatment 
at  bedtime,  as  the  patients  will  probably  sleep  all  the  better  after  the 
electrical  treatment.  The  electric  bath  is  much  more  agreeable  and 
efficient  than  the  treatment  by  sponge  electrodes.  Cases  of  advanced 
alcoholic  neuritis  sometimes  recover  completely  under  prolonged  bath 
treatment.  If  the  interrupted  current  cause  painful  sensations  the  con- 
stant current  may  be  used  instead. 

Lead  Poisoning.  — The  treatment  of  lead  poisoning  is  slow :  in  hos- 
pital patients  it  is  usually  made  slower  because  the  patients  return  to 
their  work  as  soon  as  they  begin  to  recover  power,  and  then  they  again 
come  into  contact  with  the  sources  of  lead  poisoning. 

In  this  disease  one  may  occasionally  notice  that  muscles  give  a 
reaction  of  degeneration  even  before  they  are  affected  with  paralysis ; 
and,  conversely,  the  atrophy  and  paralysis  may  improve  considerably 
before  there  is  any  return  of  the  normal  reactions. 

The  electric  bath  with  constant  current  has  been  proposed  in  cases  of 
metallic  poisoning  as  a  means  of  eliminating  the  metal  from  the  system. 
I  have  found  unmistakable  traces  of  lead  deposited  upon  the  copper 
electrodes  of  the  bath  froin  a  patient  with  lead  poisoning.    It  is  doubtful, 


THE  MEDICAL  APPLICATIONS   OF  ELECTRICITY  369 

however,  whether  the  lead  so  deposited  has  been  obtained  from  the  tis- 
sues of  the  body,  or  whether  it  comes  from  the  contamination  of  the 
surface  of  the  skin  with  lead  compounds.  Further  experiments  are 
necessary  before  the  point  can  be  cleared  up.  The  battery  current, 
labile  over  the  affected  muscles,  is  the  treatment  most  favoured.  It 
should  be  combined  with  induction  coil  treatment,  each  current  being 
applied  for  five  minutes  at  each  visit. 

Neuralgia. — Neuralgia  sometimes  yields  quickly  to  electricity,  at 
other  times  it  is  most  obstinate.  Often  the  pain  is  made  worse  by  the 
induction  coil,  but  by  using  a  secondary  coil  of  many  windings  and  a 
rapidly  vibrating  contact-breaker,  an  anaesthetic  effect  can  be  obtained 
which  has  proved  to  be  decidedly  useful  in  many  cases.  In  general  the 
an-electrotonic  effect  of  the  positive  pole  of  a  constant  current  battery 
should  be  tried ;  there  must  be  no  abrupt  makes  and  breaks  of  current, 
and  the  strength  must  be  raised  and  lowered  very  gradually  by  the  use 
of  an  adjustable  resistance  of  about  10,000  ohms.  With  this  in  circuit, 
and  set  for  its  maximum  resistance,  the  current  collector  is  slowly  turned 
on  to  twenty  cells,  the  contact  of  the  electrode  with  the  patient  being 
steadily  maintained ;  the  current  is  then  increased  by  sliding  the  traveller 
of  the  rheostat  from  its  maximum  to  a  lower  value,  until  five  or  six 
milliamperes  are  indicated  on  the  galvanometer.  The  electrode  is  kept 
moving  slowly  over  the  neuralgic  area,  but  without  any  interruptions  of 
contact  until  the  end  of  the  sitting,  then  the  rheostat  is  again  brought 
into  use  to  lower  the  current,  and  afterwards  the  current  collector  is 
turned  off.     Five  minutes  is  a  sufficient  time  for  each  sitting. 

Sciatica  is  a  painful  affection  which  commonly  comes  under  electrical 
treatment ;  the  results  are  usually  good,  and  may  be  manifested  rapidly. 
As  the  nerve  is  deep-seated,  large  electrodes  and  currents  of  ten  to  twenty 
milliamperes  are  to  be  employed.  The  indifferent  electrode  (negative 
pole)  is  to  be  placed  on  the  sacrum  or  over  the  sciatic  notch,  while  the 
other  pole  is  moved  slowly  along  the  trunk  of  the  nerve,  and  also  ap- 
plied to  any  painful  points  which  may  be  present.  The  electric  bath  is 
also  a  valuable  method  of  treating  sciatica :  one  electrode  may  be  placed 
near  the  posterior  surface  of  the  thigh,  while  the  other  is  at  the  head 
of  the  bath ;  or  the  electrodes  at  the  head  and  foot  of  the  bath  may  be 
used,  and  an  accessory  wire  led  from  the  foot-plate  to  a  pad  electrode 
placed  under  the  thigh ;  this  electrode  must  be  covered  with  a  flannel 
or  wash-leather  covering.  The  painful  counter-irritation  of  a  strong  in- 
duction coil  current,  applied  with  a  wire  brush  to  the  dry  surface  of  the 
skin  of  the  affected  region,  will  sometimes  dispel  a  sciatica. 

The  treatment  of  Lumbago  is  similar  in  all  respects  to  the  treatment 
of  Sciatica,  except  that  the  electrodes  are  to  be  applied  to  the  lumbar, 
and  not  to  the  sciatic  region.  The  results  of  electrical  treatment  for 
sciatica  and  lumbago  are  very  -satisfactory. 

HiiHterical  affections  may  often  be  dispelled  by  electrical  treatment, 
and  many  of  the  remarkable  cures  to  be  found  in  the  early  books  on  the 
application  of  electricity  to  medicine  are  of  this  sort.      This  use  of 

VOL.    I  2    B 


370  SYSTEM   OF  MEDICINE 


electricity  is  none  the  less  valuable  in  medical  treatment  because  its 
effects  may  be  due  to  an  action  upon  the  mind  of  the  patient,  for  in 
hysteria  some  such  profound  mental  impression,  acting  through  the  sen- 
sory nerves  or  otherwise,  is  chiefly  required ;  but  the  cures  effected  by 
its  means  can  only  be  attributed  in  an  indirect  way  to  the  electrical 
properties  of  the  apparatus  employed.  Occasionally  the  mere  sight  of 
the  electrical  apparatus  is  sufficient  to  dispel  hysterical  symptoms. 

Electrical  treatment,  though  it  may  cure  the  particular  symptoms 
which  are  present  at  the  time,  does  not  alter  the  peculiar  hysterical 
tendencies  of  the  patient.  In  anaesthesia,  contractures,  paralysis,  pain- 
ful joints,  weak  spines,  aphonia,  etc.,  local  stimulation  with  the  induc- 
tion coil,  either  with  the  ordinary  electrodes  or  with  the  wire  brush,  are 
to  be  used.  The  symptom  often  departs  suddenly  during  the  course  of 
the  first  sitting,  or  it  may  gradually  disappear  afterwards.  It  is  seldom 
that  more  than  a  few  repetitions  of  treatment  are  needed,  and  meanwhile 
other  treatment  to  improve  the  patient's  general  state  of  health  should 
be  adopted.  The  electro-static  machine  is  also  a  very  useful  engine  for 
the  treatment  of  hysterical  manifestations. 

Neurasthenia  and  Hypocliondriasis.  —  Patients  suffering  from  these 
maladies  are  usually  very  ready  to  try  electrical  treatment,  partly  from 
the  general  tendency  of  such  patients  to  seek  remedial  measures  of  any 
kind.  From  electricity,  as  from  any  other  new  thing,  they  seem  to  de- 
rive benefit  for  a  time.  Perhaps  the  best  thing  for  them  is  to  apply 
general  electrification,  particularly  the  electric  bath  with  interrupted 
current.  The  general  fillip  to  the  system  afforded  by  this  may  help  to 
raise  them  out  of  their  unhappy  condition,  especially  if  combined  with 
a  diet  and  regimen  calculated  to  improve  their  digestive  functions.  In 
many  of  these  cases  the  symptoms  are  associated  with  disorder  of  the 
alimentary  canal,  such  as  dyspepsia  or  constipation ;  and  it  may  be  that 
improper  diet  and  malnutrition  are  the  immediate  cause  of  most  cases  of 
hypochondriasis  and  neurasthenia.  Electricity  can  help  them  by  stim- 
ulating their  metabolic  processes,  and  so  can  indirectly  provide  them  with 
a  chance  of  escape  from  their  miserable  condition,  provided  that  in  other 
respects  their  diet  and  mode  of  life  can  be  improved. 

Insomnia.  —  It  has  often  been  observed  that  patients  sleep  better 
after  electrical  treatment,  electricity  is  therefore  a  proper  means  to  try 
in  cases  of  sleeplessness.  General  treatment  with  the  induction  coil, 
either  in  the  electric  bath  or  by  means  of  large  bath  sponge  electrodes 
moved  over  the  trunk  and  limbs,  will  thus  enable  many  patients  to  sleep 
soundly. 

The  treatment  of  locomotor  ataxy  and  progressive  muscular  atrophy  by 
electricity  has  been  hitherto  very  unpromising,  although  the  pains  of 
tabes  have  been  alleviated  by  the  treatment.  Favourable  reports  are 
published  from  time  to  time  of  cases  of  these  diseases  improved  by 
electricity,  but  no  thoroughly  definite  results  of  an  uniform  character 
are  yet  to  hand. 

The  troublesome  symptom  of  tinnitus  aurium  may  often  be  relieved, 


THE' MEDICAL   APPLICATIONS    OE  ELECTRICITY  371 

but  rarely  cured  by  electrical  treatment.  The  tinnitus  is  sometimes  as- 
sociated with  increased  electrical  irritability  of  the  auditory  nerve,  and 
it  can  be  diminished  if  the  anode  is  applied  to  the  ears  by  means  of  a 
divided  electrode  shaped  like  the  metal  part  of  a  binaural  stethoscope, 
the  indifferent  electrode  being  placed  on  the  nape.  To  protect  the  skin 
from  eloctrolytic  effects,  there  should  be  a  thick  covering  of  wetted  ab- 
sorbent wool  upon  the  active  electrode,  which  is  to  be  applied  just  in 
front  of  the  tragus.  A  current  of  ten  milliamperes  is  to  be  used  for  ten 
minutes.  It  may  be  turned  on  rapidly,  but  should  be  turned  off  very 
slowly,  and  with  the  help  of  an  adjustable  resistance.  In  favourable 
cases  the  tinnitus  is  arrested  during  the  passage  of  the  current,  and 
after  a  few  sittings  the  remissions  become  longer  and  longer  until  the 
symptom  disappears  altogether.  When  patients  with  tinnitus  come  for 
electrical  treatment,  they  should  be  submitted  to  an  electrical  testing. 
If  the  anode  modify  or  arrest  the  sounds,  the  cases  are  favourable,  and 
electrical  treatment  m.ay  be  confidently  recommended.  If  the  current 
leave  the  sounds  unaffected  the  cases  are  unfavourable.  The  kathode 
usually  increases  the  sounds,  the  anode  diminishes  them.  Sometimes 
the  converse  is  the  case,  then  the  kathode  must  be  used  as  the  active 
electrode.  If  the  sounds  are  unaffected  by  either  kathode  or  anode, 
treatment  is  not  likely  to  be  of  much  use. 

Disorders  of  Cii'culation. — Dr.  Barlow  has  recommended  electricity 
in  those  cases  of  local  asphyxia,  known  as  Raynaud's  disease,  in  which 
the  extremities  become  blue  and  cold,  and  are  liable  to  chilblains,  or  even 
to  gangrene.  The  mode  of  treatment  is  as  follows :  The  hand  or  foot  is 
immersed  in  a  basin  of  warm  water  in  which  one  pole  of  the  battery  is 
placed,  while  the  other  is  fixed  to  the  upper  portion  of  the  limb,  or  to 
some  neighbouring  part  of  the  trunk  ;  the  current  should  be  as  strong  as 
the  patient  can  bear.  Dr.  Barlow  advises  the  use  of  the  continuous  cur- 
rent, but  probably  the  interrupted  current  would  prove  equally  effica- 
cious. The  same  treatment  is  very  good  for  patients  who  are  subject  to 
chilblains,  and  will  prevent  their  formation,  or  dispel  them,  if  the  treat- 
ment be  begun  as  soon  as  the  first  signs  of  the  chilblains  show  them- 
selves. If  the  skin  be  broken  it  is  difficult  to  apply  electrical  treatment, 
as  it  produces  a  good  deal  of  pain  in  the  excoriated  surfaces. 

A  course  of  electric  baths  usually  cures  any  acne  of  the  skin  of  the 
back  that  the  patients  may  suffer  from,  and  I  have  seen  a  chronic  ec- 
zematous  ulcer  of  the  leg,  after  having  been  a  great  trouble  for  years, 
resisting  many  remedies,  heal  in  a  few  weeks  under  the  use  of  the 
induction  coil  bath. 

Exophthalmic  Goitre.  —  The  electrical  treatment  of  this  disease  has 
received  a  good  deal  of  attention,  and  from  time  to  time  favourable  re- 
sults have  been  obtained  and  published.  Among  the  most  recent  publi- 
cations on  the  subject  is  an  account  by  Dr.  Rockwell  of  forty-five  cases  ; 
the  method  which  he  recommends  is  to  use  strong  electrical  currents  — 
twenty,  forty,  or  even  sixty  milliamperes.  These  are  applied  by  means 
of  electrodes  of  very  large  surface ;    the  kathode  over  the  pit  of  the 


372  SYSTEM  OF  MEDfCIJVE 

stomach,  and  the  anode  to  the  nape  of  the  neck.  General  electrical 
treatment  by  the  electrical  bath,  or  otherwise,  may  be  used  concurrently. 
Vigouroux  has  recommended  the  use  of  the  induction  coil,  applying  it 
in  turn  to  the  eyeballs,  the  chest,  the  thyroid,  the  sides  of  the  neck,  and 
the  cardiac  region.  Other  writers  advise  other  operative  procedures ; 
there  is  no  certainty  of  relieving  the  patient  by  any  of  them.  Electrol- 
ysis of  the  enlarged  gland  is  perhaps  the  most  promising  method. 

Incontinence  of  urine  is  also  a  favourable  subject  for  electrical  treat- 
ment. In  the  reflex  nocturnal  incontinence  of  the  j^oung  it  is  usually 
successful.  One  electrode  is  applied  to  the  lower  dorsal  spine,  and  the 
other  to  the  perinaeum,  and  the  induction  coil  current  is  used  for  six 
minutes,  followed  by  the  battery  current  for  three  minutes.  The  latter 
current  should  be  repeatedly  made  and  broken  and  reversed  by  hand ; 
about  fifty  such  interruptions  will  suffice.  Current  five  to  ten  milliam- 
peres,  positive  pole  to  spine,  negative  to  perinaeum.  Improvement  soon 
shows  itself,  but  treatment  must  be  continued  for  a  month,  or  several 
months,  as  the  cases  are  very  apt  to  relapse.  The  effect  of  elec- 
tricity here  is  to  stimulate  the  centres,  both  cerebral  and  spinal,  by  the 
repeated  setting  up  of  painful  local  impressions,  which  in  time  bring 
the  inhibitory  cerebral  mechanism  into  closer  relation  with  the  reflex 
centres  in  the  lumbar  cord.  Usually  the  patients  begin  by  being 
free  for  a  night  or  two  after  each  application,  and  they  go  on  grad- 
ually improving.  It  may  take  some  time  to  overthrow  completely 
the  bad  effects  of  habit  in  these  cases,  but  with  perseverance  they 
will  all  improve,  if  there  be  no  organic  mischief  behind.  It  is  impor- 
tant to  try  to  combat  the  tendency  to  very  deep  sleep  which  many  of 
these  patients  exhibit.  This  may  be  done  by  various  means  —  for 
example,  the  bedclothes  should  be  scanty,  and  a  clock  which  strikes 
the  hours  loudly  may  be  placed  in  the  bedroom.  When  the  inconti- 
nence is  diurnal,  and  due  to  weakness  of  the  sphincter,  the  best  mode 
of  application  is  the  introduction  of  a  metal-tipped  sound  into  the 
urethra,  the  indifferent  electrode  being  as  before ;  the  same  treatment 
with  the  induction  coil  followed  by  galvanism  should  be  employed. 
This  state  sometimes  follows  when  patients  have  been  forced  to  hold 
their  water  for  a  long  time.  In  women  a  small  want  of  tone  in  the 
sphincter  is  not  at  all  uncommon,  and  the  urine  is  apt  to  be  expelled 
involuntarily  during  any  muscular  effort.  I  have  seen  electrical  treat- 
ment cure  a  number  of  such  cases  permanently,  even  when  one  hardly 
dared  to  hope  for  so  fortunate  a  result.  When  the  bladder  symptoms 
form  part  of  a  general  paraplegic  state,  the  local  treatment  described 
above  will  not  be  of  use  unless  the  condition  of  affairs  in  the  spinal 
cord  can  be  improved  also. 

Electricity  has  been  applied  for  various  uterine  affections,  par- 
ticularly for  uterine  fibroma.  The  methods  of  Apostoli  have  fallen  into 
discredit  in  this  country,  but  no  doubt  there  is  some  value  in  his  treat- 
ment; in  Paris  he  continues  to  carry  it  out,  and  is  able  to  publish 
favourable  results  in  large  numbers  of  cases :  moreover,  independent 


MASSAGE:     TECHNIQUE,  PHYSIOLOGY,   ETC.  373 

observers  have  confirmed  his  statements.     It  is  quite  possible  that  it 
may  again  be  revived  here. 

Tlie  use  of  electricity  for  surgical  purposes  —  for  the  heating  of 
wires  in  the  galvano-cautery ;  for  the  lighting  of  small  incandescent 
lamp  instruments ;  for  the  destruction  of  naevi,  moles  and  warts,  and 
the  removal  of  superfluous  hairs,  are  fully  dealt  with  in  the  special 
articles  and  handbooks. 

H.  Lewis  Jokes. 

Among  the  standard  works  on  the  medical  uses  of  electricity  the 
following  may  be  enumerated :  — 

1.  BouDET  DE  Paris.  Electricity  M(idicale,  1S88.— 2.  Dawson  Turner.  Medical 
Electricitij .  Balliere,  Tindall  and  Son,  1892. — 3.  Duchenne.  Electrisation  Localisee, 
1872. — 4.  Duchenne.  Electrisation  Localisee,  translated  in  part  by  Dr.  G.  V.  Poore. 
New  Sydenham  Society,  1883. —5.  Erb.  "Electro-therapeutics,"  in  von  Ziemssen's 
Handbook  of  General  Therapeutics,  vol.  vi.,  translated  by  De  Watteville.  Smith,  Elder 
and  Co.  1887.— 6.  Hedley.  Hydro-electric  Methods  in  Medicine,  1892.  —  7.  Lewis 
Jones.  Medical  Electricity.  H.  K.  Lewis,  1895.  —  8.  Onimus  and  Legros.  Traiti 
d'Electricite  Medicale,  1888.— 9.  Steavenson.  Elect7-olysis  in  Surgery.  Churchill, 
1890. 

H.  L.  J. 


MASSAGE :  TECHNIQUE,  PHYSIOLOGY,  AND  THEEAPEUTIC 

INDICATIONS 

No  endeavour  will  be  made  in  the  present  article  to  consider  the  history 
of  massage,  but  to  give  simply  and  briefly  an  outline  of  the  technique 
sufficient  to  enable  a  physician  to  judge  whether  a  masseur  is  well 
taught  and  works  conscientiously ;  then  to  recapitulate  the  physiologi- 
cal effects  which  experimental  studies  have  of  late  firmly  established, 
to  deduce  from  these  its  applicability  in  disease,  and  to  indicate  the 
diseases  in  which  clinical  experience  has  taught  us  its  usefulness. 

No  doubt  some  of  the  distrust  of  massage  has  been  due  to  the  igno- 
rance or  incompetency  of  many  of  the  professional  manipulators,  and  to 
the  absurd  and  extravagant  efforts  to  proclaim  it  as  an  exclusive  method 
of  treatment.  Unless  inflammation  be  present,  or  some  unusual  tender- 
ness or  susceptibility,  little  direct  harm,  beyond  discomfort,  is  likely  to 
be  done  to  a  patient  by  rough  or  wrongly  applied  massage,  but  failure 
of  any  good  result  is  harm  enough.  The  practice  of  "  median o-therapy  " 
by  manipulators  usually  quite  ignorant  of  medicine,  certainly  with  no 
scientific  training,  and  independent  of  proper  diagnosis  and  directions 
from  a  physician,  is  altogether  to  be  deprecated,  and  is  one  of  the  great 
sources  of  the  prejudice  against  the  method  still  existing  in  the  minds 
of  many  medical  men.  It  is  not  necessary  that  such  work  should  be 
undertaken  by  the  practitioner  himself  —  though  this  has  been  done  in 
Germany  and  Sweden  —  but  that  he  should  be  sure,  if  need  be  by  per- 


374  SYSTEM   OF  MEDICINE 

sonal  observation,  that  tlie  person  lie  employs  is  well  taught,  industrious, 
conscientious,  and  obedient  to  orders. 

The  technique  of  massage  is  not  difl&cult  to  acquire  ;  and,  as  the  whole 
value  of  the  treatment  lies  in  the  proper  execution  of  minute  details,  one 
who  prescribes  it  should  be  familiar  at  least  with  the  movements  com- 
monly used.  "  The  various  manipulations  and  their  modifications  natu- 
rally suggest  themselves  to  one  who  clearly  comprehends  the  anatomical, 
physiological,  and  pathological  indications  in  any  given  case  "  (1). 

With  the  single  exception  of  Dr.  Granville's  percussor,  no  instru- 
ment, among  the  hundreds  devised  for  the  performance  of  some  of  the 
movements,  can  usefully  replace  the  human  hand.  Great  manual 
strength  is  not  necessary,  though  a  hand  not  too  small  is  desirable ;  but 
very  large  and  muscular  hands  lack  the  delicacy  of  touch  which  is  so 
desirable.  The  most  rational  classification  of  the  various  movements  is 
that  into  four  kinds,  for  which  the  French  names  are  usually  employed, 
as  follow :  Effleurage  (stroking),  petrissage  (kneading),  friction  (rubbing), 
tapotement  (percussion  or  striking).  These  may  all  of  them  be  used 
lightly  or  strongly,  deeply  or  superficially,  and  in  various  combinations, 
as  needful  for  special  ends. 

Effleurage  is  performed  with  slow  strokes,  made  with  the  flat  or  with 
the  heel  of  the  hand,  or  with  its  ulnar  edge  or  with  a  finger  only.  The 
stroking  should  always  be  centripetal,  the  hand  in  the  return  movement 
only  lightly  grazing  the  skin.  The  chief  usefulness  of  effleurage,  apart 
from  its  slight  stimulation  of  the  skin-nerves,  is  in  hastening  the  move- 
ment of  the  contents  of  the  veins  and  lymphatics. 

Petrissage — the  most  important  and  most  difficult  of  the  several 
movements  —  is  done  by  grasping  with  the  whole  hand  the  tissues  to  be 
manipulated,  lifting  them  somcAvhat,  and  kneading  them  with  an  alter- 
nate tightening  and  loosening  of  the  hold.  In  large  masses  of  muscle, 
like  those  of  the  thigh  or  calf,  it  is  sometimes  best  to  use  both  hands. 
The  movement  is  very  different  from  pinching.  Care  must  be  used  that 
the  skin  moves  with  the  hand  over  the  underlying  tissues.  The  surface 
hairs  will  be  painfully  dragged  if  the  hand  is  permitted  to  slip  over  the 
skin.    In  certain  favourable  situations  —  in  the  upper  arm,  for  example 

—  the  extended  hands  are  placed  upon  opposite  sides  of  the  limb  and 
moved  rapidly  back  and  forth  with  firm  pressure,  rolling  the  muscle 
masses  between  them  and  pressing  them  together  or  against  the  bone, 

—  a  motion  entitled  "fulling,''^  from  its  likeness  to  the  movements  used 
by  fullers  in  handling  linen.  The  effects  are  identical  with  those  of 
ordinary  petrissage,  but  somewhat  more  stimulating  from  the  greater 
speed  of  the  manipulation.  A  slight  contraction  of  the  muscles  is  in- 
duced by  this  operation,  the  absorption  of  infiltrations  in  the  tissues  is 
promoted,  and  their  progress  through  the  lymph-vessels  assisted. 

Friction  is  performed  by  firm  rubbing  in  small  circles  with  the  thumb, 
finger-tips,  or  whole  hand.  It  might  well  be  included  as  a  modified  form 
of  petrissage,  as  it  has  precisely  similar  effects,  and  is  useful  where  the 
tissues  are  too  closely  attached  to  bones  to  be  picked  up  by  the  hand,  as 


MASSAGE:     TECHNIQUE,   PHYSIOLOGY,   El  C.  375 

in  the  neighbourhood  of  joints ;  in  such  situations  it  is  especially  of 
value  in  the  removal  of  articular  effusions. 

Tapotement  is  the  application  of  rapid  blows  delivered  with  the  ulnar 
edge  of  the  hand,  witn  the  tips  of  the  bent  lingers,  or  with  the  flat  of 
the  open  hand.  The  end  to  be  attained  and  the  tissue  to  be  affected 
decide  which  method  shall  be  used.  It  acts  for  the  most  part  as  a 
mechanical  stimulant.  If  we  wish  to  excite  the  peri2:)heral  skin-nerves 
we  use  the  flat  hand  —  for  instance,  in  anaesthetic  areas ;  to  reach  a 
nerve-trunk,  blows  with  the  finger-tips,  rapidly  delivered  from  the  wrist 
(not  using  the  whole  forearm  in  a  hammering  fashionj,  are  employed, 
and,  to  excite  muscles,  "  chopping,"  with  the  edge  of  the  hand,  trans- 
versely to  the  long  axis  of  the  muscles. 

The  French  and  the  Swedish  masseurs  have  wasted  much  ingenuity 
iu  subdividing  the  several  manipulations  with  great  subtlety,  and  some 
operators  perform  a  great  variety  of  what  can  only  be  called  ornamental 
movements,  fantastic  flourishes  and  airy  graces,  like  the  affectations  of 
a  fashionable  pianist. 

In  the  consideration  of  the  force  and  frequency  of  application  desir- 
able in  any  particular  case,  the  usual  direction  to  the  student  of  massage 
must  be  remembered,  namely,  that  his  mind  is  to  be  given  not  to  the 
movements  his  hands  are  making,  but  to  the  tissues  upon  which  he  is 
operating  and  the  effect  he  wishes  to  produce.  The  foi'ce,  therefore,  must 
be  such  as  to  attain  the  desired  end,  and  this  will  necessarily  vary  with 
the  state  of  the  tissues  and  the  condition  of  the  patient.  In  a  chronic 
arthritis  with  firm  exudation  vigorous  friction  will  be  required ;  in  a  more 
acute  trouble  —  a  sprain,  for  instance  —  much  less  force  will  be  needed  ; 
at  first,  certainly,  only  light  ef&eurage.  Xervous,  hysterical,  or  excitable 
patients  must  be  very  gently  handled  at  first,  and  only  for  short  periods. 
In  certain  cases  (again  a  recent  sprain  may  be  cited  as  an  example)  mas- 
sage three  or  four  times  daily  will  be  of  service,  each  application  lasting 
only  from  five  to  fifteen  minutes.  Most  massage  procedures,  to  be  of 
use,  should  be  repeated  at  least  once  daily.  General  massage,  such  as 
is  used  for  convalescent  pa,tients  or  "  rest-cure  "  eases,  must  last  from 
thirty  minutes  to  an  hour  every  day. 

The  usefulness  of  massage  is  greatly  lessened  by  the  common  practice 
of  employing  some  oily  substance  for  lubricating  the  skin.  Moreover 
it  is  dirty ;  and  the  excuses  offered  that,  unless  an  oil  be  applied,  the 
operator  will  pinch  unpleasantly  or  will  pull  the  hairs  painfully,  are  con- 
fessions of  incompetency.  In  old  or  much  emaciated  patients,  whose  skin 
is  harsh,  dry,  and  scaly,  it  is  sometimes  desirable  to  use  an  emollient; 
and  for  such  purposes  the  best  unguent  is  lanolin  with  the  addition  of 
enough  oil  of  sweet  almond  to  render  it  of  the  consistency  of  thick  cream. 
Vaseline  is  difficult  to  remove  satisfactorily  after  use,  is  not  absorbed,  and 
to  some  skins  is  irritating.  Generally  it  may  be  said  no  oily  application 
should  be  used  without  the  physician's  orders. 

There  can  be  no  questicm  of  the  much  greater  value  to  the  patient  of 
massage  when  used  directly  upon  the  skin.     Done  through  clothing,  even 


376  SYSTEM   OF  MEDICINE 

the  thinnest,  the  operator  must  fail  in  technique :  the  palpation  of  the 
tissue  will  be  imperfect,  and  an  additional  amount  of  force  must  be  used. 

General  massage  is  a  form  of  passive  exercise  for  those  ixnable  to  take 
active  exercise,  or  for  whom  active  exercise  is  undesirable.  It  is  usual, 
but  not  important,  to  begin  with  a  lower  extremity.  After  manipulating 
the  foot  the  leg  is  worked  with  kneading,  fulling,  efileurage,  and  friction 
about  the  joints.  It  is  best  to  put  a  sock  or  stocking  on  the  foot  when 
the  massage  is  over ;  and  every  care  must  be  taken  to  keep  the  parts 
warmly  covered  with  a  blanket  as  they  are  finished.  After  the  legs  the 
operator  proceeds  to  the  arms  and  treats  them  in  the  same  way.  In  mas- 
sage of  the  back  vigorous,  rapid  efileurage  over  the  spine  is  employed,  as 
well  as  the  treatment  to  the  muscles.  In  rubbing  the  chest  in  women 
the  breasts  are  usually  left  untouched.  Last  comes  the  very  important 
operation  of  abdominal  massage.  In  order  to  obtain  relaxation  of  the 
aladominal  muscles,  the  head  is  raised  upon  a  pillow  and  the  knees  bent, 
while  the  patient  is  directed  to  breathe  deeply.  At  first  there  is  always 
difficulty  in  overcoming  the  tension,  largely  involuntary,  of  the  recti 
abdominales,  especially  in  hysterical  women,  but  as  they  grow  accus- 
tomed to  the  manipulation  the  muscles  slacken.  Deep  friction  in  small 
circles,  continued  over  the  whole  abdomen,  is  made  first,  using  the 
fingers  of  one  hand;  kneading  movements,  chiefly  with  the  heel  and 
palm,  in  a  large  circle  round  the  navel ;  then  similar  applications  are 
made  over  the  large  intestine,  beginning  at  the  right  iliac  fossa,  and 
following  the  course  of  the  ascending,  transverse,  and  descending  colon  ; 
the  hands  are  placed  on  the  two  sides  below  the  ribs  and  drawn  forward 
with  deep  pressure  several  times ;  the  region  of  the  liver  and  the  left 
hypogastric  and  hypochondriac  regions  are  kneaded,  reaching  in  this 
way  the  small  accessible  portion  of  the  stomach,  and  the  whole  process 
ends  by  the  operator  grasping  the  abdominal  walls  lightly,  but  firmly, 
and  imparting  a  rapid  vibratory  movement  to  them  and  to  the  underlying 
structures.  Occasionally  tapotement  or  clapping  \Wth  the  hand  over  the 
liver  may  be  added  to  these  procedures.  After  the  completion  of  the 
massage  the  patient  should  be  warmly  covered  and  lie  quiet  for  an  hour. 

The  effects  of  general  massage  are  very  decided  and  apparent.  The 
immediate  results  are  a  fine  sense  of  well-being,  a  feeling  of  comfortable 
tiredness  without  exhaustion,  and  a  pleasant  drowsiness.  In  rare  cases 
hysterical  patients  are  aroused  and  excited  by  it,  and  more  rarely  still, 
persons  are  found  whom  massage  leaves  chilled,  irritated,  and  uncom- 
fortable. In  such  cases  the  experiment  may  be  tried  of  reversing  in 
part  the  order  of  procedure,  rubbing  the  abdomen  first  instead  of  last, 
then  the  chest  and  back,  and  finally  the  arms  and  legs.  Occasionally  it 
may  be  found  that  massage  has  been  overdone,  and  that  lighter  appli- 
cations are  needed  to  give  good  results.  Very  seldom  indeed  do  we 
find  patients  to  v/hom  massage  is  so  disagreeable  as  to  make  its  appli- 
cation entirely  impossible. 

The  later  effects  are  also  well  marked ;  the  skin  softens  and  shows 
a  better  colour ;  the  appetite  is  improved  as  well  as  the  digestion ;  the 


MASSAGE:    TECHmQUE,   PHYSIOLOGY,   ETC.  377 

bowels  act  more  freely ;  sleep  is  more  prolonged  and  sounder,  and  the 
muscles  become  larger  and  firmer.  The  results  in  cases  of  disease  will 
be  considered  later  in  more  detail. 

Studies  of  the  results  of  massage  in  health  and  in  various  maladies 
have  been  numerous  and  valuable  in  late  years ;  the  work  of  Bunge, 
Brown-Sequard,  Ziemssen,  Weir  Mitchell,  Playf air,  Sinkler,  Gerst,  Good- 
hart,  Kleen  and  Profanter,  taking  the  subject  from  the  clinical  side,  has 
been  confirmed  and  wider  possibilities  for  massage  application  suggested 
by  the  physiological  experiments  of  several  of  these  same  observers,  as 
well  as  by  the  labours  of  Lombard,  Mosso,  Maggiora,  Lassar,  Eccles, 
Glovetzky,  Mosengeil,  Mezger,  Kronecker,  Lauder  Brunton  and  Tunni- 
cliffe,  Winternitz  and  Zabludowsky. 

The  immediate  effect  of  massage  is  to  increase  the  amount  of  blood  in 
the  region  rubbed ;  the  skin  is  flushed,  the  vessels  in  the  muscles  receive 
a  larger  amount  of  blood,  and  the  flow  of  blood  is  greater  through  the 
part  for  some  time  subsequently.  Accompanying  this  there  is  a  fall  of 
general  blood  pressure  and  a  slowing  of  the  pulse,  if  the  manipulation 
has  been  a  deep  muscular  stimulation.  Superficial  skin  stimulation 
increases  blood  pressure.  An  increased  activity  in  the  movement  of 
the  lymph-stream  has  also  been  accurately  demonstrated. 

It  is  obvious  that  we  have  here  a  useful  indication  for  the  treatment 
of  recent  local  inflammatory  conditions,  such  as  result  from  sprains,  luxa- 
tions, etc.  The  increased  circulation  will  not  only  prevent  stasis  and  the 
migration  of  white  corpuscles  into  the  tissues,  but  will  rapidly  remove 
the  corpuscles  and  lymph  which  have  been  already  thrown  out.  Again, 
the  secondary  effect  of  the  larger  amount  of  blood  passing  through  the 
region  is  valuable  in  case  of  any  local  disturbances  of  nutrition,  indolent 
ulcers,  undue  amount  of  deposit  following  fractures,  contusions  and 
myositis. 

Bonders,  Pagenstecher,  Damalix,  Klein  and  others  have  reported 
successes  in  the  treatment  of  both  catarrhal  and  phlyctenular  conjunc- 
tivitis, opacities  of  the  cornea,  pannus  and  even  cataract,  by  means  of 
massage.  For  full  descriptions  of  their  methods  the  articles  by  these 
and  other  ophthalmic  surgeons  must  be  consulted  [vide  References]. 

Besides  these  and  such  effects  other  general  consequences  are  per- 
ceived. One  result  of  the  changes  in  blood  pressure  is  an  increased  secre- 
tion of  urine,  another  is  that  fatigue  —  whether  local,  as  in  an  over-used 
group  of  muscles,  or  general  —  may  be  rapidly  and  pleasantly  removed 
by  massage,  that  is,  by  the  removal  of  fatigue-products  and  by  the 
flushing  of  the  muscles  and  nerve-centres  with  quantities  of  fresh  blood. 
Lombard,  Mosso,  Maggiora  and  Zabludowsky  have  shown  by  experiments 
in  their  own  persons,  or  upon  animals,  the  prompt  power  of  massage  to 
restore  functional  ability  to  exhausted  muscles.  Maggiora  found  that 
this  improvement  did  not  take  place  in  muscles  whose  blood-supply  had 
been  shut  off.  He  further  concluded  that  tapotement  and  friction  were 
less  effectual  than  kneading,  and  this  again  not  so  useful  as  mixed 
massage ;  and  that  the  beneficial  effects  of  manipulation  were,  within 


378  SYSTEM  OF  MEDICINE 

certain  limits,  directly  proportional  to  its  duration.  That  more  blood 
actually  flows  through,  the  tissues  during  and  after  the  rubbing  has 
been  proved  by  the  careful  experiments  of  Lauder  Brunton  and  Tauni- 
cliffe.  A  series  of  clinical  examinations  of  the  blood  before  and  after 
massage  under  very  varied  conditions  of  health  and  disease  have  recently 
been  made  by  myself.  Originally  it  was  my  intention  to  study  the 
effects  of  massage  in  anaemia,  bat  a  wider  field  opened  itself  out  as  the 
very  marked  results  in  such  cases  appeared.  In  sixty  observations  upon 
thirty  patients  only  three  failed  to  show  aii  increased  number  of  red 
corpuscles  after  general  massage.  The  conclusions  reached  were  as  fol- 
lows :  —  In  health  massage  increases  the  number  of  red  corpuscles,  and 
to  a  less  degree  and  not  so  constantly,  their  haemoglobin  value.  In  all 
forms  and  grades  of  ancumia  there  is  a  very  large  and  constant  increase 
in  the  number  of  red  corpuscles  after  massage ;  this  is  greatest  about  an 
hour  after  treatment,  slowly  decreasing  from  that  time.  This  decrease 
is,  however,  postponed  further  and  further  if  the  manipulation  be  daily 
repeated.  There  is  an  occasional  but  inconstant  increase  in  the  haemo- 
globin value,  an  increase  proportionately  less  great  than  that  of  the 
cellular  elements.  The  additional  red  corpuscles  discovered  by  the 
Thoma-Zeiss  haemocytometer  after  an  hour's  massage  was  often  as 
great  as  20  per  cent,  and  in  some  cases  reached  50  per  cent  of  the 
number  originally  observed. 

The  increased  activity  of  the  superficial  circulation  does  not  suffice  to 
account  for  so  great  a  change :  moreover,  if  the  increase  arise  merely 
from  an  addition  to  the  number  of  red  cells  in  the  peripheral  vessels 
at  the  expense  of  the  rest  of  the  circulating  fluid,  there  should  be  an 
increase  of  haemoglobin  directly  proportional  to  the  increase  in  the  red 
globules;  yet  in  no  case  did  the  haemoglobin-increment  exceed  15  per 
cent,  even  when  the  cell-increase  reached  50  per  cent.  It  can  scarcely  be 
supposed  that  an  hour's  massage,  much  as  it  hurries  the  current  in  the 
vessels,  can  actually  cause  a  greatly  increased  production  of  blood-cells ; 
although  the  repetition  of  treatment  no  doubt  stimulates  cell-making. 
Still,  the  effect  of  this  new  activity  and  movement  of  the  cells  upon 
metabolic  processes  must,  at  any  rate  for  the  time,  be  much  the  same  as 
if  a  considerable  addition  were  made  to  their  number.  Further,  these 
examinations  make  it  seem  in  every  way  probable  that,  in  health,  there 
are  vast  numbers  of  corpuscles  ready  for  use  if  called  for,  and  also 
probable  that  a  part  of  the  trouble  in  anaemic  diseases  may  be  a  lack  of 
availability  or  of  activity  in  the  corpuscles,  that  many  of  them  are  slug- 
gishly lingering  in  the  by-ways  of  the  circulation,  and  only  forced  or 
pushed  into  greater  activity  and  usefulness  by  the  direct  stimulus  of 
massage.  "  The  state  of  things  in  the  system  in  anaemias  may  be,  to 
draw  an  analogy  from  economic  conditions,  like  the  want  of  circulating 
money  during  times  of  panic,  when  gold  is  hoarded  and  not  made  use  of, 
and  interference  with  commerce  and  manufactures  results." 

Effusions  of  lymph  or  blood  in  serous  cavities,  in  the  substance  of 
muscles,  and  in  the  sheaths  of  the  tendons  or  nerves,  may  be  removed  by 


MASSAGE:    TECHNIQUE,    PHYSIOLOGY,  ETC.  y]9 

means  of  massage.  Reibmayr  and  Hoffinger  injected  water  into  the 
abdominal  cavity  of  rabbits,  subjected  some  of  tlie  animals  to  massage 
afterwards,  and  on  opening  the  abdomens  found  that  in  those  which  had 
been  massaged  the  proportion  of  the  fluid  absorbed  in  a  given  time  was 
more  than  one-third  greater  than  in  those  not  so  treated. 

Von  Mosengeil  made  injections  of  Indian  ink  into  two  joints  in 
rabbits,  and  massaged  one  joint.  Upon  examining  the  articulation 
treated  very  little  of  the  injected  matter  could  be  discovered  in  it,  even 
when  opened  after  only  a  few  minutes'  massage.  The  ink  could  be 
traced  through  the  lymphatic  vessels  into  the  neighbouring  glands.  In 
the  untouched  joints  the  ink  was  found  unchanged,  no  attempt  at  absorp- 
tion having  taken  place. 

Acute  arthritic  disorders,  like  rheumatism  and  gout,  accompanied  by 
general  constitutional  disturbance,  are  not  suitable  for  massage  until  the 
acute  stage  has  passed;  but  localised  or  traumatic  arthritis  and  synovitis, 
where  there  is  no  risk  of  promoting  the  resorption  of  toxic  products,  may 
properly  be  so  treated.  The  results  in  sprains,  teno-synovitis  and  the 
like,  are  sometimes  amazing ;  and,  if  massage  be  instituted  immediately, 
speedy  recovery  may  be  confidently  predicted.  The  sooner  after  the 
injury  manipulation  can  be  begun  the  better.  At  first  the  swollen, 
bruised,  and  tender  structures  should  not  be  touched  at  all,  but  effleurage 
made  from  the  seat  of  the  accident  centripetally,  to  hasten  the  circulation 
from  the  congested  part  and  help  to  carry  oft'  the  exudation.  Similar 
stroking  should  be  used  below  the  injured  part,  and,  before  the  end  of 
the  application  (which  should  last  ten  to  fifteen  minutes),  it  will  be 
found  possible  to  give  etfleurage  and  light  friction  directly  to  the 
inflamed  tissues.  At  first  manipulations  should  be  made  several  times 
daily,  and  a  firm  bandage  put  on  in  the  intervals. 

Where  we  find  old  synovial  inflammation  with  thickened  connective 
tissue  and  firmly  organised  deposits,  much  more  force  may  advantage- 
ously be  used ;  and  such  a  case  presents  one  of  the  few  occasions  where 
the  use  of  some  unguent  is  desirable,  since  sufiiciently  strong  and  fre- 
quently repeated  friction  will  sometimes  injure  the  skin  unless  a  lubri- 
cant be  applied. 

Massage  of  the  neck,  in  the  form  of  downward  stroking  on  the  sides 
of  the  neck  and  friction  and  stroking  from  the  occiput  downwards,  serves 
as  a  means  of  lessening  the  amount  of  the  blood  in  the  head  by  pushing 
onwards  the  venous  flow.  This  manner  of  relieving  cerebral  congestion 
may  be  made  use  of  for  insomnia,  where  the  activity  of  the  brain  is  so 
great  as  to  prevent  rest,  as  it  brings  about  that  mild  degree  of  cerebral 
ansemia  which  is  the  physiological  condition  necessary  for  sleep.  Even 
where  flushing,  headache,  sleeplessness,  dizziness,  and  confusion  of  mind 
point  to  a  threatening  apoplexy,  the  same  procedure  is  of  service ;  and 
in  migraine  the  effects  are  occasionally  most  happy.  In  the  easily  recog- 
nised complexus  of  symptoms  somewhat  loosely  described  under  the 
vague  name  of  "spinal  irritation"  —  a  state  in  which  insomnia  is  fre- 
quently very  persistent  —  eflieurage,  vigorously  applied,  will  be  found  a 


38o  SYSTEM  OF  MEDICINE 

valuable  aid  in  inducing  sleep :  here,  however,  it  must  be  used  upon  the 
back  as  well  as  upon  the  neck.  The  technique  is  of  the  simplest.  The 
operator,  standing  behind  the  sitting  patient,  lays  the  hands  flatwise 
upon  the  lateral  aspects  of  the  neck  below  the  ears,  and  pressing  gently, 
strokes  downward,  over  the  jugular  veins,  at  first  with  the  ulnar  edge 
of  the  hand,  gradually  turning  the  hand  as  it  moves  until  the  palm  and 
then  the  radial  edge  carry  on  the  movement.  Pressure  upon  the  hyoid 
bone  and  the  larynx  should  be  avoided. 

Gerst  has  used  the  same  means  for  the  removal  of  the  hyperaemia 
attendant  upon  concussion  of  the  brain  and  upon  fracture  of  the  skull. 

In  migraine,  trigeminal  and  supra-orbital  neuralgias,  or  neuritis,  much 
relief  is  felt  from  local  massage ;  of  course  its  use  should  not  cause  neg- 
lect of  other  measures,  such  as  electricity,  the  regulation  of  the  bowels 
and  digestion,  or  remedies  to  combat  the  accompanying  anaemia.  In 
migraine  especially  it  will  be  found  necessary  to  continue  the  treat- 
ment for  some  weeks  to  be  sure  of  benefit.  In  these  affections  it  is  very 
common  to  see  the  masseur  work  from  the  centre  of  the  forehead  toward 
the  temporal  region,  a  violation  of  the  maxim,  stated  above,  that  move- 
ments should  be  in  the  direction  of  the  venous  currents.  Manipulation 
should  follow  the  course  of  the  frontal  vein,  from  the  temples  toward 
the  root  of  the  nose. 

Sciatica,  whether  we  consider  it  as  neuralgic  or  neuritic,  is  much 
helped  by  carefully-applied  effleurage.  The  German  physicians  prefer 
massage  to  any  other  treatment  for  this  rebellious  affection.  Kleen's 
prescription  is  that  as  infiltrations  (myositis  in  the  glutseus  maximus  and 
medius  muscles)  frequently  accompany  or  cause  sciatica,  careful  palpation 
is  to  be  made  for  these;  and  although,  "on  anatomical  grounds,  such  in- 
filtrations may  readily  escape  the  perception  of  the  masseur,  still  the  rule 
holds  good  .  .  .  that  energetic  frictions  should  be  made  in  this  place, 
even  if  no  pathological  changes  can  be  found.  Furthermore,  one  should 
make  vigorous  tapotement  with  the  fist  along  the  course  of  the  sciatic 
nerve  as  far  as  the  hollow  of  the  knee."  Overstretching  the  nerve,  by 
flexion  of  the  thigh  with  a  straight  knee,  pushed  to  the  point  of  endur- 
ance, is,  according  to  Kleen,  to  be  added  to  the  prescription. 

Dr.  Weir  Mitchell  has  long  abandoned  these  methods  in  obstinate 
sciaticas  for  a  plan  of  his  own  which  has  been  attended  with  remarkable 
success.  To  lessen  the  blood  in  the  limb,  and  to  remove  the  irritation 
caused  by  motion,  the  patient  is  confined  to  bed,  the  leg  bandaged  firmly 
from  the  toes  to  the  groin  with  a  flannel  bandage,  and  the  hip  and  knee 
joints  fixed  by  a  long  splint  from  axilla  to  ankle,  or,  in  patients  who 
can  be  trusted  to  keep  quiet,  by  sand-bags.  The  bandage  is  removed  and 
the  leg  rubbed  twice  daily,  general  kneading  of  the  muscles  being  used 
except  of  those  near  the  nerve ;  even  indirect  pressure  upon  that  struct- 
ure is  to  be  avoided.  The  nerve  tract  is  to  be  "  efileureed  "  with  long, 
steady  strokes ;  the  hip  and  knee  joints  passively  flexed  once  or  twice 
in  a  gentle  manner,  and  the  bandage  reapplied.  Three  weeks  of  this 
procedure  will  usually  sufiice  for  a  cure,  even  in  obstinate  cases. 


MASSAGE:     TECHNIQUE,   PHYSIOLOGY,    ETC.  381 

Activity  must  be  resuraed  gradually,  and  the  use  of  the  bandage  and  of 
a  certain  amount  of  rest  in  a  recumbent  position  insisted  upon  for  a  time. 

The  treatment  outlined  for  these  neuralgias  may  serve  to  indicate  the 
manner  in  which  any  form  of  neuritis  or  painful  affection  of  a  nerve  may 
be  handled  by  massage,  whatever  the  origin  of  the  disorder.  The  results 
of  injuries,  bruises,  crushes,  and  even  sections  of  nerves  are  relieved  by 
the  same  applications,  though  of  course  the  methods  employed  will  vary 
somewhat  with  the  character  and  seat  of  the  injury,  and  the  stage  of  the 
disease.  Manipulations  cannot  be  begun  upon  wounded  surfaces  until 
skin-healing  is  complete.  The  atrophy  of  muscles  consequent  upon  nerve- 
section  can  be  minimised,  the  period  of  disability  much  shortened,  the 
subsequent  contractions  prevented,  and  the  danger  of  pressure  upon  the 
nerve  by  scar-tissue  lessened.  In  old  cases  of  wounds  of  nerves  where 
contractions,  joint-stiffening,  muscle-atrophy,  and  the  various  disturbances 
of  sensation  have  all  appeared  from  neglect  of  early  treatment,  massage  is 
an  indispensable  instrument.  It  may  perhaps  be  necessary  to  repeat 
what  I  have  already  urged,  that  such  a  statement  must  not  be  construed 
to  imply  the  neglect  of  other  aids  —  douches,  faradisation  of  the  atrophied 
muscles  and  of  the  muscles  opposed  to  contracted  groups,  galvanism  to 
the  nerves,  the  forcible  breaking  up  of  joint-adhesions,  etc.^ 

Contracted  scars  may  advantageously  be  subjected  to  the  same 
manipulations  as  contracted  muscles,  though,  as  such  tissue  is  but  ill- 
supplied  with  blood-vessels,  the  results  are  less  striking.  Firm  pressure, 
squeezing,  pinching,  kneading,  and,  where  possible,  stretching  are  the 
methods  employed.  Of  course,  the  earlier  the  case  is  seen,  and  the  less 
firm  the  cicatrices,  the  more  successful  the  result,  as  the  further  increase 
of  scar-tissue  may  be  prevented,  and  that  already  formed  thinned  and 
softened. 

Writer's  cramp  and  the  allied  forms  of  muscular  difficulty,  whether 
paralysis,  tremor,  or  spasm  from  over-use  of  single  groups  of  muscles, 
cannot  be  better  combated  than  by  massage  and  galvanism.  The  muscles 
usually  affected  are  the  flexors  of  the  forearm  or  in  the  hand,  and  the 
occupations  most  commonly  subject  to  the  professional  neuroses  are 
writers,  telegraphers,  watchmakers,  masons,  or  type-setters.  The  bicycle 
has  of  late  given  us  a  new  form,  in  which  the  muscles  of  the  thigh  are 
affected ;  and  one  or  two  examples  of  an  undescribed  neurosis  have  re- 
cently been  seen  at  the  Infirmary  for  Nervous  Diseases  in  Philadelphia 
in  tram-car  drivers,  from  the  constant  pushing  upon  the  hand-brake.  In 
all  such  disorders  absolute  rest  of  the  affected  part  is  the  first  require- 
ment, and  massage  the  next.  Authors  differ  as  to  the  proper  technique, 
but  probably  the  most  effectual  method  is  strong  effleurage  and  petris- 
sage followed  by  tapotement  to  the  affected  muscles  and  to  their  nerves 
where  these  are  accessible.     In  instances  where  muscular  infiltrations 

1  For  flfitailed  cases  of  siifh  (lisordors  and  their  successful  treatment  by  the  means  sug- 
gested the  well-known  work  of  T)r.  S.Weir  Mitchell  on  Injuries  of  N''r»es  may  be  consulted. 
The  present  writer  has  i'er)ort(!d  the  later  history  of  a  number  of  Dr.  Mitchell's  cases  in 
Remote  Consequences  of  Nerve  Injuries  and  their  Treatment.    Philad.,  181)5. 


382  SYSTEM  OF  MEDICINE 

are  found  in  connection  with  these  palsies,  or  where  neuritis  is  present, 
especial  attention  must  be  given  to  the  parts  thus  affected. 

Torticollis,  when  rheumatic  in  origin,  yields  readily  to  massage  of  the 
affected  muscles.  Where  its  cause  lies  more  obscurely  in  an  affection  of 
the  cervical  portion  of  the  cord  massage  is  of  less  use,  though  it  helps  to 
relax  the  spasm,  and  may  be  of  important  service  by  strengthening  the 
opposing  muscles. 

An  excellent  instance  of  the  difficulty  with  which  a  new  systematic 
treatment  of  disease  makes  its  way  is  furnished  by  the  facts  concerning 
the  application  of  massage  in  chorea.  Blanche  in  1854  presented  to  the 
Academic  de  Medecine  in  Paris  a  report  of  108  cases  of  chorea  success- 
fully treated  by  massage,  and  for  a  time  the  method  was  fashionable,  and 
has  continued  in  use  in  France  to  a  certain  extent;  but  the  majority  of 
medical  men  continue  to  rely  upon  drugs,  with  a  confidence  unimpaired 
by  the  fact  that  no  matter  what  or  how  much  medicine  be  given  the  clonic 
movements  continue  for  weeks.  In  the  lesser  degrees  of  chorea  minor, 
arsenic,  iron,  fresh  air,  and  proper  feeding  may  be  sufficient.  In  the  more 
severe  cases,  even  omitting  the  consideration  of  chorea  major,  bed,  with 
massage,  will  be  found  to  effect  a  very  rapid  and  visually  perfect  cure. 
As  the  co-ordination  improves,  and  the  involuntary  jerkings  lessen,  cau- 
tiously, increased  gymnastic  movements  should  be  added.  Besides  its 
influence  over  the  muscles  general  massage  is  of  value  in  counteracting  the 
ansemic  or  chlorotic  condition  so  commonly  associated  with  the  disease. 
Drs.  Goodhart  and  Phillips  in  their  series  of  cases  of  chorea  treated  by 
massage  rather  understate  than  overstate  the  favourable  results. 

In  the  treatment  of  many  other  disorders  of  the  central  nervous 
system  massage  has  a  recognised  and  well-established  place.  In  acute 
atrophic  ixirahjsis  it  is  at  least  helpful  in  maintaining  nutrition.  Dr. 
GoAvers,  Prof.  Eulenberg,  and  others  describe  improvement  in  cases  of 
pseudo-hypertrophic  ixircdysis  during  its  use.  In  the  early  stages  of  this 
disease  it  has  certainly  been  my  good  fortune  to  see  arrest  of  the  pro- 
gressing paralysis,  and  a  decided  increase  in  the  strength  of  the  weakened 
muscles. 

In  locomotor  ataxia  the  effect  is  often  astonishing,  although  one  should 
remember  that  periods  of  rest,  even  of  improvement,  occur  in  this  dis- 
order without  treatment.  But  the  results  exhibited  appear  too  con- 
sistently in  case  after  case  to  be  the  result  of  a  fortuitous  coincidence  of 
the  ''  normal  "  cessation  of  activity  in  the  degenerative  process  with  the 
beginning  of  treatment  by  massage.  Patients  with  ataxia  usually  suffer 
less  pains  if  they  take  little  active  exercise ;  and  the  mechanical  treat- 
ment is  useful  in  overcoming  the  ill-effects  of  this  inactivity.  Yet  this 
alone  would  not  account  for  all  the  improvements;  the  anaesthesia  and 
paraesthesia  disappear  or  lessen,  as  well  as  the  lancinating  pains  ;  the  in- 
somnia, so  often  present,  is  bettered ;  even  the  difficulties  of  defaecation 
and  micturition  diminish.  Eecovery  is  not  to  be  looked  for  —  no  power 
can  renew  sclerosed  nerve-cells  —  but  in  a  large  majority  of  cases  decided 
improvement  may  be  confidently  expected. 


MASSAGE:     TECHNIQUE,  PHYSIOLOGY,   ETC.  383 

Persistent  kneading,  effleurage,  and  tapptement  of  the  paralysed  parts 
will  do  much  to  restore  function  in  muscles  palsied  by  anterior  ijolio- 
myeliUs,  and  massage  and  faradism  should  be  continued  in  such  cases  for 
a  year  at  least  before  giving  up  to  despair,  even  if  there  be  no  apparent 
improvement  in  the  muscles.  The  local  temperature,  usually  very  low, 
can  always  be  raised  several  degrees  by  massage,  and  even  if  the  muscu- 
lar tone  and  voluntary  movement  are'not  restored,  the  increased  activity 
of  the  circulation,  which  by  persistent  effort  can  be  established,  will  make 
a  great  difference  in  the  patient's  comfort. 

Th6  direct  influence  of  massage  upon  nutrition,  the  peripheral  circula- 
tion, secretion,  and  excretion,  the  indirect  effects  upon  the  heart  and  upon 
respiration,  combine  to  render  it  a  most  important  aid  in  treating  the 
protean  aspects  of  hysteria  and  neurastheyiia.  Individual  aspects  of  each 
case,  in  the  way  of  sensory  disturbances,  disorders  of  digestion,  and  the 
like,  may  require  special  modifications  in  the  application  of  massage ; 
but  for  the  most  part  what  has  already  been  described  as  "  general 
massage  "  will  be  found  the  most  useful.  Combined  with  rest,  full 
feeding,  and  isolation,  it  is  an  indispensable  part  of  the  "rest-treatment " 
of  Weir  Mitchell  (13).  For  the  details  of  the  application  of  these  means 
the  original  essay  in  which  it  was  proposed  may  be  consulted,  or  Dr. 
Playfair's  book  (14)  by  which  it  was  introduced  in  England.  Care  must 
be  taken  at  first  not  to  overwork  patients  ;  but  after  a  few  days  massage 
may  be  ordered  for  a  full  hour  daily,  or  even,  as  Dr.  Playfair  has  used 
it,  twice  a  day.  Especial  attention  should  be  given  to  the  proper  and 
thorough  performance  of  abdominal  massage,  on  which  much  of  the 
patient's  ability  to  take  and  digest  food,  as  well  as  the  regularity  of 
the  intestinal  action,  will  be  found  to  depend.  A  weekly  weighing  of 
the  patient  will  tell  whether  massage  is  properly  performed  or  not.  If 
weight  is  not  being  gained  some  oversight  will  be  found,  either  the  diet 
is  insuf&cient  or  imperfect,  or  the  massage  ill  performed.  Dr.  Playfair  is 
of  opinion  that  the  desire  for  food  and  the  power  to  assimilate  it  is  the 
best  guide  as  to  the  efficiency  of  the  rubbing.  Another  indication  will 
be  found  in  the  urine,  where  the  presence  of  deposits  of  urates  or  uric 
acid  will  quickly  tell  of  mal-assimilation. 

Patients  with  melancholia  and  various  forms  of  insanity  may  advan- 
tageously be  rubbed  should  the  general  indications  call  for  it.  Those 
often  need  it  who  refuse  to  take  active  exercise,  or  if  forced  out  of  doors 
drag  listlessly  about.  Melancholia,  occurring  about  the  time  of  the 
menopause,  has  many  of  its  most  disagreeable  symptoms  greatly  miti- 
gated by  massage;  for  instance,  the  flushing  so  often  complained  of  in 
various  forms  is  improved  by  the  better  balance  of  circulation  which  is 
brought  about  by  manipulation. 

Massage  for  gynaicolor/ical  ends  is  a  matter  for  a  special  treatise  —  at 
least  so  far  as  the  direct  manipulation  of  tlie  uterus  by  P>randt's  method 
is  concerned.  Its  desirability  is  open  to  very  grave  doubts,  although  its 
utility  sf'cms  to  })e  estal)]ished  l)y  the  testimony  of  Profanter's  reports  of 
Schulze's  cases  (15j,  Bunge's  (10)  articles,  and  the  studies  of  Eecves 


384  SYSTEM   OF  MEDICINE 

Jackson  (17)  of  Chicago.  These  authors  have  described  successes  in 
the  treatment  of  the  various  forms  of  displacement  of  the  uterus  and 
its  appendages,  of  hyperplasia,  of  chronic  metritis,  and  most  decidedly 
of  pelvic  exudates,  para-  and  peri-metritis. 

The  technique  consists  in  raising  the  uterus  (and,  so  far  as  may  be, 
its  appendages)  by  a  finger  of  the  left  hand  in  the  vagina,  by  Avhich  it  is 
held  against  the  abdominal  wall,  where  it  is  kneaded  and  pressed  upon 
by  the  right  hand.  That  such  treatment  may  be  of  great  usefulness  in 
the  removal  of  old  inflammatory  deposits,  and  restore  tone  to  the  uterine 
walls  and  to  the  ligaments,  is  evident  from  the  effects  of  like  manipula- 
tions elsewhere.  Pregnancy,  acute  inflammation,  and  of  course  the 
presence  of  catamenia,  are  contra-indications.  Further,  it  is  obvious 
that  such  treatment  can  only  be  carried  out  by  the  hands  of  a  physician, 
whether  man  or  woman;  and  whatever  the  results  may  be,  it  is  so 
tedious,  fatiguing,  and  unpleasant  to  the  performer,  so  annoying  and 
painful  to  the  patient,  and  open  to  so  much  abuse,  that  it  is  little  likely 
to  find  favour. 

Massage,  in  conjunction  with  other  and  more  useful  measures,  may 
be  applied  to  the  reduction  of  obesity.  Dr.  Weir  Mitchell,  Dr.  Goodell, 
and  others  have  used  it,  together  with  a  minimum  quantity  of  food,  to 
reduce  the  unwholesome  adipose  deposit  of  that  very  troublesome  class 
of  patients,  the  fat  ansemics.  By  keeping  them  quiet  in  bed  and  giving 
nothing  but  skim  milk  in  small  amounts,  weight  may  be  rapidly  and 
safely  lost.  [  Vide  art.  on  "  Obesity."]  Unusual  or  excessive  local 
accumulations  of  fat  may  be  removed  by  massage  limited  to  the  abnor- 
mal areas,  and  used  with  considerable  vigour  at  short  intervals. 

There  is  a  remarkable  unanimity  of  opinion  among  those  who  have 
used  it  as  to  the  value  of  massage  in  morphia  habit,  and  the  other  forms 
of  drug  addiction.  It  should  be  used  throughout  the  course  of  treatment 
whatever  be  the  plan  employed,  and  with  special  care  during  the  collapse 
which  almost  inevitably  follows  the  final  withdrawal  of  the  accustomed 
stimulus,  be  it  opium,  cocaine,  chloral,  or  alcohol.  The  weak  heart  calls 
loudly  for  help  in  such  patients,  especially  in  the  slaves  of  morphia ;  and 
as  the  stomach  is  apt  to  be  very  irritable,  it  is  an  advantage  to  have  this 
means  of  strengthening  the  movement  of  the  blood  without  risk  of  up- 
setting a  feeble  digestion.  Moreover,  it  has  a  remarkable  sedative 
effect,  due  in  part,  no  doubt,  to  the  resulting  relaxation  of  the  peripheral 
vessels  and  in  part  to  its  soothing  influence  upon  the  irritable  nerves. 

Though  the  conditions  which  render  massage  undesirable  or  impossi- 
ble are  implied  in  much  that  has  already  been  said,  a  few  words  on  the 
coyitra-indications  may  be  added. 

Acute  skin  inflammation,  burns,  unhealed  wounds,  in  fact  any  break 
in  the  cutaneous  surfaces,  render  the  use  of  massage  impossible,  at  any 
rate  upon  the  affected  locality ;  although,  as  has  been  stated,  it  may 
sometimes  be  employed  in  the  neighbourhood  for  its  derivative  effects. 

The  presence  of  fever  should  act  as  an  absolute  prohibition  on  account 
of  the  rise  of  temperature  induced  by  manipulation.     Treatment  may  in 


THE    GENERAL   PRINCIPLES    OF  DIETETICS  IN  DISEASE     385 


certain  cases  —  in  consumptive  patients,  for  example  —  be  used  in  the 
afebrile  interval. 

In  all  jDrocesses  in  which  pus  is  formed,  as  well  as  in  cases  of  malig- 
nant tumour,  it  is  obviously  undesirable  to  apply  a  means  which  may 
result  in  the  dispersion  of  infective  products  into  the  tissues  or  through- 
out the  system. 

Weakened  vessel  walls  from  general  causes,  fragility  of  the  arteries, 
or  dilated  veins,  forbid  deep  kneading,  though  ef&eurage  may  be  em- 
ployed. 

Pregnancy  contra-indicates  abdominal  massage,  though  no  hesita- 
tion need  be  felt  in  using  muscle-kneading,  and  friction  to  the  rest  of 
the  body  up  to  a  very  late  date  in  the  period  of  gestation. 

John  K.  Mitchell. 

REFERENCES 

1.  E.  Kleen.  Handbook  of  Massage.  Translated  by  E.  H.  Hartwell,  M.  D.,  1802, 
the  best  and  most  moderate  treatise  on  the  art  and  science  of  massage.  —  2.  Pagen- 
STECHER.  Centralblatt  f.  prakt  Auf/enheilk.  1878 ;  Archiv  f.  Aug"nheilk.  18!i0-l.  — 
3.  Damalex.  Arch,  d' Ophthalmol igie,  1880-1. — 4.  Klein.  Wien.  Med.  Presse,  1882. 
—  5.  Mosso.  Archiv.  Anat.  wid  Physiol.  1890." — 6.  Maggiora.  Archivio  per  le  Sc. 
Medisch.,  xvi.  2,  1891.  —  7.  Brunton  and  Tunnicliffe.  Jour,  of  Physiol,  xvii.,  5, 
1894.-8.  J.  K.  Mitchell.  Am.  Journ.  of  the  Med.  Sci.  May  1894.  —  9.  Mansell- 
MouLLiN.  On  Sprains.  — 10.  Graham.  Treatise  on  Massage.  — 11.  Gerst.  Uber  d. 
Therapeiit.  Wert'i  der  Massage.  Wiirzburg,  1879.  — 12.  Goodhart  and  Phillips. 
Lancet,  Aug.  5,  1882. —13.  S.  Weir  Mitchell.  Fat  and  Blood.  — U.  W.  S.  Play- 
fair.  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria.  — 15.  Profanter. 
Die  Massage  in  der  Gyndcol.  Vienna,  1887.  — 16.  Bunge.  Berl.  kiin.  Wochensch., 
xix.  1882.-17.  Reeves  Jackson.  Boston  Med.  and  Surg.  Jour.  1880.  — 18.  A.  Symons 
EccLES.     The  Practice  of  Massage.    London,  1895. 

J.  K.  M. 


THE   GENERAL  PRINCIPLES   OF  DIETETICS   IN   DISEASE; 
OR,  THE   FEEDING   OF   THE    SICK 

The  best  writers  on  medicine  from  the  earliest  times  have  been  careful 
to  include  in  their  treatises  some  account  of  the  conduct  of  diseases  by 
means  of  diet;  and,  with  the  advancing  changes  and  improvement  in 
the  art  of  medicine,  the  subject  of  dietetics  has  not  failed  to  receive  an 
increasing  share  of  attention. 

As  in  respect  of  treatment  by  means  of  drugs  or  other  therapeutic 
measures,  so  here  we  find  that  many  changes  of  opinion  have  occurred; 
methods  at  one  time  in  vogue  have  been  subsequently  discountenanced, 
and  at  a  later  date  again  enjoined.  It  must  be  admitted  that  the  whole 
subject  of  dietetics  has  rested  on  an  empirical  basis,  and  been  destitute 
of  any  scientific  principles  till  within  tlie  last  half  of  this  century. 

VOL.  I  2  c 


SYSTEM  OF  MEDICINE 


With  the  progress  of  chemistry  and  physiology,  and  by  more  exact 
clinical  researches,  a  truly  scientific  basis  has  been  laid ;  we  have  now 
indeed  attained  a  measure  of  certainty  in  respect  of  dietetics  as  an 
instrument  of  medicine  which  may  fairly  be  counted  amongst  the 
triumphs  of  modern  therapeutics.  This  work  has  been  done  by  many 
labourers :  it  has  required  the  combined  efforts  of  the  chemist,  the 
physiologist,  and  the  clinical  physician ;  and  in  no  other  manner  could 
such  a  task  have  been  accomplished. 

Dietetics  have  always  formed  part  of  any  system  of  medicine,  how- 
ever peculiar  or  erroneous;  and  contributions  to  the  subject  have  come 
from  many,  and  sometimes  strange  sources,  all  tending  to  throw  light 
on  difficult  and  unillumined  parts  of  it.  Of  this  we  may  feel  sure 
when  we  review  the  claims  made  for  their  several  methods  by  those 
who  have  enjoyed  high-living,  low-living,  "vegetarianism,"  hot-water 
drinking,  total  abstention  from  alcoholic  liquids,  and  full  stimulation 
with  them ;  to  say  nothing  of  many  varied  and  fantastic  fashions  in 
diet,  all  of  which  have  been  tried  and  fairly  appraised.  We  have  wit- 
nessed the  results  of  so-called  homoeopathic  treatment  of  patients,  in 
Avhich  a  large  amount  of  attention  is  paid  to  diet,  and  feel  that,  in  all 
fairness,  it  should  be  granted  that  at  one  time  some  accession  to  our 
knowledge  of  clinical  dietetics  came  from  this  source. 

In  this  article  we  are  only  concerned  to  set  forth  the  principles  and 
practice  of  dietetics,  in  so  far  as  they  relate  to  the  needs  of  patients 
suffering  from  various  diseases;  and  to  illustrate  their  application  in 
practice.  This  effort  necessarily  comprises  a  due  consideration  of  the 
best  methods  of  which  we  have  now  certain  knowledge,  and  can  only  be 
grounded  upon  extended  and  carefully-weighed  clinical  experience. 

In  recent  times  less  and  less  heed  has  been  paid  to  drug-treatment, 
and  more  attention  has  been  given  to  diet  and  general  hygienic  environ- 
ment. This  waning  faith  in  drug-administration,  which  is  unwarrant- 
able and,  to  a  large  degree,  unAvise,  has  come  of  a  fuller  knowledge  of 
the  natural  course  of  many  morbid  conditions.  More  reliance  is  placed 
on  the  vis  medicatrix  natarce ;  and  the  art  of  the  older  drug-giving  phy- 
sicians has  gradually  fallen  into  desuetude,  and  ceased  to  engage  the 
attention  of  many  of  the  most  capable  minds  in  medicine.  In  the  mean- 
time, however,  much  certain  knowledge  has  been  secured, — -knowledge 
which  is  absolutely  necessary  in  order  to  guide  our  efforts  successfully  in 
relieving  suffering  and  helping  on  recovery.  It  would  plainly  be  beyond 
the  limits  of  this  article  to  attempt  to  discuss  the  dietetic  treatment  of 
each  malady :  it  will  suffice  to  lay  down  the  principles,  and  to  suggest 
the  practical  application  of  them  in  dealiitg  with  disease  of  the  several 
systems  of  the  body,  referring  more  in  detail  to  the  more  important 
general  morbid  states,  and  to  the  requirements  of  some  special  disorders. 

I  propose  to  discuss  clinical  dietetics  in  relation  to  the  following :  — 

1.  Specific  Infectious  Diseases ;  2.  Diseases  of  the  Nervous  System  ; 
3.  of  the  Respiratory  Organs ;  4.  of  the  Circulatory  Organs ;  5.  of  the 
Digestive  Organs;  6.  of  the  Blood,  Lymphatic  System,  and  Ductless 


THE    GENERAL   PRINCIPLES    OF  DIETETICS  IN  DISEASE      387 


Glands ;  7.  of  the  Urinary  Organs  ;  8.  Chronic  Intoxications ;  9.  Diseases 
of  the  Locomotory  System ;  10.  of  the  Skin ;  11.  Atrophy.  Obesity  I 
shall  deal  with  in  a  later  article. 

I  prefix  a  few  remarks  on  the  Feeding  of  Helpless  Patients.  Refer- 
ence will  frequently  be  made  in  the  following  pages  to  feeding  of  patients 
who  cannot  help  themselves.  This  is  conducted  by  means  of  a  spoon,  by 
the  feeding-cup,  or  by  the  nasal  tube.  The  best  size  of  spoon,  in  the  case 
of  adults,  is  that  known  as  the  dessert-spoon,  or  small  tablespoon,  hold- 
ing two  or  three  fluid  drachms ;  a  teaspoon  is  the  most  convenient  for 


Pig.  32.  —  Feeding-cup  with  well-curved  spout  and 
india-rubber  tube  attached. 


Apparatus  for  nasal  feeding 


children.  When  the  sensorium  is  dull,  liquid  nourishment  is  best  intro- 
duced slowly  at  the  side  of  the  mouth.  The  best  form  of  feeder  is 
depicted  in  Fig.  32.  The  spout  should  be  well  curved,  and  it  is  often 
advisable  to  add  a  piece  of  soft  rubber  tubing  to  the  end  of  it  with  a  glass 
nozzle.  Feeders  with  straight  spouts  are  unsuitable ;  the  contents  of  such 
feeders  are  apt  to  be  shot  out  in  spurts  which  may  be  spilt  over  the  patient. 
Dr.  F.  M.  Watt,  of  Edinburgh,  has  recently  recommended  a  feeder  with 
three  handles  as  being  easily  seized  by  a  recumbent  patient — one  right,  one 
left,  and  one  posterior,  with  a  flattened  tubular  mouthpiece.  The  most 
useful  form  of  apparatus  for  nasal  feeding  is  that  shown  in  Fig.  33.  It  is 
readily  made  by  taking  the  barrel  of  an  ordinary  glass  urethral  syringe, 
and  affixing  to  the  nozzle  a  piece  of  soft  red  rubber  tubing  of  a  size  suitable 
for  passage  along  the  floor  of  the  nose,  and  about  ten  inches  or  a  foot  in 
length.  This,  after  being  well  oiled,  is  j)assed  along  the  nose  in  a  line 
backwards  towards  the  external  auditory  meatus,  and  slipped  over  the 


388  SYSTEM   OF  MEDICINE 

posterior  surface  of  the  velum  palati  into  the  pharynx  and  gullet. 
This  is  a  simple  method,  and  even  children  soon  become  tolerant  of  it. 
The  nutriment  is  to  be  poured  from  a  small  lipped  jug  into  the  glass 
barrel  held  up  vertically  over  the  patient's  face.  With  this  arrangement 
the  progress  of  the  fluid  as  it  passes  into  the  gullet  can  be  accurately 
determined,  and  as  much  food  as  is  necessary  can  thus  be  readily  intro- 
duced at  regular  intervals.  In  cases  of  apoplexy,  insensibility,  melan- 
cholia, or  other  forms  of  insanity,  and  after  tracheotomy,  this  method 
of  feeding  is  of  supreme  value  and  importance.  Half  a  pint  to  a  pint  of 
nutriment  may  be  given  at  one  time.  A  small  piece  of  glass  tubing  may 
be  introduced  into  the  length  of  india-rubber  tube  to  allow  the  transit  of 
food  to  be  observed. 

Dietary  in  Specific  Infectious  Diseases.  —  A  consideration  of  this 
subject  naturally  includes  the  dietetic  management  of  the  febrile  state 
as  such. 

The  condition  common  to  all  these  temporary  acute  illnesses  is  that 
recognised  as  fever  or  pyrexia.  Pyrexia  is  a  symptom  which  is  now 
acknowledged  by  many  modern  observers  to  be  no  longer  an  inimical,  but 
rather  a  friendly  process  so  long  as  it  is  restrained  within  certain  limits. 

In  febrile  conditions  the  alimentary  system  is  more  or  less  disturbed, 
almost  without  exception :  the  common  indications  of  this  are  —  first, 
the  loss  of  natural  appetite ;  secondly,  the  presence  of  thirst.  Solid  food 
is  loathed,  and  if  taken  or  pressed,  commonly  rejected  by  vomiting.  The 
changes  in  the  mucous  surfaces  tend  to  dryness  and  greatly  reduced 
secretion  from  salivary  and  mucous  glands,  gastric  tubular  glands, 
duodenal  (Brunner's)  glands,  Lieberkiihnian  follicles  and  the  pancreas. 
The  condition  of  the  intestinal  solitary  and  agminate  glands  when  they  are 
not  specifically  involved,  is  hardly  known ;  nor  that  of  the  four  million, 
more  or  less,  villi  of  the  intestine  ;  but  it  may  fairly  be  believed  that  these 
are  in  a  more  hyperajmic  and  sluggish  condition,  as  regards  normal  absorp- 
tive function,  than  in  health.  Certainly,  in  most  cases,  we  have  clinically 
to  note  a  greater  or  lesser  degree  of  catarrh  as  pervading  the  entire  course 
of  the  alimentary  canal  and  of  the  ducts  which  lead  into  it ;  and  we  take 
heed  to  this  condition  in  determining  a  diet  for  patients  thus  affected. 

With  respect  to  digestive  capacity  we  particularly  note  the  absence 
of  sufficient  saliva  and  pancreatic  secretion  on  the  one  hand,  and  of  gastric 
and  intestinal  juices  on  the  other,  and  are  thus  in  the  presence  of  in- 
capacity to  deal  effectually  either  with  amylaceous  food  or  with  the 
several  varieties  of  albumins.  In  the  severer  forms  of  prolonged  fever, 
gastric  digestion  is  commonly  more  in  abeyance  than  that  carried  on  in 
the  intestines.  Pyrexia  thus  reduces  digestive  capacity  somewhat  to 
that  which  is  the  normal  state  of  the  infant  during  the  first  six  months 
of  life,  more  particularly  in  respect  of  the  inactivity  of  salivary  and 
pancreatic  functions. 

In  practice,  however,  it  is  possible  to  pay  too  much  heed  to  these 
facts  and,  as  in  politics  "  the  Queen's  Government  must  be  carried  on," 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE     389 

SO  here  our  patients  must  be  fed  and.  sustained  through  the  exhausting 
conditions  associated  with  and  dependent  on  fever.  Ample  experience 
has  proved  the  value  of  a  diet  consisting  mainly  of  milk  and  meat  juices. 
The  points  to  attend  to  in  such  a  dietary  relate  to  the  purity  and  dilution 
of  the  milk,  and  to  the  variety  and  quality  of  the  meat  juices.  First, 
with  respect  to  milk :  it  is  of  essential  importance  to  employ  fresh  milk 
whenever  procurable.  Preserved  milk,  in  all  forms,  is  vastly  inferior  for 
nutritive  purposes.  As  a  rule,  unless  the  source  is  beyond  suspicion, 
fresh  milk  is  best  scalded,  but  not  boiled.  It  is  then  to  be  diluted  with 
barley  water,  or  toast  and  water,  to  the  extent  of  one-third  or  one-half. 
If  diarrhoea  be  present  lime  water  should  be  added,  and  half  the  amount 
of  barley  water  may  be  thus  replaced.  If  constipation  prevail,  the 
addition  of  sodium  bicarbonate,  instead  of  lime  water,  to  the  mixed  fluids 
is  advisable  —  one  drachm  (a  teaspoonf ul)  being  stirred  with  each  pint. 
These  measures  prevent  the  formation  of  curd  in  any  but  a  finely-granular 
condition,  and  so  prevent  pain,  flatulency  and  intestinal  disturbances. 
When  milk  is  badly  borne  whey  is  often  available,  and  to  it  cream  may 
be  added  if  desirable. 

Beef  juices  may  be  given  at  intervals  in  the  form  of  well-made  beef 
tea,  mutton  tea,  chicken  or  veal  tea ;  or,  occasionally,  if  the  stomach  be 
queasy,  in  the  form  of  essences,  of  which  there  are  now  several  trust- 
worthy preparations.  Fresh  beef  essences,  if  they  can  be  procured,  are 
probably  better  than  any  of  the  latter;  and  vegetable  juices  may  be 
incorporated  with  all  forms  of  these  by  immersing  in  the  cooking-vessel 
a  muslin  bag  containing  finely-divided  vegetables  such  as  cabbage,  carrot, 
etc.,  and  so  securing  variety  both  of  flavour  and  nutrient  elements.  A 
good  rule  is  to  change  the  meat  juice  from  day  to  day,  so  as  to  prevent 
the  monotony  of  the  spoon-food.  Nothing  better  relieves  such  monotony 
than  the  regular  administration  of  draughts  of  iced  water  which  are 
always  grateful  to  fever  patients  and  are  too  often  omitted.  In  many  cases 
both  tea  and  coffee  may  be  given  with  advantage.  Refreshing  drink  is 
available  in  most  febrile  states  —  enteric  fever  and  rheumatic  fever  ex- 
cepted—  in  the  form  of  freshly-made  lemonade  containing  a  drachm  of 
acid  tartrate  of  potash  in  each  pint,  and  a  very  little  sugar.  Regard  is 
to  be  paid  to  the  amount  actually  consumed,  and  care  taken  that  enough  is 
presented  in  each  twenty -four  hours.  Modern  skilled  nursing  commonly 
secures  this,  and  a  register  is  to  be  kept  from  hour  to  hour.  Fruit  is 
sometimes  of  use,  and  cooked  apples  may  be  given,  carefully  prepared, 
also  grapes  and  oranges.  In  small-pox  the  latter  are  especially  grateful. 
Whenever  it  is  advisable  to  add  to  the  nourishment,  yolks  of  eggs  may 
be  added  to  milk  or  beef  juice,  or  given  with  brandy  as  egg-flip. 

We  have  thus  considered  the  essentials  of  a  so-called  fever  diet.  The 
question  of  alcoholic  fluids  now  presents  itself.  These  form  no  routine 
part  of  dietetic  treatment  either  in  febrile  or  in  any  other  morbid  con- 
dition. They  may,  however,  be  necessary,  and  are  often  indispensable, 
in  the  conduct  of  particular  cases.  The  skill  demanded  in  the  prescription 
of  alcohol  (that  is,  of  alcoholised  fluid  of  whatever  kind)  is  of  the  same 


390  SYSTEM  OF  MEDICINE 

order  as  that  wMch  is  required  in  determining  the  use  of  any  other  article 
of  food  or  medicine  for  the  sick.  We  do  not  af&rm  that  because  the 
patient  has  fever,  or  has  pneumonia,  he  therefore  requires  wine  or  spirit. 
He  may  or  he  may  not.  We  are  guided  by  various  considerations  as  to 
the  specific  requirements  of  each  patient,  and  we  give  or  we  witlihold 
as  the  case  may  be.  We  lend  ourselves  to  no  fashion  or  wave  of  opinion 
in  respect  of  food  or  drugs,  and  study  the  precise  indications  of  the  case 
for  the  time  being.  The  opinions  to  be  here  stated  are  the  result  of  no 
small  experience,  and  have  been  gathered  only  at  the  bedside. 

We  are  met  at  the  outset  by  those  who  contend  that  alcohol  is  not  a 
food,  and  has  therefore  no  place  in  any  dietary.  We  might  put  this 
opinion  aside,  and  still  contend  that  it  has  a  high  place  in  the  treatment 
of  disease.  As  clinicians  we  maintain,  however,  that  alcohol  is  practically 
available  as  a  food,  even  in  the  form  of  a  pure  spirit ;  and  if  the  several 
constituents  of  wine  be  taken  into  consideration  we  have  to  deal  with  a 
variety  of  nutrient  materials  in  subtle  combination,  with  which  alcohol, 
in  moderate  percentage,  is  bound  up.  We  recognise  that  alcohol  holds 
an  intermediate  place  between  carbo-hydrates  and  tho  fats,  being 
less  oxygenised  than  the  former  and  more  so  than  the  latter.  In  its 
circulation  thi'ough  the  system,  within  certain  well-understood  limits, 
it  becomes  destroyed  and  indefectible ;  we  must  therefore  believe,  as 
physiologists,  that  this  process  of  destruction  and  transformation  is 
attended  by  oxygenation  and  a  correlative  liberation  of  energy.  We  may 
thus  explain  some  of  the  benefits  derivable  from  the  use  of  alcoholised 
fluids  in  various  morbid  states. 

The  clinical  incUcations  for  alcohol  in  febrile  states  are  now  fairly  well 
understood  and  reduced  to  principles.  It  is  recognised  that  if  no  extreme 
pyrexia  be  present,  if  the  action  of  the  heart  continue  sufficiently  vigorous, 
and  food  be  well  taken,  alcohol  is  unnecessary.  But  if  high  fever  pre- 
vails, the  heart's  action  falters,  and  ordinary  nutriment  is  taken  with 
difficulty,  at  any  age,  and  in  any  such  case,  alcohol  is  indicated,  and  its 
effects  are  under  such  conditions  uniformly  satisfactory.  Thus  by  its 
use  we  control  pyrexia,  we  sustain  the  action  of  the  heart  and  the 
vigour  of  the  circulation,  and  we  secure  a  substitute  for  other  nutriment 
till  such  time  as  a  better  appetite  returns.  We  gather  all  these  indications 
from  the  thermometer,  the  stethoscope,  the  character  of  the  pulse,  and  the 
capacity  for  taking  nourishment.  The  best  form  for  alcoholic  administra- 
tion is  either  that  of  brandy  or  whisky  well  diluted  with  milk.  Neither 
should  be  given  with  beef  tea  or  any  meat  juices,  and  the  quantity  is 
best  administered  at  regular  intervals  of  two  or  four  hours,  according  to 
the  particular  indications,  both  by  day  and  by  night.  The  amount  re- 
quired is  to  be  determined  by  the  age  and  previous  habits  of  the  patient, 
and  no  less  by  the  conditions  requiring  to  be  met.  Young  children  bear 
alcohol  well  when  it  is  indicated ;  and  the  amount  sometimes  called  for 
may  be  very  large.  In  practice  it  is  seldom  found  necessary  to  exceed 
for  an  adult  of  average  condition  in  any  febrile  state  six  ounces  of 
brandy  or  whisky  per  diem,  and  two  or  three  will  often  secure  all  that 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE     391 

is  needed.  Over-stimulation  is  harmful,  and  is  recognised  by  flushing, 
foul  breath  and  discomfort.  Hyperpyrexia  demands  the  use  of  alcohol, 
and  the  patient  is  benefited  by  it.  The  cardiac  indicatiohs  for  the  use 
of  alcohol  in  fever  are  a  notable  loss  of  tone  in  the  first  sound,  especially 
if  this  be  inappreciable  at  the  base  (Stokes'  sign),  and  the  associated 
condition  of  pulse  that  of  low  arterial  pressure,  and  the  phase  of 
it  known  as  dicrotism.  The  tendency  to  formation  of  sordes  on  the 
tongue  or  gums  in  grave  febrile  states  also  indicates  the  employment  of 
alcohol. 

Preparations  of  malt  are  certainly  available  in  febrile  conditions, 
and  are  agreeable  to  patients.  Granulated  malt  extract  dissolved  in 
warm  water  or  milk  constitutes  a  grateful  variety  of  readily  digestible 
nutriment  when  the  constant  use  of  milky  food  palls  on  the  appetite. 

When  the  stomach  is  irritable,  and  most  of  the  food  already  indicated 
disagrees,  recourse  may  be  had  to  koumiss  in  small  quantities  (Koumiss, 
No.  2).  Milky  food  may  sometimes  be  better  borne  if  given  in  doses 
of  half  an  ounce  to  an  ounce  every  quarter  of  an  hour  by  the  clock. 
After  a  few  hours  larger  quantities  may  be  tolerated. 

The  dietary  thus  enjoined  is  available  for  most  febrile  conditions, 
however  induced,  including  pneumonia,  all  the  exanthemata,  and  the  con- 
tinued fevers,  v/ith  the  exception  of  enteric  fever,  to  which  reference  will 
presently  be  made.  The  same  holds  good  for  paroxysmal  stages  of  re- 
mittent and  intermittent  fevers,  allowance  being  always  made  for  the 
degree  of  pyrexia,  the  age,  and  bodily  state  of  each  patient. 

Certain  precautions  are  of  extreme  importance  in  the  case  of  enteric 
fever,  the  specific  conditions  of  the  intestinal  tract  from  day  to  day  being 
always  borne  in  mind.  The  necessity  for  introducing  only  bland  and 
unirritating  nutriment  is  paramount.  Hence  the  importance  of  prevent- 
ing any  masses  of  milk-curd  from  passing  through  the  pylorus  which  may 
chafe  or  lodge  upon  ulcerated  patches  in  the  ileum  and  colon,  and  induce 
diarrhoea  or  constipation.  Attention  is  further  necessary  to  prevent 
fruit  in  any  form  being  administered  by  injudicious  attendants  or  friends. 
Lemonade  is  to  be  forbidden,  and  all  wines,  for  these  are  distinctly  apt 
to  promote  action  of  the  bowels.  Vegetable  juices  may  be  introduced,  as 
already  indicated,  with  meat  juice.  Alcohol  is  only  permissible  in  the 
form  of  brandy,  whisky,  or  gin.  These  matters  appear  to  smack  of 
pedantry,  but  the  rule  enjoined  has  been  dictated  by  the  amplest  ex- 
perience, and  no  point,  however  small,  is  unimportant  which  may  turn 
the  scale  in  favour  of  life  or  death  in  these  terrible  cases.  Lives  have 
been  needlessly  sacrificed  by  inattention  to  or  inappreciation  of  matters 
seemingly  trifling  such  as  these. 

It  has  been  freely  asserted  of  late  that  milk  is  an  inappropriate  food 
in  enteric  fever,  inasmuch  as  it  is  a  pabuhim  highly  favourable  to  the 
growth  of  the  specific  bacilli  of  the  disease,  and  it  has  been  urged  that 
preparations  of  malt  are  much  safer.  Indeed,  Dr.  Springthorpe,  of 
Melbourne,  has  strongly  urged  the  use  of  a  sterilised  hopped   malt 


392  SYSTEM  OF  MEDICINE 

extract,  which  resists  the  growth  of  Eberth's  bacillus  in  cases  of  enteric 
fever.^  The  value  of  malt  has  been  already  noted.  The  disadvantages 
of  milk,  properly  diluted  and  alkalised,  are,  however,  by  no  means 
proved,  and  it  would  require  very  strong  evidence  to  convince  careful 
physicians  that  it  is  not  a  satisfactory  basis  of  diet  in  these  cases.  Voit 
asserts  that  three  and  a  half  pints  of  milk  per  diem  are  insufficient  for 
nourishment  in  a  case  of  fever,  there  being  a  lack  of  albumin,  twice  too 
much  fat,  and  deficiency  of  carbo-hydrates  by  two-thirds.  Further,  that 
even  with  the  addition  of  animal  broth  such  a  dietary  is  inadequate. 
Clinical  experience  does  not  justify  the  acceptance  of  these  statements. 
The  average  patient,  as  a  matter  of  fact,  does  very  well  on  such  a  diet ; 
and  beef  tea  or  mutton  tea  may  be  fortified  with  essences  of  one  or  other 
as  required. 

It  is  found  that  where  diarrhoea  is  a  prominent  feature  of  the  illness, 
beef  tea  or  beef  essence  may  act  as  a  peristaltic  stimulant,  or  otherwise 
as  a  purgative ;  whereas  mutton  tea  and  essence,  veal  broth  and  chicken 
broth  have  no  such  effect,  and  it  is  a  good  rule  of  practice  to  attend 
to  this  point.  In  cases,  not  uncommon,  where  constipation  prevails 
beef  juices  may  be  used,  and  sodium  bicarbonate,  rather  than  lime 
water,  should  be  added  to  the  milk.  In  rebellious  diarrhoea,  or  where 
haemorrhage  occurs,  milk  is  better  avoided  and  whey  employed,  the  latter 
in  the  form  of  alum  whey,  made  by  adding  one  drachm  of  powdered  sul- 
phate of  alumina  to  each  pint  of  scalded  milk  and  straining  through 
muslin.     jMutton  essence  is  best  in  such  cases. 

The  greatest  care  is  called  for  in  the  dietary  during  convalescence  from 
this  disease,  no  solid  food,  or  nutriment  entailing  debris,  being  permissible 
for  many  days  after  all  fever  has  passed  away.  Ordinary  diet  may  be 
resumed  at  once  in  cases  of  typhus  fever  or  in  pneumonia,  but  not  in 
enteric  fever.  We  do  well  to  begin  with  milky  arrowroot,  with  yolk  of 
eggs  in  milk  or  brandy  and  water,  then  to  pass  on  to  boiled  pap  of  bread- 
crumb and  milk,  custard  pudding,  and  lightly-boiled  fresh  egg.  Next, 
pounded  fish  may  be  cautiously  given,  pounded  mutton  or  beef  in  puree, 
rusks  soaked  in  tea  or  milk,  and  so  on  to  fish  of  delicate  fibre,  mashed 
potatoes,  etc.  In  all  cases  it  is  better  to  be  too  late  rather  than  too  early 
in  reinforcing  the  dietary. 

Typhus,  Relapsing,  and  other  Fevers.  —  In  arranging  the  dietary  for 
patients  suffering  from  typhus  and  other  continued  fevers,  no  special  pre- 
cautions, such  as  are  of  imperative  necessity  in  enteric  fever,  have  to  be 
taken.  The  indication  is  to  meet  the  exhausting  character  of  the  febrile 
processes  by  the  introduction  of  such  food  in  liquid  forms  as  the  patient 
can  take,  and  with  the  abatement  of  symptoms  following  on  the  crisis 
solid  food  may  be  safely  given,  care  being  taken  not  to  overload  the 
stomach  by  excessive  amounts,  the  appetite  being  large.  The  indications 
for  alcohol  are  the  same  as  in  enteric  fever,  but  wine  may  be  safely  given, 
or  malt  liquors  if  preferred.  Good  wine,  of  which  mature  port,  Bur- 
gundy, or  Bordeaux  are  the  most  desirable,  is  as  a  rule  preferable 
1  Australian  Medical  Journal,  22nd  July  1894. 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE      393 

in  febrile  exhausting  conditions  to  pure  spirit.  The  aethers  of  old  wine 
are  especially  sustaining  to  flagging  cardiac  action,  and  the  associated 
salts  in  wine  are  further  beneficial.  Champagne  of  good  quality  is  useful 
in  many  cases  when  other  wines  are  distasteful,  but  it  can  seldom  be 
safely  employed  in  enteric  fever.  There  is  no  routine  treatment  in  any 
case,  and  in  early  life,  and  in  constitutions  otherwise  sound,  it  is  some- 
times unnecessary  to  resort  to  any  alcoholic  support,  either  during  the 
fever  or  the  convalescence  from  it.  Each  case  must  be  judged  by  itself, 
and  a  well-trained  clinical  observer  gives  or  withholds  stimulants  as 
circumstances  indicate.  Elderly  patients,  as  a  rule,  need  stimulants 
earlier  and  in  larger  amounts  than  younger  ones.  Typhus  fever  is  almost 
certainly  fatal  after  the  seventh  climacteric,  whatever  the  treatment. 
Habitual  drunkards,  under  the  stress  of  continued  fever,  require  some- 
times very  large  amounts  of  stimulants.  The  tendency  to  collapse  after 
the  crisis  in  relapsing  fever  demands  free  stimulation,  especially  in 
elderly  patients. 

Exanthemata.  —  In  the  exanthemata  the  dietary  is  that  for  the  py- 
rexial  state  generally.  Later  complications  may  occasionally  demand 
moderate  stimulation  and  a  generally  supporting  diet,  the  condition  of 
the  kidneys  in  scarlet  fever  demanding  especial  attention. 

Sterilised  Milk  ;  Boiled  Milk  and  Water.  —  No  reference  has,  so  far, 
been  made  to  the  employment  of  sterilised  milk,  or  of  peptonised  milk 
and  animal  broths.  As  to  the  first,  it  is  a  good  rule  to  scald  all  milk, 
unless  the  source  and  treatment  of  it  be  certainly  beyond  suspicion  :  this 
holds  good  not  only  in  India,  but  all  over  the  world.  The  same  may  be 
affirmed  for  water  under  all  conditioiis,  and  in  India  and  in  most  parts 
of  the  world  the  rule  holds  good,  especially  in  the  case  of  children  and 
young  adults. 

Peptonised  Foods.  —  With  respect  to  peptonised  food  I  think  there  is 
now  too  great  a  tendency  to  employ  it.  All  articles  of  diet  come  best 
direct  from  nature,  as  far  as  possible ;  and  without  more  chemical  or 
culinary  meddling  than  is  absolutely  necessary.  Food  is  one  thing, 
physic  is  another.  I  feel  sure  that  peptonised  foods  are  now  too  fre- 
quently administered,  and  are  often  unnecessary.  They  have  their 
jjlace,  without  doubt,  for  gastric  and  for  rectal  alimentation  as  a  tempo- 
rary measure,  the  object  being  to  present  predigested  albumin  for  rapid 
assimilation  when  digestive  power  is  at  a  minimum,  as  malted  foods 
present  predigested  starches  in  cases  where  salivary  and  pancreatic 
secretions  are  inadequate ;  but  it  has  become  a  fashion  to  resort  to  the 
use  of  predigested  food  in  many  cases  which  do  not  require  it.  Most 
cases  of  pyrexia  can  be  treated  successfully  without  peptonised  food,  but 
if  the  digestive  powers  be  enfeebled,  it  may  certainly  be  used.  The 
liquor  pancreaticus  is  probably  one  of  the  best  agents  to  employ  in 
peptonising  milk,  animal  broth  or  gruel. 

ParotitiH.  —  In  cases  of  mumps  spoon-food  only  is  to  be  given,  and 
generally  in  a  concentrated  form,  the  act  of  deglutition  being  painful. 

Pertussis.  —  In  whooping-cough  nourishing  diet  is  necessary.  Vomit- 


394  SYSTEM  OF  MEDICINE 

iug  is  frequent  after  paroxysms,  but  the  patient  is  commonly  ready  to 
replace  what  is  lost. 

Injiuenza.  —  There  is  loss  of  appetite  in  the  primary  stage.  But  soon 
the  specific  depression  of  this  malady  necessitates  the  use  of  a  supporting 
dietary  in  any  desirable  form,  and  alcohol  is  required,  sometimes  in  large 
amount,  to  counteract  the  tendency  to  asthenia  and  cardiac  failure ; 
especially  in  elderly  persons  with  pulmonary  complications,  and  dui-ing 
convalescence  which  may  be  very  prolonged.  Yolks  of  eggs  with  brandy, 
strong  soups,  oysters,  and  pounded  meat  are  suitable  forms  of  nourish- 
ment, also  strong  coffee  with  plenty  of  milk. 

Malarial  Fevers  and  Yelloiv  Fever. — In  the  intervals  between  the 
paroxysms  it  is  desirable  to  employ  a  supporting  diet.  Alcohol  is  best 
given  well  diluted,  and  diluted  champagne  is  valuable. 

Dysentery.  —  Few  diseases  call  for  more  skill  and  discretion  in  feeding 
than  dysentery.  In  simple  and  acute  forms  the  diet  must  be  fluid, 
and  the  same  holds  good  for  many  cases  of  the  chronic  form.  It  is 
common  to  find  milky  and  farinaceous  food  recommended  and  weak 
animal  broths.  Without  doubt  milk  should  be  the  staple  aliment,  and 
it  may  be  given  alone  for  weeks  together,  diluted  Avitli  warm  toast  and 
water  and  lime  water.  My  reading  and  experience  lead  me  to  recommend 
nothing  else.  Beef  tea  is  distinctly  to  be  avoided.  Veal  or  chicken 
broth  are  the  least  harmful  of  animal  broths,  and  the  yolk  of  eggs  may 
be  added.  An  adult  will  need  four  or  five  pints  of  milk  diluted,  as 
advised  (three  parts  of  milk,  one  each  of  barley  water  or  toast  and  water 
and  lime  water),  in  the  course  of  twenty-four  hours.  And  it  is  to  be 
borne  in  mind  that  neither  diet  nor  drugs  will  be  of  any  avail  without 
strict  confinement  to  bed  and  the  use  of  draw-sheets  for  defaecation.  No 
vegetable  food  or  fruits  are  admissible,  and  starchy  food  is  undesirable  ; 
in  chronic  cases  freshly-made  bael  jelly  or  extract  in  drachm  doses  twice 
a  day  is  allowable.  Food  should  be  administered  warm,  to  prevent  too 
active  peristalsis.  Alum  whey  is  useful  as  an  alternative  when  milk 
diet  has  to  be  long,  submitted  to,  and  the  mouth  should  be  washed  out 
occasionally  with  warm  boracic  lotion. 

Erysipelas.  —  Supporting  and  stimulating  diet  is  necessary.  Milk 
and  animal  broths,  containing  plenty  of  salt,  with  brandy  or  port  wine 
are  to  be  given. 

Diphtheria.  —  The  main  indications  here  are  for  a  supporting  diet. 
The  chief  difR.culty  arises  in  the  cases  of  infants  or  young  patients. 
The  tendency  is  to  collapse  and  cardiac  failure  all  through  the  illness 
and  early  convalescence.  After  tracheotomy,  which  is  necessary  in  the 
majority  of  cases  of  the  laryngeal  form,  feeding  can  often  be  carried 
on  only  by  means  of  the  soft  rubber  nasal  tube,  and  by  this  means 
many  lives  have  u.ndoubtedly  been  saved  which  would  otherwise  have 
perished  from  inanition.  Milk,  yolks  of  eggs,  chicken  essence  and  brandy, 
are  almost  always  required.  Young  children  bear  brandy  well  given  in 
milk,  and  it  may  be  needed  in  divided  doses  in  quantities  varying  from 
one-half  to  two  ounces  in  the  twenty-four  hours.    The  presence  of  albu- 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE     393 

minuria  is  no  contra-indication  to  its  employment.  From  two  to  four 
ounces  of  milk,  etc.,  may  be  given  by  the  nasal  tube  at  intervals  of  three 
or  four  hours  by  day  and  night ;  medicines  also  have  to  be  given  with 
the  food  in  this  manner.  Sometimes  the  nasal  tube  may  be  dispensed 
with,  or  it  may  be  advantageously  used  for  a  few  days  after  tracheotomy. 

Asiatic  Cholera.  —  In  the  algide  stage  it  is  of  no  avail  to  press  nour- 
ishment, everything  taken  is  rapidly  ejected.  Sips  of  iced  water  or 
pieces  of  ice  may  be  given  to  suck.  In  the  stage  of  reaction  small 
quantities  of  milk  and  soda-water,  with  bicarbonate  of  sodium,  may  be 
given  in  small  amounts  at  stated  intervals,  and  water  arrowroot  is  admis- 
sible, a  gradual  return  to  very  light  food  being  cautiously  carried  out. 

Syphilis. — The  indications  in  all  stages  of  syphilis  being  to  secure 
the  highest  attainable  level  of  the  general  health,  good  diet  is  necessary. 
The  continued  use  of  mercury  or  iodide  salts  still  further  necessitates  this 
course.  So-called  diet  drinks  are  of  extreme  value.  None  is  superior 
to  a  pint  or  more  of  a  good  compound  decoction  of  sarsaparilla  taken  in 
the  course  of  each  day. 

Hydrophobia.  —  In  this  disease  feeding  must  be  carried  out  by  nutrient 
enemata,  and  remedial  agents  are  conveyed  by  the  same  means,  or  hypo- 
dermically.  Swallowing  may  be  possible  towards  the  end  of  the  case, 
and  food  be  thus  freely  taken,  too  late,  however,  to  save  life. 

Tetanus.  —  Feeding  presents  great  difficulties  here.  It  is  best  con- 
ducted by  the  use  of  the  nasal  tube,  or  advantage  may  be  taken  of  a 
gap  in  the  teeth  to  insert  liquid  nourishment.  Rectal  feeding  is  apt 
to  induce  spastic  paroxysms.  Alcohol  is  necessary,  sometimes  in  large 
quantities.     [  Vide  art.  on  "  Tetanus."] 

Dietary  in  Nervous  Diseases.  —  Neuritis:  (a)  Gouty,  (b)  Alcoholics- 
Sciatica.  —  In  cases  due  to  gouty  influence  the  diet  is  that  proper  for 
the  gouty  state  present  at  the  time.  This  will  vary  according  to  age, 
previous  habits,  and  the  vigour  of  the  constitution.  In  alcoholic  neuritis 
a  plain  nourishing  diet  is  necessary,  and  complete  abstention  from  all 
alcoholic  fluids. 

Diseases  of  the  Spinal  Cord;  Bulbar  Paralysis.  —  A  generous,  readily 
digestible  diet,  containing  an  abundance  of  milk  and  fatty  elements,  is 
required  in  these  cases.  In  bulbar  paralysis  constant  supervision  is 
necessary  to  prevent  choking.  A  soft  tube  should  be  passed  into  the 
stomach  and  liquid  food  injected  as  often  as  it  can  be  tolerated.  Failing 
this,  nutrient  enemata  must  be  employed. 

Cerebral  Haemorrhage.  —  Liquid  food  is  to  be  given  by  the  mouth  if 
there  is  power  to  swallow ;  otherwise  nutrient  enemata  must  be  used. 
No  stimidants  are  to  be  given.  On  recovery  the  diet  must  be  light, 
consisting  of  fish,  milk,  vegetable  and  farinaceous  foods.  In  many 
cases  the  renal  condition  demands  careful  study  in  respect  of  diet. 

Embolism  and  Thrombosis  of  Cerebral  Arteries ;  Endarteritis;  Athe- 
roma.—  In  most  convalesc-ent  cases  it  may  be  necessary  to  administer 
more  nourishing  food  and  stimulants  in  small  quantities:  the  conditions 


396  SYSTEM   OF  MEDICINE 

of  the  heart  and  circulation  are  the  guides  in  this  respect.  The  age 
and  general  state  of  nutrition  must  also  be  considered. 

Epilepsy.  —  In  patients  subject  to  epileptic  paroxysms  much  benefit 
is  derivable  from  carefully-prescribed  diet.  This  should  be  so  arranged 
as  to  preveut  any  overloading  of  the  stomach,  and  all  food  difficult  of 
digestion  is  to  be  withheld.  The  principal  meals  are  best  taken  in  the 
earlier  part  of  the  day,  and  only  a  light  meal  consumed  in  the  evening. 
Experience  clearly  indicates  that  a  diet  not  too  rich  in  albuminoids  is 
advisable.  Animal  food  should  be  sparingly  taken,  but  fish  may  be 
used  freely.  Butchers'  meat  is  better  given  on  alternate  days,  if  at  all, 
and  never  in  large  amount.  Farinaceous  foods  and  fat  are  desirable. 
Milk  in  large  quantities  is  harmful.  Alcohol  is  better  dispensed  with, 
or  very  sparingly  taken  in  the  form  of  diluted  light  wines.  Butter, 
cream,  and  fat  bacon  may  be  taken  freely,  and  butter-milk  in  moderation 
has  been  found  useful.  Coffee  and  cocoa  are  commonly  preferable  to 
tea.  There  can  be  no  doubt  that  recurrence  of  paroxysms  may  be 
materially  checked  by  strict  attention  to  the  points  just  noted. 

Migraine.  —  Few  disorders  are  better  controlled  by  careful  dieting 
than  this.  There  is  distaste  for  food  during  the  paroxysms.  Iced 
aerated  water  is  sometimes  helpful  in  the  attack.  Tea  and  coffee  are 
also  sometimes  of  avail.  There  is  a  gouty  element  in  many  cases, 
especially  in  females,  and  errors  of  diet  leading  to  goutiness  may  induce 
migraine  in  such  persons.  In  the  intervals  between  attacks  regard  must 
be  had  to  this  fact,  and  to  the  "  growing-up  "  tendency  to  outbursts  of 
varieties  of  paroxysms.  More  water  driuking  is  desirable,  and  a  strict 
limitation  of  animal  and  rich  foods.  Abundance  of  well-cooked  green 
vegetables,  such  as  spinach,  is  important.  Malt  liquors  and  strong 
wines  are  not  to  be  taken. 

Chorea.  —  In  acute  cases  only  "  spoon-food  "  is  to  be  given.  At  the 
height  of  the  disorder  nasal  feeding  may  be  necessary.  Abundance  of 
nourishment  is  necessary,  and  wine  is  usually  beneficial.  The  rheumatic 
nature  of  the  disorder  (as  held  by  the  writer)  does  not  in  this  case  forbid 
the  use  of  animal  broth,  but  milk  appears  to  be  the  most  suitable  form 
of  nourishment.  Assiduous  attention  on  the  part  of  the  nurse  is  needed 
to  secure  a  sufficiency  of  liquid  food  in  grave  cases.  In  milder  cases  care 
must  be  taken  to  prevent  the  patient  suddenly  bolting  any  masses  of 
unmasticated  food. 

Hysteria;  Anorexia  nervosa;  Vomiting;  Refusal  of  Food.  —  The  dif- 
ferent and  multiform  phases  of  hysteria  demand  special  attention  in  each 
case.  The  main  principles  relate  to  the  use  of  a  sufficiently  nourishing 
diet,  care  being  taken  to  avoid  incautious  resort  to  stimiilants.  Loathing 
of  certain  foods  and  many  idiosyncratic  vagaries  may  be  encountered. 
These  must  be  overcome  as  far  as  possible,  or  substitutes  for  any  one  of 
them  provided.  Aversion  from  red  meat  and  from  fat  is  not  uncommon. 
Firm  but  gentle  discipline  is  often  needed  to  secure  due  nutrition. 
Morbid  cravings  demand  special  study,  and  the  practitioner  must  beware 
of  becoming  an  inflexible  doctrinaire.     There  may  be  digestive  capacity 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE     397 


for  articles  of  food  theoretically  reckoned  as  unfit.  Thus,  lobster  and 
pork  may  be  desired,  and  beef,  mutton  and  fish  found  repulsive.  Com- 
plete anorexia  is  occasionally  met  wiih,  and  "  fasting  girls  "  may  come 
under  notice.  These  "phenomena"  are  not  to  be  watched  with  vulgar 
curiosity,  but  the  miserable  subjects  of  them  are  to  be  forcibly  fed,  if 
necessary  by  the  tube,  and  medically  treated.  Remarkably  good  results 
have  accrued  from  such  treatment  in  the  hands  of  Weir  Mitchell  and 
others  who  have  followed  this  method.  Seclusion  from  friends  and 
ordinary  environments,  with  rest,  massage,  and  enforced  meals  of  strong 
soup,  milk,  cream,  eggs  and  pounded  meats  constitute  this  method.  Its 
great  demerit  is  its  costliness,  which  render  it  unavailable  for  any  but 
wealthy  patients,  and,  unfortunately,  the  good  results  are  not  always 
permanent.  The  infirmity  of  will,  and  the  general  instability  of  the 
nervous  centres,  have  to  be  dealt  with,  and  such  patients,  though  much 
has  been  secured  for  them  of  late  years,  —  and  they  tend  to  grow  more 
numerous  with  what  we  are  pleased  to  call "  civilisation,"  —  mostly  remain 
objects  of  pity,  and  a  sore  tax  both  upon  their  friends  and  their  medical 
attendants. 

Hysterical  vomiting  and  dysphagia  demand  the  disciplinary  use. of  an 
oesophageal  bougie,  rectal  alimentation  being  carried  on,  or  nasal  feeding, 
the  bougie  and  nasal  tube  being  subsequently  threatened  in  terrorem. 

Neuralgia.  —  Generally  speaking,  supporting  diet  is  called  for.  If 
neuralgia  be  "the  prayer  of  the  nerve  for  healthy  blood,"  that  prayer 
must  be  answered.  We  distinguish  between  nerve  pain  due  to  specific 
morbid  condition,  capable  of  removal,  and  that  due  to  lowered  vitality 
and  exhaustion  with  poverty  of  blood.  Thus  gouty,  syphilitic  and 
diabetic  neuralgias  have  to  be  considered,  and  appropriate  dietetic 
measures  adopted  for  each.  In  the  neuralgias  due  to  exhaustion  we 
have  to  insist  on  a  full  supply  of  digestible  food  with  plenty  of  fatty 
elements.  Butter,  cream,  Devonshire  cream,  and  fresh  unburnt  fats  are 
thus  of  value.  Post-catarrhal  and  influenzal  neuralgia,  the  miserable 
paroxysms  of  pain  in  affections  of  the  fifth  and  occipital  nerves,  and  post 
herpetic  (zonal)  neuralgia  are  often  benefited  by  the  temporary  free  use 
of  mature  port  wine,  best  taken  with  meals. 

Disease  of  the  Respiratory  Organs.  —  Tubercular,  Syphilitic  and 
Cancerous  Laryngitis.  —  In  advanced  cases  of  any  of  these  diseases  feed- 
ing becomes  difficult  and  painful.  Spoon-food  is  necessary,  and  the  most 
nourishing  fluids  must  be  given.  Yolks  of  eggs,  milk  thickened  with 
arrowroot,  and  thin  jellies  are  suitable.  Care  has  to  be  taken  that  no 
food  enters  the  larynx.  It  is  sometimes  advisable  in  painful  cases  to 
paint  or  spray  the  pharynx  and  glottis  with  a  solution  of  cocaine  (to  be 
freshly  made  every  week,  5  per  cent  strength)  five  minutes  before 
attempts  are  made  to  swallow.  A  soft  tube  may  have  to  be  passed  into 
the  oesophagus  to  conduct  liquid  food  in  these  cases  and  in  the  sensory 
paralysis  dependent  on  diphtheria  and  bulbar  disease. 

Bronchitis:  (a)  acute,  (b)  chronic. — The  diet  should   be  light  and 


398  SYSTEM   OF  MEDICINE 

nourishing  in  acute  bronchitis.  In  chronic  bronchitis  the  patient  com- 
monly requires  strong  nourishment  and  abundance  of  fatty  food. 
Alcohol  in  some  form  is  generally  useful. 

Asthma.  —  The  diet  is  often  an  important  element  in  successful  treat- 
ment of  these  cases.  Indiscretion  and  inappropriate  diet  often  induce 
paroxysms.  Small  meals  of  readily  digestible  food  are  best.  Many 
idiosyncrasies  are  met  with  respecting  tolerance  or  intolerance  of  articles 
of  diet.  I  have  known  fresh  butter  to  be  constantly  and  immediately 
provocative  of  an  attack.  Hard  meats,  cheese,  pastry,  beer  and  ill- 
cooked  food  are  generally  inadmissible.  Full  evening  meals  are  to  be 
avoided,  and  the  chief  meal  is  best  taken  early  in  the  afternoon. 

Emi)hysema.  —  The  chief  point  to  guard  against  is  the  use  of  any  food 
that  may  create  flatulent  distension  of  the  stomach  and  bowels. 

Pneumonia. — The  diet  here  is  as  for  fever  till  the  crisis  occurs. 
After  this  the  patient  may  have  solid  food  if  desired,  and  the  amount  of 
liquids  be  somewhat  restricted.  Alcohol  may  be  required,  as  in  fever, 
and  is  often  beneficial.  It  may  have  to  be  freely  given  in  elderly  persons 
and  confirmed  hard  drinkers.  The  onset  of  gangrene  is  the  signal  for 
free  stimulation,  strong  meat  essences  and  milk. 

PhtJdsis  Puhnonalis.  —  The  indications  in  all  forms  and  stages  of 
pulmonary  phthisis  in  respect  of  diet  are  to  supply  as  much  digestible 
nutriment  as  can  be  disposed  of.  The  condition  of  dyspepsia  which 
is  often  concurrent  needs  appropriate  dietetic  treatment.  The  meals 
should  be  smaller  and  more  frequent  than  in  health.  All  varieties  of 
flesh,  fowl  and  fish,  with  abundance  of  fatty  food,  are  proper.  Milk  is 
of  great  value.  An  early  breakfast  in  bed  is  often  advisable,  consisting 
of  tea  made  with  cream,  or  instead,  half  a  pint  of  warm  milk  with  the 
yolk  of  a  raw  egg  stirred  into  it.  Where  night-sweats  are  present,  a  cup 
of  cold  tea  made  with  cream,  or  two  ounces  of  claret  and  water,  may  be 
taken  on  awaking  at  four  or  five  o'clock  in  the  morning.  Malt  ex- 
tracts are  certainly  of  use,  and  may  be  given  in  warm  milk.  Diluted 
warm  drinks  of  nourishing  quality  aid  in  promoting  free  expectoration 
and  lessen  harassing  cough.  Malt  liquors  are  excellent  if  they  can  be 
digested.  Failing  these,  any  form  of  alcoholic  liquid  taken  with  meals  is 
advisable.  Half  an  ounce  of  rum  taken  in  half  a  pint  of  milk  is  a  well- 
approved  combination  taken  early  in  the  morning,  and  again  in  the  fore- 
noon. Eggs,  oysters,  sweet-bread,  fat  bacon  and  tender  ham,  roe  of  fish, 
caviare  and  brains,  are  all  useful  in  varying  the  diet  and  encouraging 
languid  appetite.  In  early  cases  of  phthisis  there  is  no  better  midday 
meal  than  a  large  fat  mutton  chop,  grilled,  and  half  a  pint  of  good 
draught  porter.  Junket  and  Devonshire  cream  with  custard  pudding 
or  stewed  fruit  may  be  taken.  The  presence  of  tubercular  enteritis 
demands  the  diet  found  useful  in  diarrhoea  or  dysentery,  the  curds  of 
milk  being  harmful  and  solid  food  unsuitable.  Alum  whey  and 
koumiss  may  be  of  service  in  such  cases,  and  mutton  or  chicken  essence 
preferable  to  beef  essence.  To  promote  good  digestion  of  suitable  nour- 
ishment is  to  secure  the  first  line  of  defence  in  resisting  the  progress 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE      399 


of  tuberculosis  in  any  part  of  the  body,  and  no  therapeutic  measures 
are  of  any  avail  in  default  of  this.  A  great  raodern  error  is  to  be 
guarded  against.  It  is  now  sought  to  combine  food  and  physic  in 
numberless  preparations  foisted  on  the  practitioner  by  manufacturing 
chemists.  These  are  mostly  nauseous  and  harmful.  It  needs  good 
judgment  to  keep  well  apart  food,  which  is  to  be  enjoyed  if  possible, 
and  physic,  which  is  to  be  tolerated  only  so  far  as  is  necessary.  Too 
often  one  finds  the  stomach  oppressed  by  continual  alternations  of  food 
and  physic,  and  the  end  sought  is  not  attained.  Simplicity  and  orderly 
method  will  accomplish  much  more  than  an  elaborate  and  fanciful  scheme 
of  diet;  and,  certainly,  in  the  earlier  stage  of  phthisis  the  patient  must 
not  be  too  much  regarded  as  an  invalid  to  be  coddled  and  stuffed.  We 
have  to  seek  robustness,  and  to  cultivate  all  the  bodily  powers  of  resist- 
ance. 

Coryza  ;  Common  Colds  ;  Febrile  Catarrh.  —  In  ordinary  catarrhal 
states  of  the  nasal,  faucial  and  bronchial  mucous  surfaces,  there  is  hardly 
any  justifiable  interference  with  the  usual  diet.  In  severer  febrile 
attacks  a  slop  diet  is  advisable,  and  alcohol  should  be  withheld.  It  is 
a  common  error  to  over-feed  and  over-stimulate  in  this  condition.  Ani- 
mal broths,  well  salted,  milky  and  farinaceous  food,  with  plainly-cooked 
vegetables,  are  best.  Lemonade,  freshly  made,  and  taken  hot  at  bed- 
time is  an  approved  remedy,  and  tamarind  tea,  barley  water  sweetened 
with  liquorice,  and  linseed  tea,  are  all  useful  varieties  of  diluents.  A 
diet  restricted  in  liquids  has  been  recommended,  but  has  found  little 
favour.  During  the  course  of  a  progressive  febrile  process  diluents  are 
in  many  ways  advisable. 

Diseases  of  the  Organs  of  Circulation.  —  Inflammatory  Conditions  of 
the  Heart  and  Pericardium.  —  In  these  cases  we  have  practically  to  do 
with  the  conditions  which  underlie  and  induce  the  several  disorders  in 
question.  These  relate  to  the  peccant  matter  of  rheumatism,  to  morbid 
blood-states  in  renal  diseases,  and  to  specific  toxaemia  due  to  bacillary 
invasion. 

The  diet  proper  for  patients  with  cardiac  complications  of  rheuma- 
tism is  mainly  that  for  febrile  states,  except  that  animal  broth  is  harm- 
ful. Milk  properly  diluted  and  farinaceous  food  only  are  allowable. 
Rusks  and  biscuits  soaked  in  milk,  bread-pap,  arrowroot,  simple  nurs- 
ery puddings  (without  eggs),  and  mashed  potato  may  be  given.  In 
pericarditis  with  effusion  the  diet  should  be  restricted  somewhat  in 
respect  of  fluids,  and  all  sources  of  flatulence  be  avoided.  The  pulse 
condition  will  determine  the  employment  of  alcohol. 

Malignant  (Ulcerative)  Endocarditis.  —  In  malignant  endocarditis 
stronger  nutriment  is  necessary,  and  animal  broths,  eggs  and  pounded 
meat  may  be  given,  and  spirit  or  wine  will  commonly  be  needed. 

Myocarditis.  —  Myocarditis  calls  for  the  use  of  alcohol  whenever 
recognised.  In  simple  rheumatic  pericarditis  stimulants  are  best 
avoided  as  far  as  possible. 


400  SYSTEM   OF  MEDICINE 


Pericarditis  in  Bright'' s  Disease.  —  In  these  cases  the  condition  of 
the  kidneys  determines  the  diet.  These  organs  are  inadequate  to  the 
perforinance  of  their  functions,  and  can  ill  bear  any  undue  work  thrown 
upon  them.  A  milky  and  farinaceous  diet  is  suitable ;  lemonade  or 
imperial  drink  are  useful ;  so  likewise  are  whey  and  koumiss.  Vomit- 
ing may  be  a  serious  complication,  and,  in  any  case,  the  prognosis  is  as 
grav^e  as  can  be. 

Valvular  Diseases  of  the  Heart  and  Complications;  Hypertrophy; 
Dilatation.  —  The  main  objects  are  to  give  sufficient  supporting  food, 
but  to  ensure  its  digestion  with  comfort,  and  never  to  overload  the 
stomach.  Gastric  and  intestinal  catarrh  are  often  present,  and  a  light 
diet  is  then  imperative.  The  condition  of  the  kidneys  must  always  be 
considered  together  with  that  of  the  circulation,  and  no  less  the  state 
of  the  pulse  in  respect  of  arterial  tension.  Alcohol  is  commonly  useful 
and  necessary,  and  no  form  of  cardiac  valvular  disease  per  se  contra- 
indicates  it ;  in  aortic  reflux  it  is  generally  advisable,  especially  in  ad- 
vanced stages,  and  some  should  be  given  at  bedtime  in  addition  to  that 
taken  with  meals.  When  hypertrophy  of  any  cavity  is  sufficient,  espe- 
cially in  young  persons,  there  may  be  no  need  for  alcohol.  When  dila- 
tation sets  in  alcohol  is  valuable.  In  the  latter  condition  it  is  well  to 
restrict  the  amount  of  fluid  taken,  a  "dry  diet"  being  advisable  and  pro- 
ductive of  much  benefit.  Four  or  five  small  meals  may  be  taken  in  the 
course  of  the  day,  and  liquids  taken  after  them.  AVhey,  milk  and  lime 
water,  or  milk  and  bicarbonate  of  sodium,  are  useful  when  nausea  and 
anorexia  are  present,  with  engorged  liver  and  acute  gastro-enteric  catarrh. 
Prudent  medication  in  these  conditions  much  aids  the  appetite.  Impe- 
rial drink  is  of  service,  and  fresh  or  well-cooked  fruits  are  admissible. 
Coffee  and  cocoa  are  generally  better  than  tea,  though  the  latter  is  well 
borne  by  many  people  if  not  too  strong. 

Congenital  Malformations.  —  In  these  cases  gastric  catarrh  is  apt  to 
recur,  and  the  diet  must  be  adapted  to  this  condition.  The  digestion 
is  feeble,  and  very  plain  food  suits  best.  Alcohol  is  only  needed  for 
cardiac  failure  in  the  later  stages. 

Functioned  Heart  Disorders.  —  Overloading  of  the  stomach  and  even 
a  discreet  use  of  tea  and  coffee  may  cause  or  aggravate  some  of  these. 
Alcohol  is  not  advisable  in  tachycardia,  and  in  many  cases  of  infrequent 
and  intermittent  cardiac  action  it  is  unnecessary.  Each  case  requires 
special  study. 

Angina  Pectoris.  —  In  this  disorder  care  must  be  taken  to  provide 
small  and  digestible  meals,  especially  towards  evening.  The  specific 
character  of  each  case  must  determine  the  employment  of  alcoholic 
drinks. 

Exophthalmic  Goitre.  —  The  same  rules  apply  here  as  in  the  two  fore- 
going conditions.     Vomiting  and  diarrhoea  often  need  special  care. 

Aneurysms ;  Arterial  Degeneration.  —  Much  benefit  is  to  be  derived 
from  a  more  or  less  close  practice  of  Tufnell's  dietetic  treatment.  This 
is  not  available  for  elderly  patients,  or  for  persons  with  aneurysm  and 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE     401 

aortic  reflux,  and  in  very  few  cases  is  it  a  successful  remedy.  One  main 
principle  of  the  plan  consists  in  a  small  intake  both  of  fluids  and  solids, 
the  chief  benefit  being  probably  derived  from  the  reduced  amount  of 
fluid.  Eight  ounces  of  fluids  and  ten  of  solids  may  be  enjoined  for 
several  weeks  on  a  bedridden  patient ;  a  water-bed  and  a  bed-pan  are 
imperative.  In  summer  this  restriction  is  often  found  intolerable,  thirst 
is  common,  and  constipation  the  rule.  Two  or  three  ounces  of  port  wine 
form  part  of  the  fluids.  The  latter  have  often  to  be  increased,  and 
towards  the  end  of  six  or  eight  weeks  the  whole  diet  is  gradually  in- 
creased. A  modification  of  this  system  is  found  to  answer  well  in  most 
suitable  cases.    Some  lemon  juice  is  necessary  in  addition  to  this  dietary. 

The  subjects  of  arterial  decay  are  to  be  sparingly  fed,  but  some  wine 
is  commonly  advisable,  especially  in  elderly  persons.  The  condition  of 
the  kidneys  must  be  carefully  ascertained  before  enjoining  a  diet. 

Tliromhosis  ;  Embolism.  —  The  particular  feediug  of  patients  with 
thrombosis  of  veins  will  depend  on  the  conditions  which  caused  it.  In 
ansemic  persons  good  diet  is  necessary,  with  alcohol.  In  gouty  persons 
a  very  plain  diet  is  imperative,  and  alcohol,  if  required,  is  best  given  in 
the  form  of  diluted  spirit.  Abundance  of  green  vegetable,  such  as 
spinach,  is  useful,  and  any  cruciferous  vegetable.  Water  drinking  and 
diluents  are  important. 

The  presence  of  arterial  embolism  commonly  demands  a  good  diet, 
with  some  alcohol,  especially  in  elderly  patients. 

Diseases  of  the  Digestive  Organs.  —  Stomatitis.  —  Fluid  nourishment 
is  alone  -to  be  employed  in  all  forms  of  stomatitis.  Milk  and  sodium 
bicarbonate  is  best,  and  should  be  given  tepid  or  warm.  Milk  arrow- 
root, and  a  little  brandy  with  it,  is  useful.  Yolk  of  egg  with  milk  is 
admissible.  After  feeding,  the  mouth  should  be  washed  out  with  warm 
boracic  lotion. 

Tonsillitis.  —  Supporting  liquid  nourishment  is  to  be  given.  Milk, 
beef  essence,  yolk  of  eggs,  and  port  wine  are  best ;  and  in  severe  cases 
these  must  be  firmly  pressed  in  spite  of  painful  deglutition.  ISTutrient 
enemata  may  be  required  for  a  time. 

(Esophageal  Obstruction.  —  Concentrated  liquid  food  is  best,  a:id  when 
this  no  longer  passes,  nourishment  must  be  given  by  a  small  tube,  with  a 
funnel-shaped  end,  worn  in  the  gullet,  its  lumen  being  kept  patent  by  a 
cat-gut  bougie,  both  being  affixed  to  the  side  of  the  mouth  by  diachylon 
plaster  (Symonds'  and  Berry's  method).  Eectal  feeding  is  usually  neces- 
sary in  addition,  or  by  the  stomach  directly,  if  gastrostomy  has  been 
performed. 

Gastritis  (acute). — Nutrient  enemata  are  best,  perfect  rest  being 
given  to  the  stomach.  Milk  and  soda  water  and  small  pieces  of  ice 
may  be  given  by  the  mouth  after  twenty-four  hours.  Subsequently, 
milk  and  sodium  bicarbonate,  with  barley  water,  custard  puddings,  and 
yolks  of  eggs. 

Gastritis  (chronic).  —  Only  the  most  digestible  and  bland  nourish- 

VOL.    I  2d 


402  SYSTEM   OF  MEDICINE 

ment  is  advisable.  .Tea,  coffee,  and  alcohol  are  inadmissible.  Milk  and 
farinaceous  food,  soft  fresh  hsh,  pounded  meat,  mutton,  chicken,  mashed 
potato,  and  lightly-boiled  fresh  eggs  may  be  given  in  small  quantities. 
Sugar  is  inadvisable.  Nourishment  is  to  be  given  at  regular  and  not  too 
long  intervals  —  every  three  or  four  hours. 

Di/spepsia,  Varieties  of.  —  Each  case  must  be  specially  studied.  Gen- 
erally the  diet  is  as  for  chronic  gastritis.  Many  idiosyncrasies  may  be 
noted  in  respect  of  tolerance  and  digestive  capacity.  Alcohol  will  aid 
in  some  forms,  given  with  or  just  after  a  meal,  and  painful  dyspepsia  will 
sometimes  yield  to  a  few  spoonfuls  of  hot  brandy  or  whisky  toddy  at  the 
end  of  a  meal.  Many  cases  do  best  without  alcohol  in  any  form.  Malt 
liquors  are  generally  inadvisable.  Excess  of  bread-eating  is  sometimes 
harmful.  Toast  or  "pulled"  bread  or  biscuits  often  well  replace  bread. 
Browned  and  over-cooked  fats  generally  provoke  acid  dyspepsia,  and  all 
rich,  twice-cooked,  or  highly-seasoned  dishes  are  inadmissible.  Small 
meals,  no  second  helpings,  avoidance  of  soups  and  of  much  liquid  with 
meals,  are  points  to  be  attended  to.  All  vegetables  should  be  sparingly 
used,  and  cooked  as  a  French  cook  always  —  and  an  English  cook  never 
—  cooks  them.  Indulgence  in  the  sweet  courses  is  a  fertile  source  of 
acid  dyspepsia,  and  indigestion  of  amylaceous  food  leads  to  the  same  in 
more  cases  than  is  generally  supposed.  Boiled  fish  and  plain  roasted 
and  grilled  meats  are  generally  well  digested,  also  custard  pudding  and 
light  omelettes. 

Recumbency  is  to  be  avoided  after  meals,  and  no  brain-work  under- 
taken during  or  soon  after  them.  Solitary  meals  are  disastrous,  and 
that  customary,  but  very  unwholesome,  combination,  the  tea-dinner,  is 
to  be  avoided.  No  meals  should  be  taken  after  eight  o'clock  in  the 
evening.  Very  weak  tea  or  some  hot  water  may  be  taken  an  hour  after 
the  evening  meal.  A  glass  of  water  may  be  slowly  sipped  at  bedtime, 
but  no  alcohol  is  permissible  with  it.  Further  details  cannot  be  set 
forth  here.  No  food  is  advisable  between  meals,  and  full  intervals  of 
rest  must  be  secured  for  the  digestive  organs.  Many  strange  dietetic 
methods  for  treating  the  varieties  of  dyspepsia  are  in  vogue.  Of  all  of 
them  I  will  only  affirm  that  they  are  unwarrantable,  and  that  common 
sense  and  experienced  clinical  skill  will  effectually  secure  all  that  is 
attainable  for  the  permanent  welfare  of  the  patient. 

Gastric  Ulcer.  —  Rest  to  the  stomach  is  the  key-note  of  treatment  — 
nutrient  enemata  alone  being  employed  for  some  days.  A  little  water 
by  the  mouth  or  pieces  of  ice  may  be  taken,  but  even  this  may  be  in- 
advisable if  vomiting  be  urgent,  or  hsematemesis  have  lately  occurred. 
Afterwards, whey,  or  milk  with  lime  Avater  and  barley  water,  may  be  given, 
in  tablespoonful  doses,  each  quarter  of  an  hour  by  the  clock.  I  object 
to  peptonised  food  in  these  cases,  as  the  ulcer  may  be  injured  and  checked 
in  healing  thereby.  Subsequently,  milk  arrowroot,  yolk  of  egg,  biscuit 
powder  and  milk  in  thin  pap,  bread  crumbs  and  milk  in  fine  pappy 
condition,  and  milky  cocoa  (without  sugar)  may  be  given.  Beef  essence, 
liquid  jelly,  pounded  fish,  pounded  chicken  or  mutton  may  next  be  tried, 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE     403 

once  in  each  day,  and  the  effects  carefully  noted.  Vegetables,  fruits  and 
alcohol  are  to  be  avoided.  Strict  confinement  to  bed  is  absolutely 
essential. 

Cancer  of  the  Stomach.  —  The  diet  is  as  for  ulcer  of  the  stomach. 
Peptonised  foods,  however,  are  admissible  when  there  is  no  vomiting, 
pain  or  haemorrhage,  and  pultaceous  or  even  solid  food  may  be  remarkably 
well  borne.  Light  wine,  champagne,  dry  Moselle  wine,  or  port  wine  may 
be  employed.  A  teaspoonful  of  neat  brandy  sometimes  much  relieves 
pain  in  these  cases.  When  vomiting  is  rebellious,  iced  foods  and  well- 
aerated  waters  may  do  good.  Some  patients  tolerate  an  ordinary  mixed 
diet  very  well  if  the  pylorice  orifice  is  free. 

Pyloric  Stenosis  from  cancerous  or  simple  over-grovjths  ;  Gastric  Dilata- 
tion.—  The  diet  here  is  as  for  chronic  gastric  catarrh.  Dilatation  from 
pyloric  stenosis  leads  to  retention  of  contents,  and  to  fermentative  decom- 
positions, growth  of  sarcinae  ventriculi,  etc.  Washing  out  of  the  stom- 
ach daily  or  every  second  day,  before  the  principal  meal,  is  of  great  value, 
and  amylaceous  food  is  to  be  much  restricted.  Beef  essence,  yolk  of 
eg^,  custard,  pounded  meat,  jellies  and  milk,  with  some  diluted  alcohol, 
are  admissible.  Much  fluid  is  undesirable,  and  a  somewhat  dry  diet  is  to 
be  enjoined. 

Intestinal  Diseases;  Enteritis.  —  The  food  should  be  the  same  as  for 
gastric  ulcer,  and  not  taken  too  hot. 

English  Cholera;  Cholera  nostras.  —  Milk  and  barley  water  with  a  little 
brandy  are  best  when  the  vomiting  subsides.  Chicken  and  mutton  broth 
are  preferable  to  beef  tea. 

Infantile  Enteritis.  —  Inquiry  is  necessary  as  to  the  mother's  milk.  If 
this  is  unsuitable,  diluted  coav's  milk,  one  to  two  or  three  of  barley  water 
and  lime  water,  ass's  or  goat's  milk  is  advisable.  Sterilised  milk  is 
often  desirable ;  it  is  made  by  steaming  it  in  bottles  for  half  an  hour 
before  adding  the  lime  water.  If  milk  be  rejected  malt  food  is  generally 
available ;  or  raw  beef  juice,  or  Valentine's  essence  diluted  freely,  may  be 
tried.  Brandy  is  commonly  of  value,  especially  if  any  signs  of  collapse 
set  in.     The  feeding-bottle  must  be  kept  scrupulously  clean. 

Ulcerative  Colitis.  —  The  feeding  here  is  as  for  cases  of  dysentery  or 
chroiiic  diarrhoea.  A  drachm  of  fresh  suet  melted  into  a  pint  of  warm 
milk  is  useful  (the  "  Lac  Sevi"  of  Guy's  Hospital),  and  malted  foods  are 
available. 

Typhlitis  ;  Perityphlitis.  —  Milk  diet  with  lime  water  or  sodium  bicar- 
bonate, whey,  mutton  essence.  Any  food  likely  to  leave  debris  of  tough 
or  irritating  matters  must  be  avoided.  If  vomiting  occur,  the  diet  should 
be  as  recommended  in  cases  of  peritonitis. 

Dia.rrhfpAi.  —  Milky  diet,  arrowroot  and  milk,  a  little  raw  arrowroot 
being  stirred  into  each  cupful.  Mi;tton  tea  with  rice ;  brandy  or  port 
wine  with  arrowroot.  Sometimes  equal  parts,  half  an  ounce  each,  of  old 
port  wine  and  good  brandy,  prove  useful,  taken  two  or  three  times  a  day 
when  exhaustion  occurs  after  severe  vomiting  and  purging.  No  hot  food 
is  to  be  taken.     When  milk  disagrees,  veal  or  chicken  broth,  and  malted 


404  SYSTEM   OF  MEDICINE 

foods  may  prove  of  value.  When  arrowroot  is  not  available,  a  few 
spoonfuls  of  flour,  baked  to  a  light  brown  pastry  colour,  may  be  given 
with  water  or  milk. 

Diarrhoea,  as  a  symptom  of  tubercular  enteritis,  requires  similar  feed- 
ing, and  the  dietetic  treatment  of  diarrhoea  from  whatever  cause  must 
generally  be  the  same. 

Constipation.  —  The  diet  should  be  varied,  and  should  include  vegetable 
food  well  cooked,  especially  spinach,  fats,  oil,  fish  or  cooked  fruits,  brown 
bread,  oatmeal  porridge,  whole  meal  bread,  "  parkin,"  gingerbread,  and 
molasses.  Cocoa  is  preferable  to  tea  or  coffee.  Half  a  pint  of  cold  water 
may  be  taken  before  breakfast,  and  the  same  at  bedtime.  Beef,  white 
bread,  cheese,  and  milk  favour  constipation. 

Intestinal  Obstruction.  —  The  feeding  in  these  cases  is  as  for  those  of 
peritonitis.  The  less  food  given  in  any  form  the  better.  Nutrient 
enemata  may  be  employed.  Hot  water  in  spoonfuls  is  useful,  and  whey. 
All  food  tending  to  leave  curd  or  debris,  as  milk,  is  to  be  avoided. 

Diseases  of  the  Liver;  Jaundice.  —  In  cases  of  obstructive  jaundice  it 
is  advisable  to  limit  the  amount  of  farinaceous  and  fatty  foods.  Beef 
and  other  animal  foods  and  green  vegetables  are  best.  Milk  and  sodium 
bicarbonate  with  barley  water  is  advisable.  Water  drinking  is  certainly 
of  use.  Alcohol  should  be  avoided  as  a  rule.  HoAvever  induced  in  any 
patient,  the  diet  should  be  simple  and  unstimulating.  Extra  water 
drinking  is  often  advisable,  and  Vichy  water  may  be  taken  to  the  extent 
of  fifteen  or  twenty  ounces  in  the  day. 

Hepatic  Dyspepsia;  Lithcemia.  —  Plainly  cooked  animal  food.  Dimi- 
nution of  amylaceous  food  and  fatty  matters.  Avoidance  of  seasoned 
and  spiced  food.  Grilled  mutton  or  beef,  boiled  white  fish,  spinach. 
Sugar  in  small  amoimt  and  fruits.  Claret  or  dry  Moselle  with  water, 
or  weak  spirit  and  water,  with  meals,  if  desirable.  Cold  or  hot  water 
drinking  is  advisable  between  meals. 

Cirrhosis  of  the  Liver.  —  In  this  condition  there  is  often  gastro-enteric 
catarrh  and  vomiting  of  ingesta.  Liquid  nourishment  in  small  quantities 
is  necessary.  Alcohol  is?  to  be  withheld,  as  a  rule,  but  it  may  be  neces- 
sary to  employ  it  for  the  patient  even  if  contra-indicated  for  his  disease. 
In  many  cases  solid  food  may  be  given  with  advantage.  If  there  be 
much  ascites,  restriction  of  fluids  is  advisable. 

Cancer  of  the  Liver.  —  The  diet  in  these  cases  should  be  such  as  can 
best  be  digested.  Saccharine  and  fatty  matters  are  undesirable.  A 
little  alcohol  is  commonly  of  use,  well  diluted,  or  given  in  the  form  of 
champagne. 

Gall-stones.  —  Saccharine  and  fatty  matters  are  unadvisable.  Mutton 
fat  appears  to  favoiir  formation  of  biliary  calculi  if  taken  to  excess. 
Alcohol  should  be  moderately  employed,  if  at  all ;  it  is  best  given  in 
the  form  of  dry  white  Moselle  wine  with  some  sodic  mineral  water. 

Peritonitis.  — Vomiting  and  thirst  are  troublesome  symptoms.  Small 
pieces  of  ice  to  suck  are  useful,  but  no  food  should  be  given  by  the 
mouth.     Hot  water  is  sometimes  well  borne.     Nutrient   enemata  are 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE     405 

to  be  given,  consisting  of  milk,  animal  broth,  and  yolk  of  egg,  in  quan- 
tities of  not  more  than  four  ounces,  every  four  or  six  hours.  Nutrient 
suppositories  are  available.  A  little  laudanum  may  be  added  to  each 
enema.  If  the  vomiting  is  in  abeyance,  alcohol  may  be  given  in  iced 
water  in  small  quantities.  After  abdominal  section  it  is  best  to  give 
no  food  by  the  mouth,  and  use  small  sips  of  hot  water  for  tAventy- 
four  or  thirty-six  hours.  Small  nutrient  enemata  or  suppositories  may 
be  given. 

Chronic  Peritonitis ;  Tubercular  Peritonitis ;  Cancerous  Peritonitis. — 
The  diet  must  be  adapted  so  as  to  avoid  any  articles  difficult  of  diges- 
tion or  likely  to  leave  irritating  debris  behind  them.  Nourishing  slop 
diet,  pounded  meats,  arrowroot  with  cream,  custards,  mutton  essence 
and  jelly  are  available.     Cocoa  and  malted  foods  are  good. 

Diseases  of  the   Blood,  Lymphatic  System,   and  Ductless  Glands. — 

Anmmia ;  Chlorosis;  Pernicious  Anmmia. — The  dietary  must  vary  in 
these  cases  according  to  the  digestive  capacity  in  each  patient.  The  ob- 
ject is  to  supply  abundance  of  nourishment  in  a  readily  digestible  form. 
Red  meat,  milk,  eggs,  and  fats  are  needed.  The  possible  presence  of 
associated  gastric  ulcer  must  be  always  borne  in  mind  in  young  women, 
and  appropriate  feeding  employed  if  there  be  even  a  suspicion  of  it. 
Wine  is  generally  necessary,  and  four  to  six  ounces  of  good  Bordeaux  or 
Burgundy  may  be  given,  or  four  ounces  of  port  wine  daily  with  food. 
In  some  cases  marrow  may  be  given  with  benefit,  and  this  is  well  worthy 
of  employment  in  cases  of  pernicious  anaemia.  The  marrow  from 
grilled  ox-bones  may  be  eaten  with  dry  toast  at  one  meal  each  day. 

LeuchxBmia.  —  Nourishing  food  is  necessary  in  this  disorder.  Marrow 
is  well  worthy  of  trial.     Some  generous  wine  is  also  advisable. 

Purpura.  —  Although  there  is  no  evidence  to  prove  that  this  disorder 
in  its  ordinary  forms  is  due  to  defect  in  diet,  a  simple  nourishing  dietary 
is  always  advisable,  together  with  a  plentiful  supply  of  milk.  Some 
wine  is  generally  useful. 

Scorbiitus.  —  It  is  clearly  proved  that  deprivation  of  fresh  food,  vege- 
table or  animal,  is  the  essential  cause  of  this  disease.  It  suffices  to  add 
this  to  a  good  nourishing  diet  to  ensure  complete  recovery.  Lemon 
juice  is  by  itself  sufficiently  anti-scorbutic.  The  blood  is  deficient  in 
alkalies.  The  gums  being  spongy  and  tender,  and  the  teeth  loosened  in 
severe  cases,  it  is  necessary  to  employ  spoon-food.  Mashed  potato,  green 
vegetables,  especially  of  the  cruciferous  variety,  animal  broths,  softly- 
boiled  onions,  eggs,  and  fresh  milk  are  then  advisable.  Red  wines  are 
of  value.  Ereshly-made  lemonade  may  be  freely  given.  If  vegetables 
are  not  available,  fresh  meat  and  blood  prove  of  use  in  averting  scurvy. 
In  marine  or  other  expeditions  preserved  vegetables  and  fruits  should 
be  provided.  Vinegar  is  also  useful.  Lime  juice  should  be  served  out 
daily  in  quantities  of  one  ounce,  and  is  generally  mixed  with  10  per 
cent  of  rum  or  other  spirit  to  enable  it  to  keep  well. 

Ilf/imophilia.  —  Great  care  is  necessary  to  ensure  that  all  food  taken 


406  SYSTEM   OF  MEDICINE 

is  readily  digestible.  Fish  should  be  giren  in  place  of  excess  of  meat, 
and  wine  be  sparingly  employed,  best  in  the  form  of  diluted  claret  with 
meals.  Note  is  to  be  taken  of  any  periodic  tendency  to  plethora. 
When  haemorrhages  occur  in  the  alimentary  tract  the  diet  should  be 
that  employed  in  cases  of  enteric  fever  with  similar  symptoms,  whey 
and  thin  animal  jellies  only  being  given. 

Myxoedema.  —  The  modern  treatment  of  this  disease  is  carried  out  by 
supplying  with  the  food  thyroid  elements  in  the  form  of  various  prep- 
arations of  that  gland  taken  from  the  sheep.  This  dosage  must  be 
maintained  in  perpetuity  daily,  or  two  or  three  times  a  week,  in  order 
to  maintain  immunity  from  recurrence  of  the  disorder.  Nourishing 
food  and  a  little  wine  are  of  importance.  Tablets  or  elixir  of  thyroid 
gland  are  best  given  after  the  principal  meals,  and  the  patient  should 
remain  sitting  or  recumbent  for  half  an  hour  after  the  dose. 

Addison'' s  Disease.  —  Nourishing  diet  with  wine  is  necessary.  In 
exacerbations  \^'ith  vomiting  and  cardiac  depression  confinement  to  bed 
must  be  enjoined,  and  brandy  in  effervescing  water  or  iced  champagne 
and  soda  water  be  given.  A  small  quantity  of  brandy  or  liqueur  may 
advantageously  be  given  after  the  two  principal  meals  in  the  day. 
Oysters  are  often  useful. 

Hodgkin's  Disease;  Lympliadenoma.  —  In  addition  to  a  full  nourish- 
ing diet,  good  results  may  be  met  with  from  the  use  of  marrow,  taken 
daily,  as  recommended  in  cases  of  pernicious  anaemia. 

Tuberculosis  of  Lymph  Glands.  —  In  these  cases  the  diet  is  as  for 
pulmonary  phthisis.  Fatty  foods  are  of  mucli  value.  Cream,  suet  and 
milk,  malted  food  with  cream  or  milk.  Ass's  and  goat's  milk,  and 
whey,  the  latter  charged  with  calcium  chloride,  twenty  grains  to  the 
pint,  are  worthy  of  confidence. 

Diseases  of  the  Urinary  Organs  ;  Acute  Tubed  Nephritis.  —  It  is  now 
acknowledged  that  milk  diet  alone  is  desirable  in  this  condition.  Some 
skill  is  requisite  to  ensure  its  digestion,  and  to  prevent  aversion  from 
it  on  the  part  of  the  patient.  Fresh  skimmed  milk  is  best,  diluted  with 
one-third  part  of  barley  water.  This  may  be  alternated  with  whey. 
Draughts  of  distilled  or  Nieder-Selters  water  may  be  freely  given.  Only 
in  mild  forms,  or  when  the  kidneys  begin  to  secrete  actively,  should 
farinaceous  food  be  added.  Arrowroot,  rice,  or  well-made  gruel  may 
then  be  given.  Next,  bread  and  milk,  sago,  or  rice  and  milk,  bread  and 
butter.  Fresh  lemonade,  with  a  drachm  of  acid  tartrate  of  potassium 
in  each  pint  (imperial  drink)  may  be  given.  No  flesh  food  of  any  kind, 
or  eggs,  are  to  be  employed  in  the  acute  disorder ;  as  these  are 
cautiously  introduced,  the  effects  on  the  urine  must  be  noted  daily.  Any 
recurrence  of  hgematuria  at  once  contra-indicates  flesh  food.  If  vomit- 
ing occur  it  is  well  to  cease  administration  of  anything  but  iced  soda 
water  in  small  quantities. 

Chronic  Tubal  Nephritis. — The  diet  best  suited  is  that  just  advised 
for  recovering  stages  of  the  aciite  form,  great  care  being  taken  at  first 
to  watch  the  effect  of  animal  (nitrogenised)  foods  on  the  amount  of 


THE    GENERAL   PRINCIPLES   OF  DIETETICS  IN  DISEASE     407 

albumin  eliminated.  Lemonade  and  green  vegetables,  as  spinach,  may 
be  given  if  well  cooked,  also  fresh  fruits,  potatoes,  and  saccharo-fari- 
naceous  elements.  Fish  is  also  available,  and  may  be' alternated  with 
mutton  or  other  tender  meat.  The  patient,  and  not  the  disease,  has  to 
be  treated,  and  too  prolonged  dietetic  restrictions  of  a  pedantic  character 
may  lead  to  wasting  and  a  degree  of  low  health  incompatible  with  ulti- 
mate recovery.     There  are  worse  things  than  the  mere  loss  of  albumin. 

Chronic  Interstitial  Nephritis.  —  The  best  diet  in  these  cases  is  that 
compatible  with  the  best  health  of  the  patient.  The  exact  degree  of 
adequacy  of  the  kidneys  must  be  gauged.  Fish,  vegetables,  and  farina- 
ceous foods  agree  best.  Animal  food  must  be  given  in  moderation,  if  at 
all ;  and  red  meat  not  more  than  once  in  the  day.  Alcohol  is  best 
avoided,  or  very  sparingly  allowed  with  one  meal  and  well  diluted. 
Any  gouty  element  in  a  case  must  be  appreciated.  The  high  arterial 
pressure  so  commonly  associated  with  granulating  kidneys  may  be  mark- 
edly reduced  by  diet  alone,  and  a  better  level  of  health  thus  maintained. 

Urcemia.  —  Milk  and  soda  water  or  whey  may  be  given.  If  vomit- 
ing is  urgent,  hot  water  may  prove  of  use,  and,  after  the  bowels  have 
been  well  cleared,  enemata  of  milk  (peptonised)  may  be  given  at 
regular  intervals. 

Lardaceous  Disease  of  the  Kidneys.  —  Milk  diet  is  useful,  and  may 
also  check  tendency  to  a  diarrhoea  due  to  the  lardaceous  disease  of  the 
digestive  mucous  tract,  which  is  commonly  associated  with  that  in  the 
kidneys.     In  other  respects  the  diet  is  as  for  chronic  nephritis. 

Renal  Colic. — Warm  diluent  drinks  are  of  use,  unless  vomiting  is 
rebellious. 

Morbid     Urinary    Conditions    without    Disease    of    the    Kidneys.  — 

Diabetes  Insipidus.  —  The  difficulty  here  is  to  meet  the  ardent  thirst. 
Ordinary  nourishing  diet  is  to  be  given,  and  large  amounts  may  be 
required  as  in  saccharine  diabetes.  Fluids  should  not  be  freely  taken 
with  or  immediately  after  meals.  Some  check  to  the  craving  for  fluids 
may  be  secured  by  only  permitting  warm  or  slightly  salt  water  to  be 
drunk  ;  but  it  is  cruel  and  unavailing  to  limit  materially  the  amount 
desired.  Some  Bordeaux  or  Burgundy  wine  may  be  given,  also  fresh 
lemonade. 

Diabetes  Mellitus ;  Glycosuria. — A  very  large  clinical  experience  is 
needed  in  order  to  determine  the  dieting  of  any  case  of  this  disease. 
Every  tiro  in  medicine  knows  what  articles  are  theoretically  prohibited 
for  diabetic  patients.  For  a  fuller  discussion  I  must  refer  to  the  article 
on  Diabetes.  The  dietary  may  either  be  strict  or  partially  so.  It  may 
need  to  be  strict  for  a  time,  with  subsequent  and  gradual  relaxation,  or, 
as  in  the  case  of  chronic  glycosuria  which  may  or  may  not  be  a  chronic 
form  of  diabetes  mellitus,  it  may  require  but  few  or  occasional  restric- 
tions. The  strict  diet  precludes  the  taking  of  starchy  and  saccharine 
elements.  This  is  a  severe  measure,  and  is  hardly  to  be  completely 
achieved  or  long  endured.     All  varieties  of  animal  food  and  white  fish 


4oS  SYSTEM  OF  MEDICINE 


are  admissible  is  this  case  (with,  perhaps,  the  exception  of  liver), 
fat  in  all  forms,  cream,  milk  sparingly,  green  vegetables,  and  sngarless 
wines  and  spirits.  Bread  stnffs  can  only  be  represented  by  gluten  or 
almond  bread  or  cakes.  Tea,  coffee,  cocoa-nib  decoction,  and  cocoa 
free  from  starch  may  be  taken.  In  most  cases  this  dietary  causes  disgust 
after  a  few  weeks.  Weight  may  be  lost  or  gained  in  individual  cases 
Avhile  submitting  to  it.  If  persisted  in,  patients  of  all  classes  may  become 
demoralised,  and  take,  by  subterfuge,  forbidden  articles.  Loss  of  sugar 
may  in  some  cases  be  well  borne,  but  the  deprivation  of  bread,  and 
the  substitution  for  it  of  the  sorry  stuff,  even  in  its  best  and  cost- 
liest form,  known  as  gluten  "biscuits  "  and  cakes,  commonly  intolerable 
after  a  time.  Kelaxation  of  rigid  rules  must  then  be  permitted  if  we 
are  to  treat  the  patient  and  not  merely  his  disease.  Toasted  stale 
bread,  and  bran  bread  made  of  the  finest  milled  bran,  may  be  given. 
Gluten  bread  as  a  cake  may  be  soaked  and  toasted  with  plenty  of  butter, 
and  so  made  more  toothsome.  Loosened  teeth  have  to  be  reckoned 
with  in  severe  cases.  The  appetite  may  be  enormous,  and  no  stint  need 
be  exercised  either  in  solids  or  fluids.  Dieting  without  medicinal  treat- 
ment is,  of  course,  in  many  cases  insufficient,  and  in  the  worst  forms 
the  strictest  diet  is  unavailing  to  check  the  disorder,  even  with  associated 
medication.     Each  case  is  a  study  in  itself. 

Cases  of  glycosuria  in  obese  persons  of  gouty  proclivity  calls  for  no 
rigid  dieting,  starchy  food  being  taken  in  moderation,  and  sugar  omitted. 
Biscuits,  brown  bread,  toasted  white  bread  can  generally  be  taken,  and 
potatoes  occasionally  in  small  quantities ;  rice,  maccaroni,  beans,  a,nd 
Jerusalem  artichokes  may  be  taken  at  intervals.  Spinach  is  always 
advisable ;  sorrel,  rhubarb,  tomatoes,  and  fruits,  fresh  or  preserved,  and 
jams  are  all  to  be  shunned.  Dry  Moselle  wines  and  sound  Bordeaux 
are  the  best  forms  of  alcoholised  fluids,  or  well-diluted  spirits.  Extra 
water  drinking  is  commonly  advisable,  or  Vichy,  Nieder-Selters,  Vals, 
St.  (ralmier  Avater,  or  Saratoga  Avater  may  be  taken  from  time  to  time. 
A  course  of  a  dozen  bottles  in  a  month  is  very  suitable  in  the  case  of 
Vichy  (Celestins  spring)  or  Vals  AA^ater.  SAveet  courses  may  be  replaced 
by  light  omelettes.  Saccharin  may  be  used  to  simulate  the  SAveetness 
of  sugar. 

In  all  these  cases  regard  is  to  be  paid  to  the  general  health  and  well- 
being  of  the  indiAadual  before  us,  and  the  bodily  weight  should  be 
regularly  ascertained  at  intervals. 

Chronic  Intoxications.  —  Alcoholism ;  Delirium  Tremens.  —  The  diet  in 
these  cases  is  as  for  chronic  gastric  catarrh.  The  patient  is  practically 
starved,  and  must  be  well  fed  by  any  available  means.  Nasal  feeding  may 
be  necessary.  Milk,  strong  soup,  and  coffee  are  useful.  Peptonised  foods 
may  find  a  place  here.  Alcohol  may  or  may  not  be  required  :  there  is 
no  hard  and  fast  rule  respecting  its  use.  A  pint  of  porter  or  bitter  beer 
may  prove  the  best  sedative  or  hypnotic  in  delirium  tremens.  If  pneu- 
monia occur  stimulants  may  be- freely  needed,  but  the  complication  is 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE     409 

most  grave.  In  chronic  alcoholism,  with  gastric  catarrh,  all  alcoholic 
liquids  must  be  forbidden,  and  fluid  nourishment  be  given  till  the  appe- 
tite returns. 

Lead  Poisoning  ;  Colic;  Encephalopathia ;  Pcvrah/ses;  Cachexia. — The 
diet  must  be  regulated  according  to  the  special  features  in  each  case. 
Vomiting  may  be  troublesome  before  colic  supervenes,  and  may  indicate 
uraemia  in  chronic  cases  with  granular  contraction  of  the  kidneys.  Milk 
and  beef  tea  are  best.  In  the  chronic  forms  fatty  food  is  very  useful. 
The  amount  of  nitrogenous  food  must  be  restricted  if  the  kidneys  are 
seriously  inadequate  to  their  functions. 

Diseases  of  the  Locomotory  System. — Rheumatic  Fever. — Without 
doubt  the  most  satisfactory  diet  in  this  disease  is  that  of  milk  and 
farinaceous  matters.  Milk  and  barley  water,  bread  and  milk,  arrowroot, 
rice  and  milk,  are  the  only  allowable  articles  in  the  acute  stage.  Beef 
tea,  animal  broths,  and  nitrogenised  foods  are  positively  harmful,  and 
prevent  the  most  certain  medicinal  agents  from  acting  efficiently.  When 
all  pain  is  subdued,  and  the  temperature  remains  normal,  remedial  agents 
being  still  continued,  possibly  in  diminished  doses,  mashed  potato  may 
be  added  to  the  diet ;  chicken  broth,  or  tender  white  fish  may  be  also 
carefully  tried.  Any  return  of  pain  or  fever  necessitates  recourse  to 
the  earlier  diet.  E-elapses  are  certainly  induced  by  too  early  a  return  to 
animal  food,  however  simple,  and  the  employment  of  beef  tea  is  par- 
ticularly to  be  deprecated.  Alcohol,  as  a  rule,  is  best  withheld,  unless 
collapse  and  cardiac  failure,  as  from  pericarditis  or  myocarditis,  occur. 
A  relapse  is  practically  certain  if  medicines  be  omitted  a,nd  better  diet 
be  simultaneously  prescribed.  The  return  to  ordinary  diet  should  be 
very  gradual. 

Chronic  Rheumatic  Arthritis ;  Osteo-arthritis.  —  In  pure  cases  of  this 
disorder,  which  is  in  no  sense  rheumatic  gout,  the  diet  should  be 
abundant  and  very  nourishing ;  it  may  include  meat,  milk,  fatty, 
farinaceous,  and  vegetable  food,  and  alcohol  or  wine  in  any  form.  A 
full  supply  of  cruciferous  vegetables  is  advisable." 

Gont,  Acute  and  Chronic. — In  acute  gout,  in  young  persons,  a  re- 
stricted diet  is  essential,  and  should  consist  for  the  most  part  of  milk  and 
farinaceous  food.  In  older  patients  the  diet  may  be  more  liberal,  and 
include  fish  and  green  vegetables.  Young  persons  may  require  no  alco- 
hol, older  patients  sometimes  do  better  with  diluted  alcohol  only  at  one 
or  two  meals  in  the  day.  There  are  many  diversities  of  opinion  as  to 
the  dietary  of  the  gouty,  both  during  acute  attacks  and  in  the  intervals. 
Some  physicians  recommend  animal  food  to  be  freely  taken,  and 
allow  wine,  others  urge  a  contrary  system.  The  fact  is  that  there 
is  no  treatment  for  gout,  but  much  for  gouty  patients.  The  age,  ante- 
cedents, type  of  case,  condition  of  organs  and  tissues,  all  require  to 
be  carefully  considered  in  each.  Farinaceous  food  in  excess  may  be 
gout-provoking  for  some  who  do  well  on  a  moderate  allowance  of  animal 
food.  Some  patients  can  take  fruit  or  port  wine  with  impunity, 
others  suffer  very  soon  from  such  a  course.     Without  question   the 


4IO  SYSTEM  OF  MEDICINE 

majority  do  best  on  a  moderate  mixed  diet  of  articles  they  can  digest 
with  comfort,  care  being  taken  to  avoid  excess  in  any  one  of  them. 
Indulgence  in  the  sweet  courses,  in  rich  dishes,  in  varieties  of  wine  and 
malt  liquor,  in  burnt  fats  and  jams,  and  in  large  evening  meals, 
is  commonly  gout-provoking.  Any  wines  employed  should  be  well 
matured  and  of  good  quality.  Mature  spirit  and  water  is  better  than 
any  wine  when  gout  is  threatening.  The  aged  commonly  require  a  little 
wine.  Water  drinking  is  certainly  beneficial  between  meals.  Fresh 
fats,  starch  and  sugar  have  no  direct  influence  on  the  production  of  uric 
acid.  Caution  is  necessary  in  the  use  of  meat,  fowl,  game  and  cheese. 
Bread,  rice,  green  vegetables  and  fruit  may  generally  be  taken  freely. 
Salt  meats  and  salt  should  be  used  very  sparingly  by  the  gouty.  Sherry, 
Madeira,  Burgundy  and  Rhine  wines  are  inadvisable.  Champagne,  of 
the  best  quality,  and  not  less  than  six  or  eight  years  old,  may  be 
occasionally  taken  by  many  gouty  persons.  Dry  Moselle  and  some 
Bordeaux  wines  are  the  least  harmful,  but  of  these  the  quantity  taken 
should  be  moderate.  Mature  port  Avine  may  sometimes  agree  well,  and 
not  provoke  gout,  but  the  quantity  is  to  be  measured  by  a  very  few 
ounces.  Diluted  whisky  or  gin  may  generally  be  Avell  borne,  but  should 
only  be  taken  with  food. 

In  subjects  of  gouty  cachexia  and  tophaceous  gout  the  diet  should  be 
as  supporting  as  the  adequacy  of  the  kidneys  will  permit.  Much  harm 
may  come  in  many  gouty  cases  from  withholding  alcohol.  Such  a  plan 
is  occasionally  imperative,  but  each  case  must  be  carefully  considered 
by  itself,  and  no  routine  practice  is  possible. 

Gonorrlional  S>/noiutis.  —  After  the  severer  pains  have  passed  away 
it  is  necessary  to  give  a  good  diet  to  these  patients.  The  disorder  is  a 
lowering  and  depressing  one,  and  the  level  of  general  health  must  be 
maintained  as  far  as  possil)le. 

Rachitis.  — The  main  treatment  of  rickets  consists  in  improving  the 
diet.  Weaning  is  necessary,  and  cows',  asses',  or  goats'  milk  substi- 
tuted :  this  must  be  diluted  according  to  the  age  of  the  patient,  and 
lime  water  and  cream  may  be  added.  Beef  juice,  chicken  and  veal  broth, 
beef  gravy,  pounded  mutton,  yolk  of  egg  are  all  advisable,  and  one  or 
two  meals  of  granulated  malt,  dissolved  in  milk  &,re  certainly  valuable. 
Mashed  potato,  with  milk  or  gravy,  is  useful.  Condensed  milk  is  most 
undesirable.     Cod  liver  oil  I  regard  as  almost  a  part  of  the  dietary. 

Infantile  Scurvy. —  This  disorder  is  practically  a  variety  of  rickets, 
with  htemorrhagic  and  scorbutic  tendency  superadded.  The  same  diet 
is  necessary  here  as  for  rickets,  fresh  milk  and  puree  of  potatoes  being 
especially  valuable.  Orange  or  lemon  juice,  diluted  and  sweetened,  and 
grapes  may  be  given  daily  in  small  quantities. 

Diseases  of  the  Skin.  — Parasitic  Diseases.  —  In  the  varieties  of  para- 
sitic skin  diseases  it  is  important  to  secure  the  highest  general  nutrition. 
In  ringworm  it  is  found  advantageous  to  employ  milk  and  fatty  food 
freely,  and  a  thoroughly  good  digestible  diet. 


THE    GENERAL  PRINCIPLES   OF  DIETETICS  IN  DISEASE     411 

Erythemata.  — A  rheumatic  element  is  often  present  in  many  of  these 
manifestations,  but  it  can  hardly  be  specifically  reached  by  dietetic 
measures.  Chilblains  attack  persons  of  this  habit,  and  those  of  gouty  in- 
heritance, with  some  frequency.  A  good  diet,  with  some  wine,  is  often 
helpful  in  preventing  their  occurrence. 

Urticaria.  —  The  diet  should  be  plain,  and  personal  idiosyncrasies 
should  be  noted  as  to  the  influence  of  fruit,  honey,  shell-fish,  or  certain 
wines. 

Eczema.  —  Much  benefit  is  to  be  derived  from  precautions  in  diet  in 
many  varieties  of  eczema.  Condiments  should  be  dispensed  with  alto- 
gether, or  as  far  as  possible.  Sugar  and  salt  are  sometimes  provocative, 
and  highly-seasoned,  salted,  and  concentrated  foods,  and  even  ham  and 
bacon  should  be  avoided.  Vinegar  and  even  fresh  fruits  are  sometimes 
harmful.  Tomatoes,  sorrel  and  rhubarb  are  inadvisable.  Soups  are  not 
seldom  to  be  placed  in  tbe  same  categor3^  A  gouty  tendency  is  often 
expressed  in  eczema,  and  the  dietetic  management  for  the  former  is 
commonly  effectual  in  disposing  of  outbursts  of  the  latter.  In  acute 
diffused  eczema  the  diet  should  be  that  suitable  for  a  febrile  condition. 

Pityriasis  rubra, ;  Exfoliative  Dermatitis.  —  Good  diet  is  certainly 
helpful  in  many  of  these  cases.  The  general  level  of  nutrition  is  com- 
monly low. 

Psoriasis.  —  The  diet  in  these  cases  should  be  that  recommended  for 
eczema.  Thyroid  feeding  has  certainly  proved  of  benefit  in  some  cases, 
and  may  be  tried. 

Acyie  vulgaris ;  Gutta  rosacea.  —  Some  variety  of  dyspepsia  is  com- 
monly associated  with,  these  disorders.  Plain  food,  with  avoidance  of 
alcohol,  seasoned  and  hard  meats,  coffee,  cheese,  pickles,  and  much  fat 
is  advisable. 

Lupus.  —  The  tubercular  nature  of  this  disorder  naturally  suggests 
a  diet  which  is  suitable  for  those  so  disposed.  Of  late  some  good  results 
have  been  obtained  by  thyroid  feeding  as  for  myxoedema. 

Boils;  Carbuncles.  —  The  most  satisfactory  diet  when  these  disorders 
are  in  progress  is  a  milky-farinaceous  one,  without  stimulant.  If  there 
is  obvious  debility  an  ordinary  good  diet  is  necessary,  and  wine  may  be 
given.  Otherwise  it  is  better  to  reserve  the  use  of  wine  till  the  sloughs 
are  separating.  One  or  two  ounces  of  fresh  yeast  (brewer's  barm),  taken 
several  times  in  the  day,  has  been  found  of  use  where  successions  of 
boils  are  in  progress.  It  is  important  to  recognise  any  associated  gouty 
or  glycosuric  condition  in  these  cases,  and  of  course  to  modify  the  diet 
accordingly. 

Atrophy.  —  The  dietetic  treatment  of  this  condition  must  vary  with 
the  essential  cause  of  it  in  every  case.  Some  degree  or  variety  of 
dyspepsia  is  often  a  cause,  and  inability  to  take  appropriate  nutriment  is 
also  often  an  underlying  condition.  Digestive  incapacity  for  starch  and 
milky  food  may  have  to  be  overcome,  and  effort  is  to  be  made  to  give  a 
fair  proportion  of  these  with  fatty  and  albuminoid  stuff.     Oatmeal  gruel, 


412  SYSTEM   OF  MEDICINE 

malted  food,  with  milk,  yolk  of  egg,  oysters,  tender  meats,  game,  fa3 
ham,  cream,  butter,  cocoa,  and  porter  are  all  of  service  if  they  can  be 
digested.  Half  an  ounce  of  rum  in  half  a  pint  of  warm  new  milk  may 
be  given  before  leaving  bed  each  morning,  and  a  fat  mutton  chop,  with 
half  a  pint  of  draught  porter,  constitutes  an  appropriate  luncheon. 
Custard  pudding  with  Devonshire  cream,  or  suet  and  milk  (a  drachm  of 
fresh  beef  suet  dissolved  in  half  a  pint  of  hot  milk),  are  worthy  of  trial. 

In  the  foregoing  article  I  have  endeavoured  to  set  before  the  reader 
the  general  principles  relating  to  clinical  dietetics  as  adapted  for  patients 
suffering  from  various  morbid  conditions.  It  will  be  understood  that 
nothing  herein  recommended  can  ever  replace  the  necessary  and  as- 
sociated medicinal  and  other  means  which  are  requisite  in  order  to  favour 
restoration  to  health.  Diet  may,  and  can  do  much  in  this  direction, 
but  the  clinical  practitioner  must  conduct  as  well  the  dietetic  as  the 
other  therapeutical  measures  in  each  case,  and  if  he  fail  at  the  same 
time  to  manage  his  patient,  neither  the  one  nor  the  other  will  avail 
him  to  promote  the  sole  object  of  his  art,  which  is  to  ensure  the 
recovery  of  the  sick.  Dyce  Duckworth. 

REFERENCES 

1.  Pavy,  F.  W.  On  Food,  2nd  edit.,  1875. — 2.  Ebstein,  W.  Das  Regimen  bei 
der  Gicht,  1885.  —  3.  Beaumetz,  Dujardin.  Le(;ons  cle  clinique  therapeutique,  5th 
edit.  Paris,  1888.  —  4.  Yeo,  Burney.  Food  in  Health  and  Disease,  18H9.  —  5.  Burnett, 
R.  W.  Food  and  Dietaries,  189i). — 6.  Beaumetz,  Dujardin.  L' Hygiene  alinientairp, 
aliments,  alimintation,  regime  alimentaire  dans  les  maladies.  Paris,  1S90.  —  7. 
Parkes.  Practical  Hygiene.  8th  edit.,  edited  by  Notter,  1891.  —  8.  Dukes,  Clement. 
Essentials  of  School  Diet,  1891. — 9.  Roberts,  Sir  Wm.  Collected  Contributions  on 
Digestion  and  Diet,  1891.  — 10.  Martin,  Sidney.  Art.  "  Food  "  in  Treatise  on  Hygiene 
and  Public  Health,  Stevenson  and  Murphy,  p.  391.  1892.  — 11.  Duckworth,  Sir 
Dyce.  "Dietary  for  tlie  Sick,"  Practitioner,  Jan.  1892.  — 12.  Pavy,  F.  W.  The 
Physiology  of  the  Carbo-Hydrates,  1894.  — 13.  Che  adle.  Artificial  Feeding  of  Infants, 
etc.,  3rd  edit.,  1891.  — 14.  Noorden>  Von.  "Diabetes.  Diet  Tables,"  XX.  Century 
Practice  of  Medicine,  p.  1G8.  New  York,  1895.  — 15.  Griffith,  W.  S.  A.  "Artificial 
Feeding  of  Infants,"  Clin.  Journal,  15th  May  1895. 

D.  D. 


THE   DIET   AND   THERAPEUTICS   OF   CHILDEEN 

Although  on  account  of  his  special  constitutional  peculiarities  the 
young  child  bears  but  a  faint  resemblance  to  the  fully  developed  adult, 
in  one  respect  the  likeness  is  close  enough.  It  is  that  young  children, 
like  their  elders,  differ  curiously  amongst  themselves  not  only  in  general 
digestive  capacity,  but  also  in  their  individual  ability  to  assimilate  this 
or  that  kind  of  food.  One  baby  thrives  upon  fare  which  is  innutritions 
if  not  actively  hurtful  to  another ;  so  that  to  prescribe  a  dietary  for  a 


THE  DIET  AND    THERAPEUTICS   OF  CHILDREN  413 

young  infant  is  to  engage  in  an  experiment  which,  if  it  do  not  succeed 
at  once,  may  require  many  changes  in  detail  before  it  can  be  brought  to 
a  successful  issue. 

So  long  as  the  infant  can  be  fed  from  the  breast  all  is  likely  to  go 
well ;  for  in  human  milk  he  meets  with  a  digestible  and  amply  nutritious 
fluid  which  he  swallows  straight  from  the  gland,  pure  and  rmcontami- 
nated.  by  germs.  There  are  few  children  who  do  not  thrive  when  thus 
fed,  provided,  of  course,  that  the  supply  of  milk  be  sufficient  and  its 
quality  good.  But  so  many  mothers  are  unable  to  nurse  their  babies 
that  a  large  proportion  of  infants  have  to  be  brought  up  by  other  means. 
The  problem  is  to  imitate  the  natural  food  of  which  the  child  has  been 
deprived.  The  more  closely  this  can  be  done  the  better  the  prospect  of 
rearing  the  infant  with  success. 

To  be  accurately  adapted  to  the  wants  of  the  infant,  the  required 
food  must  contain  all  the  elements  of  nutrition  as  nearly  as  possible  in 
the  proportions  observed  in  human  milk ;  it  must  be  well  within  the 
powers  of  the  stomach,  so  as  to  leave  little  undigested  residue  to  ferment 
in  the  bowels  and  be  a  source  of  mischief ;  it  must  be  fresh  and  in  good 
condition ;  and,  lastly,  to  be  a  perfect  food,  it  should  contain  a  sufficient 
proportion  of  the  vitalising  element  —  whatever  that  may  be  —  which 
endows  it  with  its  antiscorbutic  properties.  Now  milk  contains  in  itself 
all  the  elements  of  nutrition ;  and  the  milk  of  many  animals  approaches 
human  milk  in  composition  more  or  less  closely.  Any  of  these  may  be 
used ;  but  practically  we  are  forced  for  convenience'  sake  to  fall  back 
upon  cow's  milk,  which  is  always  at  hand ;  and  this  can  be  adapted  to 
our  purpose  without  much  difficulty. 

As  compared  with  human  milk,^  the  milk  of  the  cow  contains  a 
larger  proportion  of  curd,  but  is  deficient  in  sugar  and  to  a  small  extent 
in  fat.  To  bring  it,  then,  to  the  standard  of  human  milk  it  must  be  di- 
luted and  sweetened.  But  this  is  not  enough.  The  curd  of  cow's  milk 
coagulates  in  one  large,  tough  lump  which  resists  digestion ;  while  that 
from  the  human  breast  forms  a  light,  loose  clot  which  is  easily  penetrated 
by  the  digestive  fluids.  When,  therefore,  cow's  milk  is  used,  steps  must 
be  taken  to  prevent  this  firm  clotting  of  the  curd.  If  we  add  to  the  milk 
some  thickening  material  the  particles  of  curd  are  kept  apart,  so  that 
when  the  casein  coagulates  in  the  infant's  stomach  by  the  action  of  the 
gastric  juice  the  clot  consists,  primarily  at  any  rate,  of  a  multitude  of 
little  lumps  of  curd  instead  of  one  solid  mass.  For  the  thickening 
material  some  form  of  starch  is  often  used;  but  as  this  is  difficult 
of  digestion  by  the  young  child,  barley  water  is  to  be  preferred.  Barley 
water  itself  contains  starch,  but  in  comparatively  small  quantity 
and  very  finely  divided.  It  rarely  disagrees,  and  when  mixed  with  a 
fourth  part  of  milk  suits  the  large  majority  of  new-born  infants.     The 

^  For  purposes  of  comparison  Dr.  V.  A.  Meigs'  (1)  analysis  is  subjoined:  — 
Water.     Siif^ar.     Casein.      Fat.        Ash. 
Woman's  milk        87-l(;:5        7'407        1-046        4-283        -101 
Cow's  milk  ,S8-54y        4-898        2-792        3-310        -451 


414  SYSTEM   OF  MEDICINE 

meal  should  be  sweetened  with,  white  sugar;  and  it  is  important  that 
the  barley  water  should  be  freshly  made,  for  it  cannot  be  given  with 
safety  if  more  than  six  hours  old.  If  the  cow's  milk  be  used  uncooked 
as  it  is  delivered  to  the  house,  it  retains  all  its  antiscorbutic  properties : 
on  the  other  hand,  in  this  state  it  is  probably  loaded  with  germs  of 
various  kinds,  which  may  indeed  be  harmless,  but  may  be  capable 
of  exciting  dangerous  fermentations,  or  conveying  the  seeds  of  serious 
disease.  Epidemics  of  diphtheria  and  scarlatina,  as  well  as  bowel  com- 
plaints of  great  gravity,  may  owe  their  origin  to  impure  milk.  Un- 
fortunately boiling  the  milk  renders  it  less  active  as  an  antiscorbutic ; 
but  it  is  wiser  to  make  this  sacrifice  for  the  sake  of  avoiding  the  greater 
evil,  and  to  use  milk  which  has  been  boiled  or  sterilised.  If  the  latter, 
it  is  best  to  add  the  barley  water  to  the  milk  before  sterilisation,^  and  to 
allow  the  child  to  suck  the  mixture  from  the  sterilising  bottle  fitted  with 
a  mouthpiece. 

This  method  of  feeding  is  to  be  preferred  to  the  common  plan  of 
giving  milk  and  water  alkalised  with  a  third  part  of  lime  water.  The 
lime  water  acts  by  partially  neutralising  the  gastric  juice,  so  that  a  con- 
siderable proportion  of  the  milk  passes  uncoagulated  from  the  stomach 
and  is  digested  in  the  bowels.  Healthy  babies  doubtless  often  thrive 
upon  this  food,  although  thus  deprived  of  a  very  important  agent  of 
digestion. 

It  may  happen  that  the  new-born  infant  has  a  special  inability  to 
digest  fresh  cow's  milk.  In  that  case  he  will  often  do  well  for  the  first 
few  months  upon  condensed  milk  and  water;  but  cow's  milk  sterilised 
and  thickened  with  barley  water  should  be  tried  again  after  an  interval, 
varying  the  proportion  of  milk  in  the  mixture  to  suit  the  child's  digestive 
capabilities,  for  an  infant  who  is  greatly  overtasked  by  a  third  part  of 
milk  may  digest  a  sixth  with  ease.  No  effort  should  be  spared  to  enable 
the  child  to  digest  the  fresh  milk,  for  condensed  milk  is  a  very  undesir- 
able food  for  him  after  he  is  three  months  old.  In  all  cases  of  difficulty, 
cow's  milk  peptonised  in  the  house  should  be  tried,  and  will  often  agree. 
We  should  also  never  fail  to  inquire  as  to  the  cleanliness  of  the  feeding- 
bottle  and  the  times  of  feeding.  Much  may  often  be  done  by  careful 
regulation  of  these  matters. 

The  temperature  of  the  meal  should  be  95°,  and  the  food  can  be 
easily  warmed  to  this  heat  by  placing  the  bottle  in  a  small  basin  filled 
with  hot  water.  The  quantity  given  in  the  first  week  should  be  a 
couple  of  ounces,  but  more  will  very  soon  be  required.  The  regulation 
of  quantity  is  a  matter  of  small  importance.  If  a  proper  interval  be 
allowed  for  digestion  the  quantity  taken  at  each  meal  may  be  left  safely 
to  the  child  himself.  A  very  young  baby  can  be  trusted  to  stop  sucking 
when  he  has  had  enough,  and  any  excess  which  may  have  been  swallowed 
is  usually  regurgitated  without  effort  shortly  after  the  meal. 

Children  may  do  well  for  the  first  six  months  upon  milk  and  barley 

1  Milk  sterilised  in  the  house  by  Sohxtet's  apparatus  is  greatly  to  be  preferred  to  that 
supplied  by  a  company. 


THE   DIET  AND    THERAPEUTICS   OF  CHILDREN  415 

water  alone  without  any  change ;  but  often  they  require  more  variety  in 
their  food :  in  all  cases  where  the  digestion  is  difficult,  and  has  to  be 
humoured,  variety  in  the  diet  is  too  important  a  stimulus  to  be  neglected. 
Sooner  or  later,  then,  the  question  of  "Infant's  Foods"  has  to  be  con- 
sidered. All  these  are  preserved  or  tinned  foods,  and  therefore  destitute 
of  antiscorbutic  properties.  On  this  account  they  are  only  allowable  as 
aids  in  the  diet,  for  cow's  milk,  when  this  can  be  borne,  must  always  be 
our  mainstay. 

The  tinned  foods  may  be  divided  into  four  classes,  viz.,  — 

1.  Milk  concentrated  by  evaporation  to  the  consistence  of  thick  cream 
and  preserved  with  sugar  or  malt. 

2.  Milk  desiccated  and  mixed  with  partially  converted  starch. 

3.  Foods  consisting  of  wheaten  flour  more  or  less  completely  digested, 
or  mixed  with  malt  or  pancreatine. 

4.  Foods  consisting  merely  of  the  flour  of  some  cereal  baked. 

All  these,  as  foods,  leave  something  to  be  desired  ;  for  besides  that  none 
of  them  possesses  antiscorbutic  properties,  all  are  found  in  some  respects 
to  be  faulty  as  nutritives.  According  to  the  analyses  of  Dr.  A.  Stutzer 
(2),  of  Bonn,  most  are  lacking  in  fat ;  and  in  many  the  amount  of  protein  is 
too  small  and  its  proportion  to  the  other  nutritious  matters  too  narrow. 
Some  are  weak  in  bone  forming  material ;  others  contain  insoluble 
carbohydrates  (unconverted  starch)  in  excessive  quantity,  and  therefore 
trying  to  the  digestive  capacities  of  an  infant.  But  although  beneath 
the  standard  of  perfect  nutrients,  and  ill  fitted  to  be  for  long  together  the 
sole  nourishment  of  a  young  child,  these  foods  are  by  no  means  useless. 
As  additions  to  the  cow's  milk,  providing  supplementary  nourishment, 
furnishing  material  for  flattering  the  palate  and  giving  variety  and  relish 
to  the  meals,  their  value  is  great.  For  infants  who  cannot  digest  fresh 
cow's  milk  we  find  in  the  foods  containing  desiccated  and  condensed  milk 
a  fair  temporary  substitute ;  and  even  if  the  inability  prove  permanent, 
we  can  often  by  this  means  and  a  little  management  maintain  the  child 
in  a  fair  state  of  nutrition  until  he  is  of  an  age  to  supply  the  deficiencies 
of  his  dietary  by  other  means. 

The  choice  of  the  food  is  of  great  importance.  Class  I.,  which 
contains  the  syrupy  condensed  milks,  should  be  reserved  for  the  .first 
three  months  of  life.  Dr.  Rotch  (3)  advises  that  these  milks  be  diluted 
with  nine  parts  of  water,  and  that  20  per  cent  of  cream  be  added  to 
supply  the  deficiency  in  the  fat.  This  should  be  about  a  teaspoonful  of 
cream  to  the  bottle  of  food.  The  only  other  tinned  food  allowable  at 
this  age  is  Mellin's  Food,  which  belongs  to  Class  III.  In  this  the  starch 
is  almost  completely  predigested  and  converted  into  dextrine  and 
maltose.  One  or  two  teaspoonf  uls  may  be  added  to  each  alternate  meal 
of  milk  and  barley  water  for  the  sake  of  giving  vr.riety.  Starches  are  to 
be  used  for  infants  below  the  age  of  six  months  with  great  caution. 
The  secretion  of  saliva  is  very  small  for  some  time  after  birth,  and  does 
not  become  free  until  the  third  month  ;  and  the  pancreatic  secretion  is 
very  scanty  for  the  first  six  months  of  life,  and  does  not  acquire  its  full 


41 6  SYSTEM   OF  MEDICINE 

diastasic  action  for  some  months  longer.  Up  to  the  age  of  six  months 
starch  should  only  be  given  when  guarded  with  a  digestive,  as  in  the 
malted  foods  or  Benger's  pancreatic  food.  Later  it  may  be  tried 
cautiously  and  in  small  quantity  without  this  safeguard,  in  the  form 
of  baked  flour  or  a  rusk,  but  always  with  milk.  Any  of  the  foods  in 
Class  IV.  may  be  used  at  this  time. 

The  child  should  be  fed  every  two  hours  for  the  first  six  weeks  ;  then 
the  interval  between  the  meals  can  be  gradually  increased,  and  the  meals 
themselves  made  larger  and  more  satisfying.  When  a  tinned  prepara- 
tion is  used  it  must  not  be  added  to  the  milk  until  the  meal  time 
comes  round,  for  if  the  food  be  allowed  to  stand  ready  made  it  quickly 
begins  to  ferment. 

It  would  be  out  of  place  here  to  refer  to  the  various  derangements 
which  may  affect  the  hand-fed  infant,  or  the  changes  in  the  diet  Avhich 
such  disorders  require.  The  reader  should  consult  special  treatises 
for  information  upon  these  important  points.  It  will  be  sufficient  to 
state,  as  a  general  rule,  that  whenever  digestion  is  difficult  and  the 
nutrition  of  the  child  unsatisfactory  we  should  aim  at  plenty  of  variety 
in  his  meals ;  that  we  should  not  persevere  with  a  food  which  is  found 
not  to  agree  ;  and  that  as  cooked  milk  is  weak  in  antiscorbutic  properties 
we  must  be  always  on  the  watch,  while  using  it,  for  early  signs  of 
infantile  scurvy.  It  may  also  be  remarked  that  healthy  digestion 
depends  in  a  great  measure  upon  the  general  management  of  the  infant. 
Soiled  linen  should  be  removed  from  the  nursery  without  delay,  and  the 
room  should  be  frequently  ventilated  so  as  to  keep  the  air  fairly  pure. 
Great  attention,  too,  should  be  paid  to  warmth  of  the  child's  feet  and 
legs  ;  and  the  washing  of  his  body  should  be  carried  out  as  quickly 
as  possible  and  without  undue  exposure.  An  infant  whose  feet  are 
habitually  cold  never  has  a  good  digestiou  ;  and  many  a  fatal  attack 
of  gastritis  has  owed  its  origin  to  a  chill  contracted  by  careless  exposure 
in  or  after  the  daily  bath. 

At  the  end  of  the  first  twelve  months  the  infant  may  be  allowed 
for  his  dinner  some  weak  veal  or  chicken  broth  thickened  with  barley 
and  strained.  On  alternate  days  he  may  take  the  yolk  of  a  new-laid 
Qgg  lightly  boiled  or  beaten  up  with  milk.  At  this  time  it  is  advisable 
to  accustom  the  child  to  take  food  from  a  cup  or  spoon,  so  as  gradually 
to  wean  him  from  the  bottle ;  and  when  he  enters  upon  his  second  year 
a  light  pudding  made  from  sponge  cake  or  rusk  may  be  given  two  or 
three  times  a  week. 

Meat  must  not  be  allowed  until  the  child  is  sixteen  months  old :  he 
may  then  begin  to  take  a  little  underdone  mutton  chop.  At  first  this 
should  be  pounded  in  a  mortar  and  rubbed  through  a  wire  sieve ;  but 
after  a  month  or  so  it  will  be  sufficient  to  mince  it  very  finely.  It  is 
important  that  all  changes  made  in  the  diet  be  made  cautiously  and  with 
judgment.  A  time  should  be  chosen  when  the  child  is  happy  and 
cheerful,  digesting  without  trouble  and  sleeping  quietly,  and  the  new 
food  must  be  given  in  small  quantity  at  first.    A  change  made  when  the 


THE  DIET  AND    THERAPEUTICS   OF  CHILDREN  aij, 

child  is  teething  or  fretful  or  restless  at  night  is  hardly  likely  to  be 
attended  with  success.  At  first  meat  should  be  given  twice  a  week  only. 
On  other  days  the  dinner  should  consist  of  strong  soup  with  some  well- 
boiled  vegetable,  such  as  cauliflower,  vegetable  marrow,  or  tender  French 
beans.  Once  or  twice  a  week  the  child  may  take  some  chicken  or  boiled 
fish.  Potatoes  are  not  to  be  allowed  every  day;  and  batter  pudding,  and 
puddings  made  from  bread  and  rusk,  are  to  be  preferred,  as  less  purely 
farinaceous,  to  rice,  sago,  and  tapioca ;  although  the  latter  are,  no  doubt, 
sanctioned  by  nursery  tradition  and  prejudice.  But  an  excess  of  starch 
in  their  diet  is  to  be  avoided  for  growing  boys  and  girls.  At  no  time 
of  life  do  young  children  find  the  digestion  of  starch  an  easy  matter ; 
and  it  is  unwise  to  overload  them  with  a  food  which  fattens  but  gives 
little  strength,  and  is  but  too  apt  to  make  them  lethargic  and  dull.  Beef 
and  mutton,  as  a  rule,  they  can  digest  without  difficulty.  I  have  been 
told  many  times  that  this  child  or  that  could  digest  no  meat,  but  have 
always  found  that  it  was  not  the  meat,  but  the  potato  eaten  with  it 
which  disagreed.  Cold  meat,  again,  is  as  harmless  as  hot ;  and  minces 
and  hashes  are  not  to  be  withheld  from  children  through  any  groundless 
fear  of  "  twice  cooked  "  meat.  Nursery  superstitions,  like  other  delu- 
sions, die  hard;  but  dishes  in  which  the  meat  is  merely  warmed  through 
without  being  really  cooked  a  second  time  are  innocent  enough.  At  all 
ages  variety  in  diet  is  to  be  aimed  at ;  and  ham  and  tongue  (thinly  sliced) 
and  bacon  for  breakfast,  help  to  lighten  the  monotony  of  the  daily  meals 
and  stimulate  the  digestion  as  well  as  gratify  the  palate. 

A  word  may  be  said  as  to  the  arrangement  of  the  meals.  Arbitrary 
custom  ordains  that  the  two  substantial  meals  of  the  day  —  the  breakfast 
and  dinner  —  must  be  confined  to  six  hours  out  of  the  twenty-four ;  and 
that  for  the  remaining  eighteen  hours  the  child  must  take  nothing  but 
milk  and  bread  and  butter,  with  the  addition,  perhaps,  of  cake  or  a  little 
jam.  This  arrangement  answers  fairly  well  with  sturdy  subjects  who 
can  be  prepared  with  an  appetite  at  the  prescribed  times,  although  even 
with  these  a  more  rational  distribution  of  their  food  is  to  be  preferred. 
But  many  children,  especially  those  who  are  anaemic  and  fragile,  cannot 
thus  be  hungry  at  command.  Often  in  the  forenoon  they  do  not  care  to 
eat  at  all.  They  hardly  touch  breakfast,  and  only  trifle  with  the  mid- 
day dinner.  Towards  evening,  however,  the  appetite  improves,  and  at 
five  or  six  o'clock  they  would  eat  a  hearty  meal  if  allowed  to  do  so.  For 
years  in  these  cases  I  have  adopted  the  plan  of  ordering  a  substantial 
meal  towards  the  end  of  the  day,  at  the  time  when  the  child  is  best  dis- 
posed to  take  it;  and  if  the  more  fermentable  articles,  such  as  sweets  and 
potatoes,  be  excluded  from  the  menu,  and  a  good  hour  before  bedtime  be 
allowed  for  digestion,  I  have  rarely  found  the  patient  anything  but  the 
better  for  the  change.  In  these  cases  a  little  stimulant  is  often  a  help  in 
improving  the  appetite  and  aiding  digestion.  It  should  be  given  with 
the  principal  meal.  I  often  order  the  St.  Raphael  wine,  but  any  sound 
wine  will  usually  agree  provided  it  be  not  acid.  I  think  a  good  Burgundy 
is  to  be  preferred  to  a  claret.     Alcohol  must  be  regarded  strictly  as  a 

VOL.    I  2   E 


41 8  SYSTEM  OF  MEDICINE 

medicine  in  the  case  of  a  child,  and  is  not  to  be  ordered  except  to  serve 
a  temporary  purpose.  It  has  no  tonic  properties,  and  must  be  discon- 
tinued when  the  appetite  improves. 

Diet  enters  so  largely  into  the  treatment  of  children's  diseases,  and 
the  rate  of  recovery  may  be  so  influenced  by  a  judicious  selection  of  the 
food,  that  an  intimate  acquaintance  with  these  matters  is  indispensable 
to  success  as  a  practical  therapeutist.  Children,  especially  young  chil- 
dren, are  more  dependent  than  adults  upon  a  daily  supply  of  nourishment, 
and  suffer  more  in  proportion  if  this  be  withheld.  The  digestion  fluctu- 
ates from  day  to  day  in  strict  relation  to  the  general  health ;  and  flags  at 
once  when  this  is  impaired.  In  acute  disease  with  a  high  temperature 
the  digestive  power  is  very  limited,  and  in  order  that  the  nutritive  supply 
be  not  cut  off  altogether,  the  food  provided  must  be  of  the  lightest  and 
most  digestible  kind.  But  "light"  food  is  not  to  be  taken  to  mean  fari- 
naceous food.  Starches,  especially  when  cooked  with  milk,  are  ill-suited 
to  such  a  condition,  and  must  be  given,  if  given  at  all,  with  great  caution, 
or  they  may  do  harm.  As  a  thickening  material  for  broth  they  are  more 
useful,  and  beef  tea  thickened  with  tapioca  or  arrowroot  will  often  agree 
when  a  common  tapioca  pudding  only  excites  discomfort  from  acidity  and 
flatulence.  It  is  important  to  realise  early  that  rice  and  sago  and  such- 
like puddings  are  not  "  light  "  or  easilj'  digestible  foods ;  and  that  to  task 
a  disordered  or  weakened  stomach  with  such  highly  fermentable  material 
in  a  case  of  acute  illness,  or  during  an  early  stage  of  convalescence  from 
grave  disease,  is  to  aggravate  the  symptoms  and  seriously  retard  recovery. 
In  the  dieting  of  febrile  diseases  in  the  child  the  rules  which  regulate  the 
hand-feeding  of  infants  should  be  observed.  Starch  should  not  be  given 
with  milk  unless  giiarded  by  a  digestive ;  and  milk  itself,  if  not  pep- 
tonised,  must  be  thickened  with  barley  water  or  gelatine.  The  meat 
jellies  and  cold  extracts  of  meat  agree  well  with  children  beyond  the 
age  of  infancy,  if  not  given  too  liberally.  The  quantity  allowed  in  each 
case  is  to  be  determined  by  the  strength  of  the  child  and  the  state  of  his 
stomach.  A  rise  of  temperature,  disturbed  sleep,  or  discomfort  after 
the  meal,  may  be  taken  to  show  that  the  quantity  must  be  reduced.  So, 
also,  if  during  convalescence  the  urine  be  habitually  thick  with  lithates 
it  is  usually  a  sign  that  the  patient  is  being  overfed. 

It  is  often  curious  to  note  the  immediate  improvement  which  takes 
place  in  the  condition  of  a  sick  child  when  an  excessive  dietary  is  reduced, 
and  the  food  both  in  quantity  and  quality  is  adapted  with  judgment  to 
the  enfeebled  powers  of  the  patient.  But  it  is  not  enough  to  see  that 
nourishment  is  assimilated  with  little  effort ;  we  have  also  to  take  care 
that  waste  products  are  freely  eliminated;  that  the  bodily  heat,  if 
excessive,  is  controlled ;  and  that  the  skin,  the  kidneys,  and  the  bowels 
are  encouraged  to  the  full  discharge  of  their  duties.  Moreover,  we  must 
be  careful  to  enforce  proper  rest,  and  to  have  the  air  of  the  room  main- 
tained at  a  suitable  temperature  and  frequently  renewed. 

The  constitutional  peculiarities  of  the  young  child  have  an  important 
bearing  upon  the  treatment  of  disease  in  early  life.    The  curious  sensitive- 


THE  DIET  AND    THERAPEUTICS   OF  CHILDREN  419 

ness  of  the  nervous  system  gives  an  especial  value  to  counter-irritants  of 
the  skin  and  external  applications  generally.  Amongst  these  remedies 
baths  take  the  first  place.  The  hot  bath  (100°  F.)  is  an  important 
general  stimulant  in  cases  of  extreme  depression  either  from  haemorrhage, 
profuse  diarrhoea,  vomiting,  pulmonary  collapse,  severe  nervous  shock, 
or  any  other  depressing  agency.  When  used  with  this  object,  the  child 
must  not  remain  longer  than  three  or  four  minutes  in  the  hot  water. 
This  bath  can  be  made  more  stimulating  by  the  addition  of  flour  of 
mustard  in  the  proportion  of  one  ounce  to  each  gallon  of  water.  The 
mustard  is  first  mixed  into  a  paste  with  cold  water,  and  is  then  squeezed 
through  a  piece  of  fine  muslin  into  the  bath. 

The  warm  bath  (90°  F.)  calms  excitement,  allays  spasm,  and  in- 
duces sleep.  It  is  useful  in  cases  of  reflex  convulsions  and  every  form 
of  nervous  agitation.  Its  diaphoretic  action  makes  it  of  great  service  in 
Bright's  disease,  especially  if  the  child  be  afterwards  wrapped  in  blankets 
to  keep  up  the  action  of  the  skin.  The  duration  of  the  warm  bath  should 
be  from  fifteen  to  twenty  minutes. 

The  cold  douche  (6o°-70°  F.)  is  only  useful  in  the  morning  before 
breakfast.  If  given  rapidly  it  is  a  bracing  tonic  for  children  in  whom 
the  system  responds  readily  to  the  shock.  Even  pallid,  delicate  subjects 
derive  great  benefit  from  it  if  proper  precautions  be  taken  to  promote  a 
healthy  reaction.  In  the  case  of  a  weakly  child  the  patient  should  be 
first  rapidly  sponged  in  a  hot  bath  (100°),  and  should  receive  the  douche 
as  he  sits  in  the  hot  water.  Immediately  afterwards  he  should  be 
wrapped  up  undried  in  a  hot  blanket,  and  returned  for  a  few  minutes  to 
his  bed.  Reaction  is  hastened  if  the  child  drink  a  cap  of  hot  milk  ten 
minutes  before  being  put  into  the  water.  This  is  the  only  way  in  which 
cold  or  nearly  cold  water  can  be  used  to  advantage  with  children  whose 
nutrition  is  at  fault.  The  cold  sponging  so  often  employed  is  highly 
objectionable  for  such  patients  on  account  of  the  long  exposure  it  involves. 
Even  when  the  douche  is  used  as  described  above,  its  temperature  must 
be  carefully  adjusted  to  the  readiness  of  reaction  shown  by  the  patient. 
Some  children  respond  best  to  a  comparatively  low  temperature,  while 
,  others,  whose  power  of  reaction  is  slight,  require  a  douche  of  75°  or  even 
80°,  and  are  depressed  instead  of  strengthened  if  the  water  be  colder. 

There  is  another  method  of  using  water  externally,  which  is  sometimes 
of  the  highest  value.  In  cases  of  ptomaine  poisoning,  with  or  vfithout 
vomiting  or  diarrhcea,  the  skin  loses  its  elasticity  more  or  less  completely, 
so  that  when  pinched  up  it  lies  in  loose  folds  upon  the  abdomen.  This 
state  of  skin  is  probably  a  sign  of  imperfect  action  of  the  kidneys,  for 
the  urinary  secretion  at  the  time  is  almost  invariably  scanty,  and  is  some- 
times suppressed.  At  any  rate,  unless  the  elasticity  of  the  skin  can  be 
restored  the  patient  will  almost  certainly  die.  It  is  my  custom  in  these 
cases  to  pack  the  child  in  a  large  towel  wrung  out  of  cold  water,  or  of 
water  containing  a  sixth  part  of  eaii  de  Cologne  or  brandy,  and  to  keep 
him  well  covered  and  packed  in  with  many  blankets  for  hours  together. 
At  the  end  of  every  three  hours  the  child  is  unswathed,  rubbed  dry,  and 


420 


SYSTEM  OF  MEDICINE 


repacked  as  before.  After  some  hours  of  this  treatment  the  kidneys 
begin  to  act  more  freely  and  the  skin  to  recover  its  elasticity.  I  have 
kept  yoting  children,  thus  packed,  for  twenty-four  hours  together  with 
the  very  best  results ;  for  if  by  this  means  the  elasticity  of  the  skin  re- 
turn, the  prospects  of  the  child's  recovery  are  very  materially  improved. 
This  form  of  blanket  bath  should  be  reserved  for  cases  where  it  is  desired 
to  increase  the  action  of  the  skin  or  kidneys.  It  cannot  be  relied  upon 
to  lower  the  temperature  when  this  is  high ;  for  unless  the  process  set  up 
copious  perspiration,  the  heat  of  the  blankets  increases  the  pyrexia  instead 
of  lessening  it.  Children  as  a  rule  bear  high  temperatures  well ;  but  if 
the  bodily  heat  exceed  105°  steps  must  be  taken  to  reduce  it.  The 
plan  I  prefer  consists  in  wrapping  the  patient  in  a  sheet  wrung  out  of 
cold  water,  and  covering  merely  -wdth  another  dry  sheet.  Under  this 
treatment  the  temperature  quickly  falls  ;  and  if  the  pyrexia  have  been 
accompanied  by  convulsions  or  great  excitement,  the  nervous  disturbance, 
as  a  rule,  quickly  subsides,  and  the  child  sinks  into  a  quiet  sleep. 

Of  the  baths  above  described  the  hot  and  mustard  baths  may  be 
considered  as  counter-irritants  and  general  stimulants.  Children  respond 
well  to  counter-irritation,  whether  this  be  used  generally  or  locally.  In 
cases  of  bronchitis  or  catarrhal  pneumonia,  long-continued  counter-irri- 
tation with  mustard  poultices  diluted  with  four  or  five  times  the  quantity 
of  linseed  meal,  and  thoroughly  mixed,  is  of  the  utmost  service.  A  large 
Aveak  poultice  kept  on  the  skin  for  six  or  eight  hours  is  to  be  preferred, 
as  a  rule,  to  a  stronger  application  used  for  a  shorter  period  ;  but  in  cases 
of  imminent  danger,  where  an  immediate  effect  is  required,  a  mustard 
leaf  or  even  dry  cupping  of  the  back  will  often  produce  speedy  relief. 
IVEustard  leaves,  however,  and  violent  applications  such  as  blisters,  are 
not  to  be  recommended  in  the  case  of  babies  and  the  younger  children, 
and  must  be  used  with  caution  even  with  older  subjects  who  are  cachectic 
or  ill-nourished ;  for  troublesome  ulcerations  or  even  gangrene  of  the  skin 
are  occasionally  seen  to  follow  their  use.  Moreover,  it  must  be  remem- 
bered that  a  blister  is  equal  to  a  burn  of  the  third  degree,  and  may  have 
a  seriously  exhausting  effect  upon  a  weakly  child.  In  a  properly  selected 
case,  however,  the  value  of  this  form  of  counter-irritation  is  great.  In 
peri-  and  endo-carditis  no  time  should  be  lost  in  having  recourse  to  it.  I 
believe  I  have  often  succeeded  in  cutting  short  an  attack  of  pericarditis 
by  a  timely  blister ;  and  the  value  of  a  vesicant  in  promoting  absorption 
when  the  pericardial  sac  is  full  of  fluid  admits  of  no  reasonable  doubt. 
In  such  a  case,  when  used  to  a  young  child,  the  blister  must  be  of  small 
size,  and  must  be  kept  in  contact  with  the  skin  for  a  short  time  only. 
Thus  it  can  be  ■applied  for  two  hours  to  a  child  of  three  years  old,  and 
half  an  hour  longer  for  each  additional  year  of  life.  If  the  blister  have 
not  formed  Avhen  the  irritant  is  removed,  a  bread  and  water  poultice  will 
soon  cause  it  to  rise  up.  In  cases  of  exceptional  delicacy  of  skin  a  sheet 
of  oiled  tissue  paper  may  be  interposed  between  the  blister  and  the 
surface  to  be  acted  on,  as  recommended  by  Bretonneau. 

Frictions  of  the  skin  with  almond  oil  or  stimulating  liniments  are 


THE  DIET  AND    THERAPEUTICS   OF  CHILDREN  421 

useful  in  various  conditions.  Threatened  collapse  of  the  lung  may  often 
be  averted  by  this  means  ;  and  if  atelectasis  have  occurred,  persevering 
friction  with  strong  counter-irritants  may  do  much  in  helping  the  lung 
to  re-expand.  In  whooping-cough  the  use  of  rubefacient  embrocations  is 
held  in  high  esteem  as  a  domestic  remedy  ;  and  in  all  cases  of  chronic 
disease  friction  of  the  surface  combined  with  systematic  massage  of  the 
muscles  has  a  general  as  well  as  a  local  value.  In  chronic  digestive 
derangements  the  skin  is  often  dry,  scaly,  and  inactive.  For  this  con- 
dition the  application  of  warm  almond  oil  becomes  a  useful  resource. 
The  patient  is  first  well  sponged  in  a  bath  of  hot  soap-suds,  then  quickly 
dried,  and  freely  anointed  all  over  the  body  with  the  warm  oil.  He  is 
then  put  to  bed  in  a  flannel  night-dress  or  wrapped  in  a  blanket.  The 
efficacy  of  a  few  repetitions  of  this  treatment  in  improving  nutrition  and 
making  the  skin  soft  and  supple  is  remarkable. 

Children  are  very  easily  depressed  by  acute  disease,  so  that  it  is  im- 
portant to  watch  for  early  signs  of  failure.  On  this  account  alcoholic 
stimulants  take  a  high  place  among  internal  remedies,  and  a  few  doses  of 
this  medicine  will  often  in  a  few  hours  completely  alter  the  aspect  of  a 
case,  and  turn  the  scale  in  favour  of  recovery.  In  chronic  disease,  also, 
the  effect  is  equally  beneficial.  It  is  a  matter  of  common  observation  at 
the  East  London  Hospital  for  Children,  that  the  young  patients  who  are 
enfeebled  and  wasted  by  privations  of  all  kinds,  combined  with  long-con- 
tinued ill-health,  often  make  no  response  to  the  action  of  drugs  until  their 
exhausted  energies  have  been  revived  by  a  few  doses  of  wine  or  brandy. 

The  rapidity  with  which  nutrition  suffers  in  early  life,  when  any 
hindrance  arises  to  the  easy  assimilation  of  food,  gives  great  value  to  all 
invigorating  remedies.  But  tonics  are  not  to  be  ordered  indiscriminately. 
It  is  of  small  use  to  prescribe  iron  or  the  mineral  acids  for  a  sickly- 
looking  child  merely  because  he  is  anaemic  and  weakly,  and  leave  un- 
noticed a  chronic  gastric  derangement  which  is  the  cause  of  his  poor 
appetite  and  feeble  digestion.  The  dyspepsia  must  first  be  treated  with 
alkalies  and  stomachics,  and  by  a  judicious  limitation  of  the  more  ferment- 
able articles  of  food,  before  tonics  can  be  given  with  any  good  result.  As 
the  digestion  is  liable  to  suffer  in  all  the  ailments  of  childhood  the  alkalies 
are  perhaps  the  most  useful  of  our  remedies.  By  this  means  we  check 
the  excessive  secretion  of  mucus  and  neutralise  acidity.  Moreover,  the 
addition  of  an  antiseptic,  such  as  spirits  of  chloroform,  and  of  warming 
aromatics,  arrests  fermentation  and  reduces  flatulence.  At  this  period 
of  life,  whenever  alkaline  remedies  are  prescribed,  an  aromatic,  such  as 
cinnamon,  dill,  or  peppermint,  should  always  be  included  in  the  mixture. 

When  tonics  are  given  the  dilute  nitro-muriatic  acid  is  very  useful 
with  small  doses  of  nux  vomica;  and  children  take  quinine  with  great 
benefit  if  the  dose  be  not  too  small.  After  any  of  the  infectious  fevers 
quinine  is  always  indicated.  A  child  of  twelve  months  old  will  take  a 
grain  three  times  a  day ;  and  half  a  grain  may  be  added  for  each  year  of 
the  child's  life  until  a  dose  of  three  grains  is  reached.  This  can  be  given 
three,  four,  or  six  times  in  the  day  as  may  seem  desirable.     The  usual 


422  SYSTEM  OF  MEDICINE 

doses  ordered  for  children  are  too  small ;  for  young  patients  are  not  at 
all  susceptible  to  the  alkaloid,  and  rarely  suffer  from  cinchonism.  Cod 
liver  oil  is  the  favourite  remedy  for  every  form  of  wasting  or  pallor. 
The  oil  is  only  useful  when  the  digestion  is  in  fair  order,  and  should 
never  be  given  to  a  bilious  or  dyspeptic  child.  It  is  usually  administered 
in  quantities  far  too  large.  A  child  of  twelve  months  old  can  rarely 
digest  more  than  ten  drops  at  one  time,  and  a  teaspoonful  should  be  the 
maximum  dose  at  any  age. 

The  dosage  of  medicine  for  children  is  often  a  cause  of  some  per- 
plexity. Of  certain  drugs  they  show  a  curious  tolerance.  Belladonna 
they  can  take  in  large  doses,  for  although  a  few  drops  of  the  tincture 
may  bring  out  the  characteristic  rash,  this  is  not  a  symptom  of  excess,  and 
has  no  relation  to  the  size  of  the  dose.  To  opium,  as  is  well  known,  they 
are  keenly  susceptible.  It  is  wise  to  prescribe  this  narcotic  in  very  small 
quantities,  but  to  repeat  the  dose  as  frequently  as  may  be  necessary.  If 
this  be  done,  and  we  give  directions  that  the  child  is  never  to  be  waked 
up  to  take  his  medicine,  we  need  have  no  fear  of  his  becoming  narcotised. 
In  connection  with  this  subject  it  may  be  remarked,  that  infants  who  are 
being  drugged  by  unscrupulous  nurses  with  "  soothing  syrups,"  or  other 
opiates,  invariably  show  it  by  symptoms  which  are  characteristic  enough 
to  the  experienced  eye.  The  child  lies  in  a  drowsy  state  with  contracted 
pupils,  he  often  vomits,  his  bowels  are  obstinately  confined,  his  water 
is  scanty,  and  his  skin  is  curiously  inelastic.  If  this  combination  of 
symptoms  be  noticed  in  a  young  baby  we  have  the  strongest  reasons  for 
suspecting  the  secret  administration  of  a  narcotic. 

Antipyrin,  like  quinine,  children  take  well ;  and  arsenic  and  iodide  of 
potassium  may  be  given  to  patients  of  four  years  old  and  upwards  in  the 
doses  usually  prescribed  for  the  adult.  Ergot,  digitalis  and  lobelia  are 
other  remedies  which  may  be  ordered  with  a  liberal  hand.  The  making  of 
these  and  other  drugs  palatable  to  young  children  is  far  from  easy.  The 
bitterness  of  quinine  it  is  impossible  to  disguise  completely ;  but  it  may 
be  modified  by  giving  it  suspended  in  glycerine  and  water.  Nauseous 
powders  are  best  given  in  ''  cachets  " ;  and  young  children  soon  learn  to 
swallow  them.  It  is  wise  to  avoid  the  use  of  syrups  for  sweetening  pur- 
poses :  there  are  few  illnesses  in  young  people  which  are  not  complicated 
by  a  certain  amount  of  gastric  disturbance ;  and  the  quantity  of  sugar 
contained  in  the  syrups  must  provide  additional  material  for  fermentation, 
and  excite  acidity  and  flatulence.  There  is  no  doubt  that  the  medicated 
syrups,  which  are  manufactured  so  largely,  are  often  the  cause  of  great 
discomfort  to  the  patient,  if  not  of  worse  evils  ;  the  syrup,  by  increasing 
the  digestive  derangement,  may  be  more  productive  of  ill  than  the  drug 

dissolved  in  it  is  of  good.  __   ■  ^ 

Eustace  Smith. 

REFERENCES 

1.  Archives  of  Psediatrics,  April  1884,  p.  229. — 2.  Pharmaceutische  Cejitral  Halle, 
Berlin,  1886,  No.  8.-3.  Keating's  Cyclopsedia,  article,  "Infant  Feeding,"  by  T.  M. 
Rotch,  M.D. 

E.  S. 


NURSING  423 


NURSING^ 

Tending  the  sick  has  risen  to  the  dignity  of  a  profession,  and  a  special 
training  is  required  for  those  who  undertake  it.  The  keynote  of  good 
nursing  is  an  intelligent  obedience,  only  attainable  by  systematic  educa- 
tion. Women  who  wish  to  be  nurses  need  practical  skill,  powers  of  ob- 
servation, and  tact  in  dealing  with  various  idiosyncrasies.  They  must 
also  remember  that  time  is  needed  in  which  to  gain  these  qualities  and 
the  knowledge  which  experience  alone  can  give. 

Hospitals,  which  offer  facilities  for  regular  instruction  both  in  theory 
and  practice,  have  become  training  schools  for  nurses.  Order,  method, 
punctuality,  obedience  are  part  of  the  groundwork  of  a  training  school ; 
but  to  these  must  be  added  thoroughness,  promptness,  accuracy  in  ob- 
serving and  correctness  in  reporting  observations,  and  a  loyal  attitude 
towards  doctors  and  patients.  The  whole  art  of  trained  nursing  depends 
upon  the  maintenance  of  this  attitude.  ]S"urses  are  bound,  by  their  very 
position,  to  render  loyal  obedience  to  medical  men.  It  is  not  their  duty 
to  suggest  or  initiate  treatment  of  any  kind,  except  by  express  permission 
or  in  some  sudden  emergency.  They  have  no  responsibility  whatever 
save  that  of  faithfully  obeying  orders,  and  the  higher  the  discipline  the 
more  readily  this  is  recognised. 

With  regard  to  patients  the  gravest  fault,  short  of  negligence,  is  love 
of  gossip,  personal  or  professional.  To  talk  to  patients  about  their  ail- 
ments and  treatment,  to  describe  other  cases  to  them,  to  indulge  them 
in  medical  histories,  and  to  discuss  the  comparative  merits  of  medical  men, 
work  infinite  harm  ;  especially  to  those  of  nervous  temperament  who  are 
chiefly  disposed  to  seek  such  confidences.  It  is  true  a  nurse  is  often  at 
a  loss  to  interest  her  patients,  but  to  gratify  unwholesome  curiosity,  to 
criticise  methods  of  treatment,  or  to  reveal  private  affairs  learned  in  the 
course  of  her  profession,  is  most  reprehensible. 

Age  for  Training.  — While  probationers  are  being  thus  educated  they 
are  also  instructed  in  the  special  branches  of  the  work.  The  demands 
upon  physical  power  and  mental  assimilation  are  alike  heavy,  and  should 
not  be  undertaken  too  soon  in  life.  From  23  to  24  is  the  earliest  age  at 
which  a  nurse  should  begin  her  training.  Even  in  children's  hospitals  to 
accept  younger  probationers  is  an  error.  The  actual  strain  of  lifting, 
moving,  etc.,  may  not  be  so  heavy;  but  the  incessant  watchfulness, 
cheerfulness,  and  absolute  self-control  necessary  in  dealing  with  children 
are  a  heavier  task  than  is  usually  supposed. 

General  hospital  training  may  be  divided  into  surgical  and  medical 
work,  and  the  probationers  are  moved  from  ward  to  ward  at  the  discre- 
tion of  those  in  charge  of  the  training.     For  the  sake  of  order  and  dis- 

1 1  havo  asked  Miss  HmkIioh  tf)  write  this  article  for  mo  in  order  that  medical  men  may 
know  what  to  expect  of  tlieir  nurses  —  not  Uiat  I  for  a  moment  suppose  any  one  of  my 
readers  to  be  unfamiliar  with  the  smallest  of  these  bedside  services.  —Ed. 


424  SYSTEM  OF  MEDICINE 


cipline  tliis  power  should  be  vested  in  the  matron^  herself  a  trained 
nurse,  who  is  guided  by  the  reports  of  the  "  sisters  "  or  "  charge  nurses  " 
of  the  different  wards. 

Surgical  "Ward  "Work  ;  Ventilation,  —  The  first  essential  in  a  surgical 
ward  is  pure  air,  the  second  absolute  cleanliness.  On  the  nurse  devolves 
the  management  of  windows  and  ventilators  so  as  to  obtain  the  maximum 
of  change  of  air  with  the  minimum  of  draught.  Common  sense  must  be 
brought  to  bear  on  the  matter  ;  the  direction  of  the  wind  and  its  effect 
on  the  ventilating  arrangements  of  the  ward  must  be  considered,  so  as 
to  avoid  a  through  draught,  also  the  nature  of  the  warming  apparatus, 
whether  open  fireplaces  or  hot  pipes,  and  its  position  in  regard  to  doors 
and  windows.  The  usual  temperature  —  from  50°  F.  to  60°  F.  —  should 
be  recorded  at  regular  intervals  during  the  twenty-four  hours,  and  fresh- 
ness must  be  equally  maintained  day  and  night. 

Absolute  cleanliness  applies  to  every  detail  of  a  ward,  from  the  patients 
and  their  beds  to  the  smallest  appliance  and  fitting.  Dusting  means 
not  merely  moving  the  offending  material,  but  removing  it  from  every 
part  of  the  walls,  floor,  furniture,  etc.  A  damp,  not  wet  duster  is  most 
effectual;  and  if  desired,  it  can  be  used  with  a  disinfectant.  Floors 
should  be  sprinkled  before  sweeping,  and  the  bedstead  of  every  patient 
dusted  daily. 

Every  appliance  must  be  scrupulously  cleansed,  no  stains  nor  fur 
allowed  on  utensils,  test  tubes,  etc. ;  strong  soda  water,  or  spirits  of  salt 
(applied  with  a  mop)  will  cleanse  any  glass  or  earthenware  vessel,  but 
the  latter  must  not  be  used  for  metals,  nor  for  lavatories,  on  account  of 
the  metal  fittings.  Bedsteads,  bedding,  mackintoshes,  splints,  etc.,  must 
be  kept  absolutely  clean. 

Surgical  cleanliness  is  a  higher  matter  than  general  cleanliness.  It 
aims  at  the  destruction  of  every  germ ;  bacteria  are  not  merely  to  be 
removed,  they  should  be  non-existent. 

This  is  attained  by  boiling  all  glass  and  metal  appliances  for  twenty 
minutes,  maintaining  the  temperature  at  212°  F.  Dressings,  sponges, 
wool  pads,  are  also  sterilised,  and  kept  hermetically  sealed  till  the  moment 
they  are  needed.  Other  antiseptic  dressings,  such  as  sal-alembroth, 
cyanide,  etc.,  have  the  same  object  in  view;  and  here  the  most  careful 
watchfulness  is  demanded  from  the  nurse  that  she  shall  not  nullify  the 
treatment  by  any  such  careless  action  as  laying  down  a  dressing,  scissors, 
or  any  of  the  appliances,  on  an  undisinfected  surface.  She  must  herself 
be  scrupulously  clean  in  person  and  dress,  and  her  hands  must  be  care- 
fully kept,  with  short  clean  nails. 

.Cleansing  of  Hands.  —  In  attending  upon  the  surgeon,  or  in  preparing 
for  dressing  cases,  etc.,  her  hands  may  be  rendered  free  from  suspicion 
by  first  thoroughly  washing  in  hot  water,  using  carbolic  soap  and  nail 
brush  freely  ;  hands  and  forearms  are  then  immersed  in  strong  Condy's 
fluid  for  a  minute,  the  stains  being  next  removed  by  the  use  of  a  saturated 
solution  of  oxalic  acid.  After  drying,  they  are  again  soaked  in  ^^-^ 
solution  of  perchloride  of  mercury,  and  may  then  be  considered  as  really 


NURSING  425 


cleansed.     This  process  does  not  take  long,  and  is  especially  necessary 
in  moving  from  any  doubtful  case  to  another  patient. 

A  knowledge  of  the  various  strengths  of  disinfectant  and  antiseptic 
lotions  is  important  to  the  nurse. 

(a)    Perchloride  of  Mercury  is  used  ^-^  for  hands,  4-jyVo  ^^^  douches, 
etc.,  other  strengths  being  specially  ordered.     Metal  instruments 
should  be  wiped  at  once  if  immersed  in  it. 
(h)    Carbolic   acid  lotion   is   used  -J^   for  hands,  instruments,   and 
external  washing  of  sound  skin,  J^  and  -g-L  for  wounds,  etc. 

(c)  Condi/s  Fluid,  3j.  to  Oj.  (or  three  to  four  crystals  of  perman- 
ganate of  potash  to  1  pint)  for  douches,  wounds,  etc. ;  it  stains 
linen,  instruments,  and  hands. 

(d)  Saturated  solution  of  Boracic  acid,  -Jg-  or  about  4  per  cent  for 
wounds. 

(e)  Sanitas,  3j.  to  Oj.,  a  pleasant  deodorant  for  foul  wounds,  and 
for  cancer,  gangrene,  etc. 

(/)  Creoliii,  3j.  to  Oj.  for  hands  and  instruments;  must  be  mixed 
with  a  little  cold  water  before  adding  hot,  and  can  be  used  with 
soap.     Same  strength  useful  for  irrigating  wounds. 

(g)  Boiling  vjater  for  instruments.  Boiled  water  for  douches  and 
irrigations. 

Poison  Bottles  and  Lotions.  —  Every  poisonous  lotion  should  be  in  a 
special  bottle,  with  conspicuous  label,  and  kept  under  lock  and  key ;  any 
possibility  of  confusion  with  medicines,  or  beverages,  whether  in  or  out 
of  use,  should  be  prevented.  Corrosive  sublimate  is  usually  coloured 
pink  or  blue  to  avoid  mistakes ;  the  other  lotions,  except  boracic  lotion, 
have  each  a  distinctive  and  easily  perceptible  smell. 

Symptoms  of  their  absorption  must  be  looked  for  and  reported,  e.g. 
in  carbolic  poisoning,  dark  green  urine,  drowsiness,  muscular  weakness, 
and  sometimes  vomiting. 

If  a  nurse  has  dressings  to  prepare  for  granulating  wounds,  the  lint  or 
gauze  must  be  cut  exactly  to  cover  the  sore  to  avoid  softening  the  edges. 

Ointments  must  be  very  thinly  spread,  and  must  never  be  allowed 
to  accumulate  on  the  sound  skin.  If  a  moist  dressing  is  ordered,  a 
piece  of  gutta  percha  tissue  considerably  larger  than  the  lint  must  be 
applied  over  the  lint,  no  portion  of  which  should  be  left  uncovered; 
but  if  an  evaporating  lotion  be  required,  the  tissue  must  be  omitted, 
and  the  application  frequently  changed  and  never  allowed  to  dry.  In 
washing  or  syringing  a  wound  a  receiver  must  always  be  placed  to  col- 
lect the  water  or  lotion  that  has  touched  the  sore;  and  if  wool  be  used 
to  cleanse,  each  piece  as  used  must  be  placed  on  a  receiver,  and  never 
dipped  again  into  the  lotion.  To  place  the  foot  of  an  ulcerated  leg,  for 
example,  in  a  basin  of  disinfectant,  and  use  one  piece  of  wool  to  cleanse 
the  wound  and  surrounding  skin  is  not  surgical  nursing. 

In  dressing  burns  the  fresh  application  should  be  ready  to  put  on  as 
the  soiled  one  is  removed ;  thus  unnecessary  exposure  to  the  air,  which 
causes  great  smarting,  is  avoided.     In  every  dressing  the  nurse  must 


426  SYSTEM   OF  MEDICINE 

observe  strict  cleanliness  in  every  detail.  Soiled  dressings  should 
always  be  removed  by  forceps,  placed  in  a  receiver  at  once,  disposed  of 
in  the  manner  of  the  hospital,  or  burned  without  delay. 

The  forceps  must  be  cleansed  with  a  nail  brush  in  soap  and  water, 
and  either  boiled,  or  soaked  in  disinfectant  for  a  few  minutes  before 
being  used  again. 

Windows  should  always  be  closed  when  a  dressing  is  being  done, 
and  every  wound  should  be  covered  as  quickly  as  possible. 

In  offensive  cases  inhalation  of  the  odour  must  be  avoided,  and  the 
patient  should  never  be  made  to  feel  the  unpleasantness  of  which  he 
is,  as  a  rule,  only  too  fully  aware.  The  nurse  must  report  the  effect 
of  the  applications. 

Cancer  patients  vary  greatly,  and  by  observing  that  which  suits  each 
special  case  much  pain  may  be  avoided.  In  dressing  extensive  cancerous 
surfaces  a  styptic  should  be  at  hand  in  case  of  haemorrhage ;  in  these 
cases,  and  for  gangrene,  burns,  etc.,  gentle,  firm  handling  is  needed,  com- 
bined with  quickness  and  lightness  in  removing  and  reapplying  dressings. 

In  padding  splints  evenness  is  ensured  by  lacing  the  padding  down 
the  back  of  the  splint  with  strong  thread,  so  that  it  can  be  regularly 
tightened.  Special  care  must  be  given  to  ensure  the  edges  being  well 
protected,  or  pressure  sores  may  arise.  Children's  splints,  and  others 
likely  to  be  soiled,  can  be  covered  in  addition  with  jaconet,  which  can  be 
cleansed  easily.  In  preparing  for  extensions  the  nurse  must  have  ready 
a  long  even  strip  of  strapping,  known  as  the  stirrup  (preferably  on 
holland),  cut  with  regard  to  the  Avidth  and  length  of  the  limb;  also  two 
or  three  thin  strips  long  enough  to  go  at  least  twice  round  the  limb 
diagonally,  to  avoid  any  arrest  of  circulation :  the  block,  pulley,  cord, 
the  weight  ordered,  sand-bags,  and  a  couple  of  thin  flannel  bandages  must 
also  be  at  hand.  If  the  nurse  be  desired  to  apply  an  extension  in  cases  of 
hip  disease,  the  ends  of  the  stirrup  must  be  well  above  the  knee  (quite  half- 
way up  the  thigh),  and  the  loop  so  arranged  that  its  sides  are  exactly  equal 
in  length,  the  block  and  cord  with  the  attached  weight  being  in  the  centre. 
The  block  is  easily  fastened  to  the  stirrup  by  a  length  of  strapping  extend- 
ing from  above  the  ankle  on  each  side,  and  is  applied  with  its  adhesive  side 
to  the  stirrup,  so  that  the  block  is  enclosed  between  the  strips.  It  may 
be  further  secured  by  a  strip  wrapped  round  on  each  side  of  the  hole 
through  which  the  cord  passes.  The  strips  which  keep  the  stirrup  in 
position  must  not  be  too  tight,  and  the  edge  of  the  lowest  one  must  be 
kept  from  chafing  the  skin  just  above  the  heel.  The  patient  must  be 
kept  flat,  with  only  one  pillow,  the  foot  of  the  bed  raised,  and  the  limb 
retained  in  position  by  sand-bags ;  careful  washing  and  powdering  are 
necessary,  when  the  extension  is  changed,  to  prevent  chafing  of  the  skin, 
turpentine  being  used  to  remove  the  adhesive  material  from  the  skin. 

The  art  of  even  bandaging,  applied  intelligently  after  due  anatomical 
instruction,  is  very  important.  The  bandage  should  be  gently  yet  firmly 
applied,  alternate  slackening  and  tightening  avoided,  also  any  jerking  or 
pulling.     In  dealing  with  an  injured  limb  it  should  be  lightly,  yet 


NURSING  427 


firmly  grasped,  supported  as  much  as  possible,  and  moved  evenly.  To 
carry  it  on  the  palms  of  the  hands  gives  less  pain  than  holding  it  in 
the  lingers. 

In  receiving  accident  cases  in  a  ward  orders  will  be  given  as  to 
bathing,  etc.  If  the  accident  be  a  fracture,  fracture  boards  must  be 
placed  under  the  mattress  in  the  bed,  and  the  splints  suitable  for  the 
case,  according  to  the  use  of  the  hospital,  should  be  got  ready,  padded, 
etc.,  and,  if  necessary  {i.e.  in  fractures  of  thigh),  an  extension  prepared. 
In  removing  the  clothes  the  patient  must  be  kept  recumbent  for  fear  of 
syncope  in  consequence  of  shock,  and  the  garments  removed  as  gently  as 
possible.  Troasers,  coat-sleeves,  shirts,  socks,  etc.,  can  all  be  divided  at 
the  seams,  and  lifted  from  the  injured  parts,  which  should  always  be 
freed  first.  The  same  applies  to  a  woman's  garments ;  skirts  can  be 
slipped  downwards  by  raising  the  back  slightly,  and  pushing  down  the 
bed  underneath  to  make  room  for  them  to  be  drawn  away. 

The  necessary  washing  must  be  done  between  blankets,  one  being 
placed  on  the  bed  before  the  patient  is  laid  in  it,  and  another  over  him ; 
the  nurse  must  watch  for  signs  of  exhaustion.  Turpentine  is  useful  to 
remove  stains  from  the  hard  skin  of  hands,  feet  and  knees,  but  it  must 
be  well  washed  off  with  soap  and  water  to  avoid  irritation.  Except  in 
the  neighbourhood  of  scalp  wounds  hair  must  never  be  cut  without  a 
direct  order  from  the  doctor.  In  head  injuries  the  nurse  must  report 
any  discharge  from  ears  or  nose,  any  peculiarity  of  the  eyes,  and  if  there 
are  fits,  she  must  specially  observe  where  the  convulsive  movements 
commence.  In  abdominal  cases,  swelling,  tenderness  in  any  special 
area,  bruises,  etc.,  must  be  reported;  also  all  cuts,  scars,  wounds,  ulcers, 
skin  eruptions,  vomiting,  discharges  or  hemorrhage  ;  in  fact,  anything  at 
all  abnormal.  After  washing,  the  blankets  are  removed,  and  if  the  pa- 
tient be  cold  or  collapsed,  hot  bottles  securely  wrapped  in  flannel  may  be 
applied  to  the  extremities.  Fractured  limbs  must  be  steadied  by  sand- 
bags, and  if  the  bed-clothes  press  on  any  injured  part  a  cradle  must  be 
used  to  support  them.    No  stimulant  must  be  given  without  direct  orders. 

In  preparing  a  patient  for  operation  the  nurse  acts  under  the  orders 
of  the  surgeon ;  it  is  usual  to  give  an  aperient  over-night,  a  simple  enema 
early  in  the  morning,  and  no  solid  food  or  milk  for  at  least  four  hours 
beforehand,  a  cup  of  good  beef  tea  being  given  about  two  hours  before 
the  appointed  time.  Antiseptic  compresses  are  often  ordered  to  the 
place  where  the  incision  will  be  made.  If  a  woman,  the  hair  must  be 
arranged  in  two  j)laits  for  future  convenience,  and  the  catheter  may  be 
ordered  shortly  before  the  operation.  Ordinary  bed-clothes  are  usually 
worn,  with  a  special  wrapper.  The  arrangements  at  the  operation  depend 
on  the  custom  of  the  hospital ;  but  the  nurse  is  often  required  to  wash 
sponges,  hand  instruments,  and  even  to  support  a  limb.  Sponges  or 
wool  pads  must  be  squeezed  as  dry  as  possible  before  handing  to  the 
surgeon,  and  the  exact  number  counted.  The  table  is  prepared  by 
folding  a  blanket  double  on  it,  and  covering  this  with  a  large  mackintosh, 
over  which  is  a  sheet.     A  low  pillow  and  a  draw-sheet  are  usual,  with 


428  SYSTEM  OF  MEDICINE 

small  mackintoslies  and  towels  tightly  wrung  out  of  a  disinfectant  lotion, 
and  arranged  to  suit  the  special  case.  A  hot  water  bed  is  sometimes 
used,  placed  next  the  table.  The  bed  to  which  the  patient  is  afterwards 
taken  must  be  well  warmed  by  hot  bottles,  and  a  warm  water-pillow 
may  be  ordered.  A  receiver  and  a  couple  of  soft  towels  must  be  in 
readiness  in  case  of  vomiting  after  the  anaBsthetic. 

After-Care. — In  moving  a  patient  back  to  bed  the  head  should  be 
kept  as  low  as  possible,  and  careful  attention  given  that  before  complete 
consciousness  is  recovered  the  dressings  are  not  disturbed,  nor  the  patient 
allowed  to  raise  himself  hurriedly,  for  fear  of  haemorrhage  or  syncope. 
In  amputation  cases  a  tourniquet  should  be  within  reach  of  the  nurse,  to 
be  applied  if  haemorrhage  occurs,  until  the  surgeon  can  be  summoned. 
Every  detail  regarding  nourishment,  stimulants,  opiates,  use  of  the  cath- 
eter, etc.,  must  be  obtained  from  the  surgeon. 

After  an  operation  the  dressings  should  be  inspected  at  frequent 
intervals,  and  if  discharge  or  blood  soak  through  them  the  fact  should 
be  reported  at  once.  If  the  surgeon  be  not  at  hand  the  dressing  should 
be  '*  packed,"  i.e.  pads  of  absorbent  wool  bandaged  over  the  points  where 
the  discharge  appears. 

No  food  should  be  given  for  some  hours  after  an  operation,  unless 
specially  ordered,  or  the  effects  of  the  anaesthetic  have  passed  off ;  but 
small  pieces  of  ice,  a  little  soda  water,  or  a  teaspoonful  of  hot  water 
may  be  given  to  allay  thirst  and  relieve  vomiting.  If  the  latter  be 
severe,  it  should  be  reported. 

The  nurse  should  have  all  in  readiness  for  the  visit  of  the  surgeons 
to  a  ward.  Hot  water,  towels,  disinfectant  lotion  for  hands  and  instru- 
ments, dressing  forceps,  probe  and  director,  and  a  tongue  spatula  im- 
mersed in  lotion  should  be  carried  round  by  the  nurse ;  and  artery  forceps, 
bistoury,  etc.,  should  be  in  readiness  if  required:  a  good  lamp  should 
always  be  ready,  and  a  receiver  for  soiled  dressing,  prepared  notes  of  cases 
beside  each  patient,  splints,  etc.,  so  that  no  unnecessary  delay  is  caused. 

Medical  Nursing.  —  The  ventilation  of  medical  wards  is  most  im- 
portant, the  temperature  must  be  higher  — usually  fron  60°  to  65°  F.  — 
and  yet  the  air  kept  quite  fresh.  It  is  advisable  to  have  two  or  more 
thermometers  in  each  large  ward,  to  ensure  an  evenly-distributed  heat. 
In  small  wards,  where  a  moist  and  higher  temperature  may  be  required 
(70°  F.),  draught  may  be  avoided  by  the  Hinckes  Bird  method  of  venti- 
lation, i.e.  a  piece  of  wood,  three  or  four  inches  deep,  exactly  fitting  the 
window  frame,  is  placed  so  that  the  lower  sash  closes  on  it,  and  the 
outside  air  passes  up  between  the  upper  and  lower  sashes  in  the  middle 
of  the  window,  and  is  directed  upwards  into  the  room. 

To  give  an  accurate  report,  the  use  of  the  clinical  thermometer 
needs  greater  care  than  is  often  bestowed  upon  it.  If  given  to  a  patient 
able  to  hold  it  in  the  mouth,  it  must  go  under  the  tongue,  and  be  held 
by  the  closed  lips  (not  by  the  teeth),  for  always  the  same  time,  at  least 
five  minutes.  The  so-called  ''half-minute  "  thermometers  are  deceptive 
if  used  for  this  interval.     If  placed  in  the  axilla  the  skin  must  first  be 


NURSING  429 


dried,  and  the  thermometer  so  inserted  that  the  bulb  touches  the  skin  on 
every  side,  the  arm  being  drawn  across  the  cliest ;  if  necessary,  the  arm 
must  be  held  there  for  the  required  time.  In  children  the  fold  of  the  groin 
is  often  convenient,  or  the  rectum.  In  every  case  the  record  should  be 
written  down  at  once,  not  trusted  to  memory,  and  the  thermometer 
placed  in  "^V  carbolic,"  or  "^-^  perchlor.,"  for  a  few  minutes  before 
replacing  it  in  its  case.  It  is  a  good  plan  to  dip  it  into  clean  Avater,  and 
wipe  it  with  a  clean  napkin,  before  giving  it  to  each  patient,  especially  if 
used  in  the  mouth.  The  temperature  of  a  patient  in  a  bath  or  pack  must 
never  be  taken  in  groin  or  axilla. 

Accurately  counting  the  rate  of  the  pulse,  and  reporting  its  character, 
are  matters  of  training  and  experience,  and  of  great  importance.  A 
nurse  should  be  able  to  notice  the  more  important  changes  that  may  oc- 
cur, also  whether  drugs,  stimulants,  etc.,  produce  any  marked  effects. 

It  is  better  not  to  let  the  patient  know  when  the  resjm-ations  are 
being  counted,  as  this  may  alter  the  rate,  and  this  record  is  at  times  of 
more  value  to  the  doctor  than  that  of  the  temperature. 

Bed-making  is  one  of  the  most  important  duties  of  a  nurse.  In  hos- 
pital wards  where  the  beds,  mattresses,  etc.,  are  of  right  size  and  height, 
no  special  difficulties  arise.  A  single  blanket  is  spread  over  the  hair 
mattress,  and  over  this  a  sheet,  the  upper  end  of  which  is  rolled  round 
the  bolster,  not  spread  over  it,  and  tucked  firmly  in  all  round.  A  draw- 
sheet,  consisting  of  a  sheet  folded  about  three  feet  wide,  is  placed  across 
the  bed,  one  end  being  tucked  in  at  one  side,  and  the  extra  length  flatly 
folded  and  tucked  in  on  the  other.  If  necessary,  a  square  of  mackintosh 
is  placed  under  the  draw-sheet,  and  may  conveniently  be  kept  in  place  by 
a  small  safety  pin  at  each  corner.  The  top  sheet  and  each  blanket  should 
be  put  on  and  tucked  in  separately,  and  the  feelings  of  the  individual 
patient  consulted  as  to  folding  back  blankets  or  quilt  at  the  top.  The 
quilt  should  be  so  pinned  or  folded  that  it  does  not  touch  the  floor  at  the 
bottom  or  sides  of  the  bed,  and  prevent  free  circulation  of  air  underneath. 

In  changing  hed-linen  for  a  helpless  case  the  upper  sheet  and  quilt 
must  first  be  removed,  and  the  patient  covered  with  his  blanket  or 
blankets ;  he  must  then  be  gently  turned  on  one  side  (if  possible  the 
right  to  avoid  any  risk  of  syncope  in  cardiac  or  pleuritic  affections). 
This  can  be  done  with  little  effort  by  means  of  the  draw-sheet ;  this  is  then, 
with  the  mackintosh,  rolled  up  tightly  towards  the  patient,  the  bottom 
sheet  untucked,  also  rolled  up  tightly,  and  with  the  other  pushed  well 
under  the  shoulder  and  buttocks  of  the  patient.  The  clean  sheet,  draw- 
sheet,  and  mackintosh  are  also  rolled  up  together  lengthwise  for  half  their 
width,  and  placed  close  to  the  patient,  the  other  portion  being  smoothly 
spread  over  half  the  bed.  For  a  weak  patient  this  is  a  good  opportunity 
for  washing  the  back  and  applying  spirits  and  dusting  powder,  so  that  he 
need  not  be  disturbed  again.  The  patient  is  then  turned  back  over  the 
rolled  linon,  and  just  turned  sufficiently  to  the  left  side  to  allow  the  soiled 
linen  to  be  removed;  the  clean  roll  is  then  drawn  through  and  evenly 
spread  over  the  other  half  of  the  bed,  and  all  well  tucked  in.    It  facilitates 


430  SYSTEM  OF  MEDICINE 

matters  to  raise  the  feet  and  legs,  and  place  them  on  the  clean  linen  before 
turning  the  patient  back,  and  the  head  should  always  be  comfortably  sup- 
ported by  pillows.  The  top  sheet  can  be  passed  in  under  the  blankets  from 
the  bottom  of  the  bed,  and  then  they  are  separately  tucked  in  and  the  quilt 
replaced.  By  placing  the  rolled  part  of  the  sheets,  etc.,  next  the  bed, 
the  hands  can  be  slipped  underneath  it,  palms  upwards,  to  draw  it 
through ;  thus  the  nurse's  knuckles  are  not  pushed  against  the  back  of  the 
patient.  Heavy  bed-clothes  must  always  be  avoided,  and  the  feelings  of 
the  patient  consulted  as  to  warmth  whenever  possible. 

In  removing  body  linen  of  helpless  patients,  it  is  well  to  draw  it  up 
from  the  back,  and,  having  unfastened  the  collar,  to  bring  the  garment 
over  the  head,  taking  the  arms  out  of  the  sleeves  last.  In  putting  on 
fresh  linen,  it  is  easier  if  the  arms  be  first  placed  in  the  sleeves,  and  then 
the  shirt  lifted  over  the  head,  and  drawn  clown  at  the  back.  AVhere  all 
movement  is  undesirable,  a  shirt  or  night-dress  can  be  divided  down  all 
the  seams  of  one  side,  neck,  shoulder,  sleeve,  etc.,  and  fastened  by  tapes; 
it  has  then  only  to  be  put  on  at  one  side,  and  the  back  rolled  and  passed 
under  the  patient  like  a  draw-sheet. 

Medical  Examination.  —  The  nurse  must  be  ready  to  remove  and  ad- 
just all  personal  or  bed  clothing  for  medical  examination.  When  the 
abdomen  is  to  be  examined  the  quilt  and  blankets  must  be  turned  back 
but  the  sheet  left  upon  the  patient  for  the  medical  attendant  to  arrange 
for  his  own  convenience. 

Helpless  Cases.  —  In  changing  the  bed-linen  for  cases  which  must  not 
be  turned  at  all  on  either  side,  the  dirty  under-sheet,  with  mackintosh 
and  draw-sheet,  can  be  rolled  up  from  the  bottom  of  the  bed,  and  pushed 
well  under  the  buttocks ;  the  rolled  part  of  the  clean  Jinen  is  now  laid 
close  to  it,  and  the  lower  part  of  it  spread  and  tucked  in  at  the  foot  of 
the  bed.  By  gently  raising  the  buttocks  the  two  rolls  are  passed  under- 
neath, and  the  patient  now  rests  on  the  clean  sheet.  The  iipper  part  of 
the  soiled  sheet  is  then  rolled  and  pushed  well  up  under  the  shoulder- 
blades,  and  the  clean  one  also  ;  and  then,  by  gently  raising  the  shoulders 
a  very  little,  both  are  drawn  up  to  the  top  of  the  bed,  the  dirty  linen 
removed,  and  the  clean  spread  smoothly.  By  changing  from  below 
upwards,  the  patient  is  not  pulled  down  the  bed,  which  entails  the  extra 
fatigue  of  lifting  up  again. 

Lifting  is  readily  done  by  two  persons,  who  pass  hands  —  left  or  right 
as  the  case  may  be  —  under  the  buttocks,  and  the  other  hands  just  below 
the  shoulder-blades,  while  a  third  helper,  if  the  patient  be  very  weak, 
supports  the  head  and  shoulders.  By  lifting  exactly  simidtaneously,  the 
heaviest  patient  can  be  raised  without  over-exertion.  Or  two  assistants 
may  grasp  the  draw-sheet  close  to  the  buttoclcs  and  under  the  shoulders, 
the  head  being  supported  as  before,  and  the  patient  raised,  but  this  is  apt 
to  bring  the  draw-sheet  too  far  up  the  bed,  and  the  patient  is  pulled  down 
again  in  endeavouring  to  rearrange  it.  A  pillow  is  useful  in  abdominal 
cases  where  the  knees  are  drawn  up ;  and  it  can  be  efficiently  protected 
by  placing  a  piece  of  mackintosh  round  it  under  the  pillow-case.     When 


NURSING  431 


used  to  support  a  limb  it  is  more  comfortable  if  hollowed  in  the  middle 
so  as  to  form  a  trench. 

When  a  cradle  is  used  to  keep  off  the  weight  of  the  clothes,  a  thin 
blanket  or  the  sheet  should  be  upon  the  patient. 

Water-beds  and  water-pillows  are  tilled  with  lukewarm  water,  so  as 
neither  to  chill  nor  overheat  the  patient.  They  should  be  covered  by  a 
mackintosh  and  thin  blanket  under  the  sheet.  A  water-bed  must  be 
filled  before  the  patient  is  placed  in  it,  but  a  water-pillow  can,  if  neces- 
sary, be  slipped  in  empty  underneath  him  as  he  lies. 

The  nurse  should  be  careful  that  the  patient  is  in  the  middle  of  a 
water-pillow,  as  if  allowed  to  rest  on  the  edge  bed-sores  will  form. 

Bed-rests  are  useful  when  the  patient  needs  to  be  more  or  less  up- 
right —  special  care  is  needed  in  such  cases  to  prevent  the  formation  of 
bed-sores,  as  extra  pressure  is  thrown  upon  the  sacrum  and  buttocks, 
and  in  these  cases  the  circulation  is  usually  defective. 

When  a  patient  has  been  ordered  to  be  placed  between  blankets,  as 
in  acute  rheumatism,  those  next  him  should  be  frequently  changed,  and 
a  draw-sheet  should  be  always  used  to  keep  the  back  in  a  good  state. 
Plannel  night-shirts  must  be  worn. 

Bed-sores.  —  The  prevention  of  bed-sores  consists  in  cleanliness,  dry- 
ness of  the  skin,  and  smoothness  of  the  bed-linen.  Except,  perhaps,  in 
some  very  rare  cases  of  cerebral  and  spinal  disease,  when  they  are  said  to 
form  with  appalling  rapidity,  bed-sores  are  ahvays  preventable ;  indeed, 
it  is  with  some  hesitation  that  I  allude  to  any  possible  exceptions.  In 
such  cases  as  fevers  or  general  paralysis  bed-sores  need  never  be  seen. 

Constant  cleanliness  and  watchfulness,  a  vigilant  eye  to  discharges, 
attention  to  the  smoothness  and  dryness  of  the  sheets,  and  judicious 
changes  of  position,  are  the  secrets  of  success.  If  waterproof  sheeting 
must  be  used  a  considerable  thickness  of  linen  and  blanket  should  lie 
between  it  and  the  patient's  skin.  The  use  of  water-pillows  or  beds  is 
imperative  in  long  or  severe  cases,  and,  being  made  of  smoother  material, 
are  preferable  to  air-beds  or  pillows  ;  they  are  also  more  elastic.  All 
parts  exposed  to  pressure  and  soiling  must,  at  least  twice  daily,  be  washed 
with  soap  and  water,  well  dried,  rubbed  with  spirit,  and  dusted  with 
powder.  A  useful  "mixture  is  one  part  boracic  powder  to  two  of  starch 
powder.  If  inclined  to  be  tender,  the  skin  may  be  painted  with  collodion 
or  balsam  of  Peru  and  powdered.  When  it  is  difficult  to  maintain  dry- 
ness, lanoline  or  zinc  ointment  may  be  rubbed  in  and  powdered. 

Dryness  of  Bed.  —  When  there  is  no  control  over  bladder  and  rectum, 
careful  and  frequent  cleansing  and  changing  is  necessary.  Incontinence 
of  urine  may  be  met  by  the  use  of  glass  urinals  for  either  male  or  female 
cases,  supported  by  pads  of  wood  wool  or  carbolised  tow  in  butter  mus- 
lin ;  in  the  former  cases  care  must  be  taken  to  avoid  pressure  on  the 
scrotum ;  and,  in  both,  absolute  cleanliness  and  frequent  dusting  with 
powder  is  essential  to  avoid  chafing.  In  female  cases  the  vulva,  par- 
ticularly within  the  labia,  must  be  attended  to  carefully.  When  there 
is  loss  of  control  over  the  rectal  sphincters,  similar  pads  on  a  piece  of 


432  SYSTEM  OF  MEDICINE 


niackintosli  may  be  advantageously  used ;  they  can  easily  be  removed, 
destroyed,  and  new  ones  applied.  In  washing  stout  patients,  especially 
women,  the  parts  under  the  breasts  and  the  folds  of  the  groin  and  thighs 
need  careful  drying  and  powdering,  as  neglect  may  soon  cause  eczema 
or  painful  sores.  Nurses  cannot  have  too  constantly  before  them  the 
suddenness  with  which  sores  may  appear  after  what  may  seem  to  them 
but  a  trifling  neglect. 

AVhen  bed-sores  have  formed  the  treatment  is  in  medical  hands.  The 
nurse  may  be  desired  to  apply  charcoal  poultices  to  separate  sloughs, 
and  to  irrigate  the  wound  with  creoline  Jg.  carbolic  or  sanitas,  cutting 
away  the  slough  as  it  becomes  loose.  She  may  have  to  protect  bony 
excrescences  by  pads  made  of  several  layers  of  lint,  Avith  a  hole  in  the 
centre  over  the  wound,  secured  by  strapping,  and  not  removed,  if  pos- 
sible, for  two  or  three  days.  Iodoform  and  dressings  of  resin,  zinc,  or 
other  ointments  may  be  ordered,  and  in  such  cases  the  dressings  must 
be  laid  on  the  wound  only. 

The  physician  or  surgeon  requires  faithful  reports  of  all  that  occurs 
to  the  patient  between  his  visits — hence  the  importance  of  a  nurse 
trained  to  accurate  observations  and  statements,  familiar  with  symptoms, 
and  aware  of  their  practical  indications. 

For  example,  in  enteric  fever  the  physician  should  be  informed  oi\ 
the  following  points  :  — 

1.  Temperature,  every  four  hours,  in  mouth  or  axilla,  as  desired. 

2.  Pulse,  at  same  intervals,  with  statement  as  to  strength  and  vari- 

ation, if  any,  at  any  stated  times ;  or  after  food,  drugs,  stimu- 
lants, etc. 

3.  Respirations,  at  same  intervals  ;  cough  is  important  as  a  warnin;^ 

of  lung  complications. 

4.  Stools.     Frequency,  colour,  and  character,  noting  if  undigested 

food  be  passed,  blood,  etc.     If  much  flatulence. 

5.  Amount  of  urine  and  its  colour  —  Avatch  for  symptoms  of  retention. 

6.  Vomiting.     Frequency  and  nature,  whether  rejected  food,  such  as 

curdled  milk,  or  "  coffee  grounds,''  etc. 

7.  Any  eruption,  characteristic  or  otherwise,  to  be  watched  for  and 

reported ;  also  abdominal  pain,  tenderness  or  distension. 

8.  Amount   of   sleep,    exactly :    its   character  —  restless    or   quiet ; 

whether  delirium,  muttering,  twitching  of  muscles  ;    also,  man- 
ner of  waking  —  quietly  or  with  a  start. 

9.  Conditionof  skin,  dry  or  moist —  of  tongue,  and  amount  of  sordes 

on  teeth.  The  mouth  and  teeth  should  be  frequently  cleansed 
by  lint  or  linen  wrapped  round  the  forceps  dipped  in  the 
lotion,  and  gently  passed  round  the  mouth ;  and,  if  able,  the 
patient  should  be  encouraged  to  rinse  the  mouth  and  gargle 
with  the  prescribed  wash. 
10.  The  exact  kind  and  amount  in  ounces  of  the  nourishment  taken, 
the  hours  when  it  was  given,  and  the  readiness  or  otherwise 
of  the  patient  for  it;  also,  the  amount  of  stimulant  and 
medicine,  and  the  times  of  each. 


NURSING  433 


11.  Effect  of  any  drug  prescribed  for  temperature  and  pulse ;  or,  if 

for  sleep,  when  sleep  is  induced,  how  long  after,  and  for  what 
length  of  time. 

12.  Effect  of  sponging,  if  ordered ;  when  done,  for  how  long,  and  the 

result  as  shown  by  temperature,  pulse,  respiration,  sleep,  and 
general  condition. 

Such  a  report  should  be  written  both  by  the  day  and  by  the 
night  nurses  for  each  other,  to  ensure  that  no  important  change  is 
overlooked. 

In  Pneumonia  the  rules  for  temperature,  pulse,  and  respiration 
would  be  the  same,  with  a  report  on  cough,  expectoration  (its  colour, 
consistency,  whether  difficult,  profuse  or  the  reverse) ;  pain  in  any 
particular  place ;  effect  of  hot  or  cold  applications ;  amount  of  sleep ; 
amount  of  nourishment ;  evacuations,  etc. 

In  acute  Rheuynatism,  temperature,  respiration,  and  pulse ;  pain,  its 
locality  and  intensity,  specially  if  in  cardiac  region  ;  breathlessness  on 
the  least  exertion;  state  of  joints;  evacuations;  condition  of  urine ;  ac- 
tion of  skin,  etc.  Effect  of  medicine,  and  any  special  symptoms  con- 
nected with  it,  such  as  deafness  and  noises  in  the  head  after  salicylate 
of  soda,  quinine,  etc.  Effect  of  sponging  or  other  treatment,  amount 
of  sleep,  exact  amount  of  nourishment,  etc.  Nothing  is  too  small  to 
report,  especially  with  regard  to  the  action  of  medicines  and  drugs. 

Effect  of  certain  Drugs.  —  The  nurse  should  be  able  to  recognise  the 
more  important  effects  of  these,  such  as  — • 

In  connection  with  oj)ium  —  drowsiness,  contraction  of  the  pupils, 
heavy  breathing,  constipation. 

While  digitalis  is  being  taken  the  pulse  must  be  carefully  noted. 

Diarrhoea  or  sickness  may  result  from  the  use  of  arsenic. 

Quinine  may  produce  headache  or  noises  in  the  head. 

Salicin  or  the  salicylates  —  deafness,  excessive  perspiration,  and 
headache. 

Mercurial  treatment  may  produce  tenderness  of  the  gums,  salivation 
and  diarrhoea. 

Iron  preparations  turn  the  tongue  black,  and  produce  very  dark, 
almost  black  stools.     Bismuth  has  a  like  effect. 

When  antipyrin  and  like  febrifuges  are  given,  the  nurse  must  watch 
for  any  symptoms  of  collapse,  as  occasionally  patients  do  not  bear  such 
drugs  well. 

In  administering  medicine  the  nurse  should  ascertain  Avhether  it  is 
to  be  given  before  or  after  food.  Quinine  is  usually  taken  before  a 
meal,  iron  and  arsenic  afterwards.  Cod  liver  oil  is  digested  more 
readily  after  food. 

Administering  of  Medicines.  —  All  medicines  must  be  accurately 
measured  in  a  graduated  glass,  as  spoons  vary  greatly  in  size.  ''Drops" 
also  must  be  measured  in  a  minim  glass.  The  glasses  must  be  washed 
directly  after  use,  and,  if  in  a  ward,  between  each  patient.  Medicine 
bottles  should  never  be  put  down  near  lotion  or  liniment  bottles. 

VOL,    I  2    F 


434  SYSTEM  OF  MEDICINE 

The  special  applications  required  in  nursing  are  many,  and  a  trained 
nurse  should  know  the  best  possible  way  of  dealing  with  them. 

Poultices  need  dexterity  to  make  them  of  the  right  size  and  weight 
for  the  case.  If  jacket  poultices  be  ordered,  the  nurse  must  prepare  two 
pieces  of  calico,  shaped  at  the  neck  and  under  the  arms,  so  that  the  poul- 
tice covers  the  sides  of  the  chest  from  the  axilla  downwards.  Two  pieces 
of  thin  mackintosh,  a  little  larger  and  similarly  shaped,  sufficient  cotton 
wool  to  cover  both  chest  and  back,  a  poultice  jacket,  safety  pins,  linseed 
meal,  a  spatula  (ordinary  painter's),  a  basin,  and  boiling  water  are  also 
needed,  and,  if  the  poultice  be  made  at  any  distance  from  the  patient,  two 
hot  plates.  The  basin  and  spatula  must  be  made  hot,  sufficient  boiling  water 
poured  in  to  make  the  required  poultice  (about  |  pint  for  an  adult),  and  the 
linseed  sprinkled  in,  being  well  stirred  all  the  time.  A  well-made  poultice 
when  turned  out  should  leave  the  basin  quite  clean.  It  is  then  quickly  and 
evenly  spread  by  the  spatula,  the  edges  (not  more  than  half  an  inch  wide), 
neatly  turned  over,  rolled  up,  placed  between  the  hot  plates  if  necessary,  and 
brought  to  the  patient.  He  must  previously  have  been  placed  on  one  side, 
with  the  night-shirt  ready  to  be  pulled  well  up  at  the  back,  if  he  be  too 
weak  to  have  it  removed.  The  poultice  is  then  half  unrolled  and  applied, 
care  being  taken  not  to  injure  the  skin,  though  this  is  not  likely  if  the 
poultice  be  not  too  wet.  It  is  next  covered  with  the  jaconet  and  a  layer 
of  cotton  wool,  both  half  rolled,  also  with  the  poultice  jacket ;  the  shirt 
is  then  pulled  down,  the  patient  turned  on  his  back,  and  the  rolled  part 
of  poultice,  wool,  etc.,  brought  round  to  the  other  side.  The  front  half 
of  the  poultice  is  made  in  the  same  way,  applied  to  the  chest,  covered  with 
jaconet,  wool,  and  the  jacket;  then  both  are  secured  by  safety  pins  on 
each  shoulder,  and  down  the  sides,  the  poultice  jacket  being  pinned 
down  the  front.  The  shirt  is  drawn  down,  and  the  patient  should  have 
some  nourishment  after  the  fatigue.  Well-made  poultices  thus  applied 
retain  their  heat  for  many  hours.  Sometimes  the  poultice  is  placed  in 
a  bag  of  flannel,  but  these  require  more  frequent  changing,  and  more 
care  lest  the  skin  be  injured  by  applying  it  too  hot.  A  little  oil  spread 
over  the  linseed  is  soothing  if  the  skin  is  becoming  tender. 

"  Poultice  ^^  or  '^  Pneumonia  jackets  ^^  are  garments  made  of  a  strip  of 
thin  flannel  or  flannelette,  the  right  width  for  the  patient,  shaped  at 
the  neck,  and  well  cut  out  under  the  arms,  meeting  in  front  and  over- 
lapping a  little.  They  are  lined  with  a  layer  of  cotton  wool  neatly 
tacked  in,  and  can  easily  be  placed  over  the  poultice,  and  secured  on 
the  shoulders  and  down  the  front  by  safety  pins,  which  are  firmer  and 
more  comfortable  than  tapes.  In  bronchitis  cases  also  this  is  useful, 
and  the  poultices  can  be  changed  without  removing  the  jacket.  In 
pleurisy  a  band  of  flannel  pinned  firmly  round  the  lower  ribs  gives 
relief  by  restraining  muscular  movements. 

Charcoal  poultices  are  made  of  equal  parts  of  charcoal  and  linseed 
mixed  in  the  same  way  —  usually  ordered  for  sloughing  wounds. 

Mustard  poultices  are  conveniently  made  by  adding  the  proportion 
of  mustard  ordered  to  the  boiling  water,  and  then  stirring  in  the  linseed. 


NURSING  435 


Mustard  plasters  are  made  by  spreading  thickly-mixed  mustard  on  a 
square  of  brown  paper  of  the  exact  size  ordered,  and  covering  it  with  a 
piece  of  muslin.  Mustard  and  any  proportion  of  flour  may  also  be 
mixed  and  applied  in  the  same  way.  Mustard  leaves  are  dipped  in 
tepid  water  and  placed  on  the  spot.  These  applications  are  left  from 
ten  to  twenty  minutes,  as  ordered;  and,  after  removal,  the  skin  must 
be  covered  with  a  layer  of  cotton  wool. 

Bread  poultices  are  conveniently  made  by  placing  the  crumb  of  white 
bread  (stale  if  possible)  on  a  piece  of  calico  or  small  towel  across  a  basin, 
pouring  boiling  water  over  it,  wringing  as  dry  as  possible,  placing  be- 
tween muslin,  and  applying,  with  jaconet  and  wool  over,  as  before. 

Blisters.  —  In  applying  blistering  fluid,  none  must  touch  the  skin 
except  at  the  place  ordered,  and  the  cover  of  cotton  wool  must  not  be 
strapped  at  all  tightly,  or  pain  will  ensue  as  the  blister  rises.  If  a 
plaster  be  used,  and  the  blister  do  not  rise,  after  an  hour  a  small  poultice 
may  be  applied,  which  usually  produces  the  desired  effect.  In  cutting 
the  raised  cuticle,  the  small  snip  should  be  at  the  lowest  side  of  the 
blister,  and  wool  arranged  to  catch  the  fluid.  If  it  is  to  be  kept  open, 
all  the  raised  skin  must  be  cut  off,  and  the  dressing  applied  exactly  to 
the  sore :  if  not,  a  simple  ointment  dressing  is  usually  put  over  the  skin, 
and  secured  by  wool  and  strips  of  strapping. 

Liniments  must  be  applied  always  to  both  chest  walls  if  ordered  for 
bronchitis,  etc.,  and  in  every  case  rubbed  in  with  the  palm  and  not  with 
the  fingers.  Painting  with  iodine  must  not  be  continued  without  orders 
when  smarting  follows  the  application. 

Fomentations  and  stupes  are  conveniently  made  of  a  length  of  flan- 
nel doubled.  This  is  placed  on  a  strong  towel  over  a  basin,  boiling 
water  poured  over  it,  and  the  towel  then  wrung  out  quite  tightly ;  a 
good  wringer  is  made  by  a  strip  of  ticking  sewn  at  both  ends,  and  a 
stick  passed  through  each.  They  are  applied  to  the  painful  place, 
covered  with  thin  mackintosh  or  jaconet,  —  at  least  one  inch  wider  in 
every  direction  than  the  fomentation,  —  and  a  layer  of  cotton  wool ;  and 
are  kept  in  position  by  a  flannel  binder  or  bandage.  Such  stupes  may 
be  made  with  decoction  of  boiling  poppy-heads,  or  may  be  sprinkled 
quickly  with  40  to  50  ^  turpentine  or  10  to  30  i^L  tinct.  opii,  as  may  be 
ordered,  just  before  application. 

In  applying  leeches,  the  skin  must  be  well  washed  with  hot  water, 
and  plain  (not  scented)  soap ;  the  leech  is  placed  in  a  test  tube,  medicine 
glass,  or  small  tumbler,  half  full  of  cotton  wool,  held  over  the  place.  If 
slow  in  biting,  a  little  milk  may  be  placed  on  the  patient's  skin,  which 
usuaHy  succeeds  if  the  leeches  are  good  ones.  They  fall  off  when  full, 
but  if  they  remain  too  long,  a  little  salt  sprinkled  on  them  will  remove 
them  at  once.  They  should  be  handled  as  little  as  possible  before  being 
applied. 

Orders  will  be  given  about  the  amount  of  bleeding  desirable  —  a 
warm  poultice  over  the  bites  encourages  it.  If  to  be  arrested,  a  very 
small  piece  of  cotton  wool,  a  mere  film,  placed  in  the  bite  generally 


436  SYSTEM  OF  MEDICINE 

causes  coagulation.  Failing  this,  pressure,  cold  applications,  or  a 
styptic,  such  as  balsam  of  Peru,  may  be  tried,  and  the  medical  attend- 
ant miist  be  informed.  Leech  bites  must  be  noticed  from  time  to  time 
for  some  hours  lest  the  bleeding  begin  again.  The  patient  should  not 
be  alarmed  or  agitated,  either  in  the  application  of  the  leeches  or  in 
controlling  the  bleeding.  If  leeches  are  pulled  off  they  are  apt  to  leave 
their  teeth,  which  form  a  tiresome  little  wound. 

Dry  cupping  is  done  by  exhaust  glasses,  or  by  placing  in  a  cupping 
glass  or  small  tumbler  a  small  piece  of  blotting  paper  dipped  in  methy- 
lated spirit,  setting  it  alight,  and  at  once  applying.  The  edges  of  the 
glass  should  be  previously  oiled,  and  it  is  easily  removed  by  pressing 
away  the  skin  from  the  edge,  and  allowing  air  to  enter. 

In  administering  enemata,  the  nurse  should  be  able  to  give  them 
equally  well  whether  the  patient  is  lying  on  the  back  or  side.  Gener- 
ally, however,  he  is  placed  on  the  left  side,  with  the  buttocks  close  to 
the  edge  of  the  bed,  and  the  knees  flexed.  The  nurse,  having  the 
enema  ready,  lubricates  the  nozzle  of  the  syringe  with  a  little  oil  or 
vaseline,  and  seeing  that  it  is  full,  so  as  not  to  inject  air,  with  the  fore- 
finger of  her  left  hand,  also  lubricated,  ascertains  the  entrance  to  the 
rectum,  and  gently  inserts  the  nozzle  with  her  right  hand.  Great  care 
must  be  taken  if  haemorrhoids,  fistula,  or  fissure  be  present,  all  exqui- 
sitely tender.  In  cases  of  fsecal  accumulation,  the  nurse  may  be  desired 
to  break  up  the  mass  gently  with  her  finger  well  oiled,  and  her  nail  filled 
with  carbolic  soap ;  she  must  also  give  the  enema  at  intervals.  When 
this  is  so,  or  when  there  is  irritability  of  the  bowel,  or  relaxation  of  the 
sphincters,  the  gum  elastic  tube  supplied  with  the  Higginson  syringe  is 
useful.  It  is  softened  by  immersion  in  hot  water,  well  oiled,  fixed  to 
the  syringe  or  irrigator,  and  gently  inserted.  I  find  this  tube  safer  and 
better  to  use  as  a  general  rule.  Indeed  the  short,  hard  bone  nozzles 
usually  supplied  for  rectal  use,  are  not  to  be  recommended :  it  is  better 
always  to  draw  three  or  four  inches  of  stout  rubber  tubing  over  them 
before  insertion.  The  bed  should  be  specially  protected  by  a  mackintosh 
and  folded  sheet.  Restoratives  should  be  within  reach  as  some  patients 
turn  faint  after  the  operation.  In  this,  as  in  douching,  washing  backs, 
etc.,  no  exposure  of  the  patient  is  necessary  or  justifiable. 

Simple  enemata  should  not  be  made  with  scented  or  medicated  soaps, 
curd  or  yellow  is  the  best. 

Starch  enemata  a.re  made  by  mixing  from  a  teaspoonful  to  a  table- 
spoonful  of  starch  powder,  according  to  the  quantity  required,  with  a 
little  cold  water  into  a  smooth  paste,  and  then  adding  boiling  water 
until  a  mucilage  is  formed,  to  which  the  special  medication  is  added. 
For  a  starch  and  turpentine  enema,  5  j-  turpentine  to  5xv.  starch  muci- 
lage may  be  ordered ;  for  a  starch  and  opium,  the  prescribed  number  of 
minims  of  opium  are  added  to  the  prescribed  number  of  ounces  of  starch 
mucilage. 

Castor  and  olive  oil  enemata  are  conveniently  given  by  warming  the 
oil  in  a  cup,  and  then  placing  the  cup  in  the  basin  containing  the  simple 


NURSING  437 


enema  which  usually  accompanies  the  oil.  The  end  of  the  syringe  is 
readily  transferred  from  the  water  to  the  cup  after  %'\\.  or  5iij-  have 
been  injected;  and  when  the  oil  has  been  given,  it  is  readily  replaced 
in  the  water  without  fear  of  admitting  air. 

In  rectal  feeding  it  is  desirable,  when  possible,  first  to  wash  out  the 
lower  bowel  by  a  small  enema  of  warm  water.  The  quantity  and 
materials  of  a  nutrient  enemata  vary  according  to  sjjecial  orders ;  they 
are  most  easily  given  by  a  ball  syringe  holding  the  right  number  of 
ounces.  The  tube,  being  longer  and  thinner  than  that  of  the  ordinary 
syringe,  is  less  likely  to  irritate  the  bowel,  and  cause  the  enema  to 
be  returned.  It  must  be  carefully  cleansed  after  use  each  time.  Nu- 
trient enemata  must  be  given  very  slowly  to  ensure  retention,  not  a 
bubble  of  air  should  find  its  way  into  the  bowel,  and  a  napkin  should 
be  held  to  the  anus  for  a  few  minutes  after :  in  all  these  applications 
great  gentleness  is  essential. 

Glycerine  enemata  are  usually  given  in  a  special  syringe  holding  the 
exact  amount  required. 

In  nasal  feeding  the  nurse  must  be  careful  that  the  tube  is  really  in 
the  oesophagus,  and  only  administer  3j.  to  3ij.  at  a  time.  Nasal  feed- 
ing, however,  should  always  be  done  by  a  carefully  instructed  person, 
if  not  by  a  surgeon  \oide  art.  on  "  Dietetics,"  p.  387]. 

In  passing  the  female  catheter  the  vulva  must  first  be  thoroughly 
cleansed  with  warm  water,  and  a  disinfectant,  4-oVo  perchloride,  gL 
carbolic,  creolin,  or  Condy.  The  patient  should  lie  on  her  back  with 
the  knees  drawn  up,  though  in  some  cases  (e.g.  ruptured  perinaeum), 
she  is  better  on  her  left  side.  The  catheter  —  generally  a  gum-elastic 
or  flexible  india-rubber  one,  size  seven  or  eight  —  must  be  perfectly 
clean,  not  rough  at  all  on  the  surface,  and  soaked  before  using 
in  4-oV-o  perchl.  or  J-g-  carbolic.  It  is  lubricated  with  carbolised 
glycerine  or  vaseline,  and  the  nurse,  holding  it  in  one  hand,  with 
the  index  finger  of  the  other  also  lubricated,  finds  the  entrance 
to  the  vagina;  just  above  this  the  hard  round  meatus  urinarius  (with 
its  depressed  central  orifice)  is  easily  felt,  and  the  catheter  passed  into 
it,  the  other  end  being  placed  in  a  convenient  receptacle.  If  there  be 
much  vaginal  discharge,  or  the  nurse  cannot  pass  the  catheter  into  the 
orifice  at  once,  the  catheter  must  be  thoroughly  recleansed,  and  the 
nurse,  separating  the  labia,  must  ascertain  the  position  of  the  meatus 
by  the  eye,  and  insert  the  catheter  after  carefully  wiping  all  discharge 
away;  it  is  most  important  that  no  discharge  be  carried  into  the 
bladder,  as  there  is  great  danger  of  cystitis  if  the  strictest  cleanliness 
is  not  observed.  Glass  catheters  can  be  boiled  each  time  after  use,  and 
no  impurity  can  remain  unnoticed,  but  there  is  danger  in  their  fra- 
gility. A  catheter  must  be  thoroughly  cleansed  in  warm  water,  held 
under  a  tajj  to  allow  the  water  to  run  from  the  eye  downwards  for  a 
few  minutes,  and  then  placed  in  a  disinfectant.  If  boracic  lotion  be 
used,  care  must  be  taken  that  crystals  do  not  become  deposited  on  the 
catheter,  as  one  used  in  this  condition  may  injure  the  urethra.     Any 


438  SYSTEM   OF  MEDICINE 

marked  tenderness  in  passing  the  catheter  must  be  reported,  as  it  may 
be  due  to  urethral  caruncle  or  other  special  cause. 

In  luashing  out  the  female  bladder  the  catheter  is  passed  in  the  usual 
way,  and  the  water  drawn  off.  The  nurse  has  ready  in  a  jug  the  pre- 
scribed quantity  of  the  warm  lotion  to  be  used  (frequently  "  boracic  "), 
and  an  india-rubber  tube,  about  one  yard  long,  to  which  is  attached  a 
glass  funnel  holding  §  iv.  to  5  vj.  The  free  end  of  the  catheter  is  placed 
in  the  tube,  which  the  nurse  compresses  a  few  inches  above  the  catheter 
between  the  second  and  third  fingers  of  her  left  hand,  holding  the  funnel 
between  her  thumb  and  index  linger.  With  the  right  hand  she  fills 
the  funnel  and  tube  from  the  jug,  and  then,  releasing  the  tube  and 
raising  the  funnel,  she  allows  the  lotion  to  flow  into  the  bladder,  com- 
pressing the  tube  again  just  before  the  funnel  empties  itself.  After 
repeating  this  once,  or  even  twice,  she  removes  the  tubing  from  the 
catheter,  and  allows  the  bladder  to  empty  itself.  It  is  wise  to  have  a 
glass  measure  to  receive  the  contents  of  the  bladder,  in  order  to  ascer- 
tain either  that  no  lotion  remains  or  only  the  right  number  of  ounces 
ordered.  The  tube  is  then  readjusted,  and  the  process  repeated  until 
the  prescribed  quantity  of  lotion  has  been  used.  The  nurse  must  care- 
fully examine  the  catheter  lest  the  eye  become  blocked  by  mucus,  as  is 
often  the  case  in  cystitis. 

In  giving  vaginal  douches  the  nurse  should  protect  the  bed  with 
a  piece  of  mackintosh  and  folded  sheet.  The  patient  should  lie  on 
her  back,  with  head  rather  low,  and  a  pillow  under  the  loins.  The 
bed-pan  should  be  warmed  before  being  used,  and  a  towel  be  at  hand. 

Having  prepared  the  douche  as  ordered,  testing  its  heat  by  the  bath 
thermometer,  and,  if  of  Condy's  fluid,  not  making  it  too  strong  (3j.  to 
Oj.  of  the  fluid,  or  two  or  three  crystals  of  the  permanganate),  the  nurse 
lubricates  the  glass  nozzle  with  carbolised  glycerine  or  vaseline,  and 
allows  it  to  fill  with  the  lotion,  to  exclude  air.  Having  placed  the 
irrigator  at  a  convenient  height  above  the  bed,  she  inserts  the  tube 
gently  into  the  vagina,  unless  the  patient  prefer  to  do  it  herself,  which 
may  be  better  in  cases  of  cancer,  etc.,  where  there  is  great  tenderness. 
The  tap  is  then  turned,  the  douche  given,  and  the  tube  removed  with- 
out allowing  any  air  to  enter.  If  a  Higginson's  syringe  be  used,  the 
glass  nozzle  is  easily  fixed  to  it  by  removing  the  bone  nozzle,  and  putting 
the  glass  into  the  india-rubber  tube ;  it  is  then  filled  with  lotion,  and  in- 
serted in  the  same  way.  The  douche  is  conveniently  contained  in  a  jug 
supported  at  the  side  of  the  bed.  Glass  nozzles  (Avithout  a  terminal 
hole,  lest  the  nurse  unwittingly  administer  an  intra-uterme  douche)  are 
the  cleanest  and  safest,  as  they  can  be  boiled  and  left  to  soak  in  disin- 
fectant until  wanted.  If  hot  douches  are  ordered  (110°  F.),  the  vulva 
may  be  smeared  with  a  little  carbolised  vaseline  to  protect  the  skin, 
which  is  often  very  sensitive.  The  bath  thermometer  should  invariably 
be  used,  and  a  careful  report  given  of  the  result  of  the  douche. 

Vaginal  plugs  and  tampons  are  made  of  absorbent  cotton  wool, 
rolled  into  the  required  shape,  and  secured  by  linen  thread.     Tampons 


NURSING  439 


are  pear-shaped  with,  the  thread  attached  to  the  lower  end,  and  are 
generally  used  for  applying  medications  to  the  vaginal  walls.  Plugs 
may  be  made  by  turning  in  the  edges  of  a  square  of  wool,  and  forming 
it  into  a  sausage-shaped  roll  secured  in  the  middle  by  a  long  thread. 
For  supporting  the  uterus  and  packing  round  the  cervix  several  of  these 
rolls  are  attached  to  the  one  string,  forming  the  "kite  tail"  plug.  For 
plugging  with  a  speculum,  rounds  of  cotton  wool,  of  varying  sizes,  with 
the  thread  passed  through  the  middle,  are  convenient.  In  every  case  the 
threads  should  be  long  enough  to  be  well  beyond  the  vagina,  and  the 
exact  number  of  plugs  inserted  noted  down. 

Gynaecological  Work.  —  A  nurse  should  understand  how  to  arrange  a 
patient  for  examination,  bringing  her  well  to  the  edge  of  the  bed  on  her 
left  side,  the  spine  as  nearly  as  possible  in  a  line  with  it,  the  knees 
flexed,  tlie  right  one  being  rather  more  drawn  up  than  the  left,  and  the 
left  arm  brought  round  to  the  back,  so  that  the  patient  is  lying  almost 
on  her  chest. 

She  should  also  know  the  names  of  the  various  specula  (Ferguson, 
Sims,  etc.),  and  be  able  to  pass  them  if  required.  This  is  done  by  plac- 
ing the  two  first  fingers  of  the  left  hand,  previously  lubricated  with 
carbolised  vaseline  or  glj^cerine,  in  the  entrance  to  the  vagina,  and  draw- 
ing the  perinaeum  backwards  so  as  to  admit  the  edge  of  the  speculum, 
which  is  passed  gently  in  a  backward  direction,  holding  the  perinseum 
well  back  so  as  to  avoid  touching  the  clitoris,  or  causing  pain,  until  the 
OS  can  be  seen.  It  may  be  necessary  to  alter  the  position  of  the  speculum 
a  little,  if  a  "Ferguson,"  to  bring  the  os  into  view,  in  order  to  carry  out 
special  directions  for  plugging  round  the  cervix  in  any  given  way.  The 
nurse  must  be  able  to  prepare  uterine  probes  for  use,  by  placing  a  very 
thin  layer  of  cotton  wool  on  her  left  palm,  laying  the  probe  at  the  edge 
of  it,  and,  by  a  little  manipulation  and  rotation  of  the  instrument,  wrap- 
ping it  smoothly  and  firmly  round.  After  use  the  wool  is  removed  and 
fresh  supplied.  Medicated  bougies  are  placed  in  the  vagina  to  dis- 
solve. Suppositories  are  gently  passed  into  the  rectum,  the  finger  being 
previously  oiled. 

Hypodermic  injections  are  given,  after  seeing  the  needle  is  clean 
and  firmly  screwed  on,  by  first  accurately  filling  the  syringe,  and  then 
driving  the  fluid  to  the  point  of  the  needle  so  as  to  expel  the  air.  The 
skin,  previously  cleansed,  is  then  firmly  held  and  raised  into  a  fold,  while 
the  needle  is  gently  but  quickly  inserted  into  the  fold  in  a  direction 
nearly  parallel  with  the  surface,  and  pressed  onward  till  the  point  has 
passed  through  the  skin  into  the  subcutaneous  tissue ;  the  syringe  is 
then  emptied  and  withdrawn,  a  finger  being  placed  over  the  puncture  for 
a  minute  or  two.  If  the  needle  is  properly  inserted  below  the  skin  no 
bleeding  or  swelling  will  ensue.  The  same  care  must  be  taken  in 
purification  of  this  syringe  and  its  parts  as  of  other  instruments. 

Baths.  —  In  giving  baths  everything  must  be  ready  before  the 
patient  is  disturbed,  and  the  temperature  verified  by  the  thermometer. 
In  a  large  bath  the  hot  and  cold  water  must  be  well  mixed  before  this  is 


440  SYSTEM  OF  MEDICINE 

done,  and  on  no  pretext  whatever  should  any  patient  be  left  with  the 
taps  running.  The  cold  water  must  always  te  turned  on  first,  and  no 
patient  or  junior  assistant  should  ever  be  permitted  to  touch  the  taps. 
Except  under  special  circumstances  —  such  as  the  special  treatment  of 
fever,  and  then  only  by  the  charge  nurse  —  the  taps  should  never  be 
turned  after  the  bathing  has  commenced. 

Towels,  a  blanket,  and  if  necessary  a  screen  should  be  in  readiness. 
The  temperature  is  ordered  to  be  from  98°  to  110°  P.  for  hot  baths, 
92°  to  98°  warm,  85°  to  92°  tepid,  and  70°  cold,  and  the  water  must  be 
tested  by  the  thermometer  during  the  length  of  time  ordered.  That  the 
bath  may  not  fall  below  the  degrees  required,  the  water  should  stand  a 
little  above  these  limits  at  first,  and  should  have  lain  long  enough  in 
the  bath  to  warm  it  through.  Thick  stoneware  baths  absorb  a  larger 
quantity  of  heat.  The  patient  has  a  blanket  laid  over  him,  and  as  he 
is  lowered  into  the  bath,  this  remains  spread  across  it,  and  is  wrapped 
round  him  again  when  lifted  out. 

With  children  the  blanket  may  be  spread  over  the  bath  first,  and 
they  are  then  rolled  in  it  and  placed  in  the  bath. 

In  giving  a  hip-bath  the  same  arrangement  is  desirable,  and  a  small 
blanket  can  be  placed  over  the  shoulders  to  avoid  chill. 

Warm  towels  and  wrapping  in  a  blanket  are  desirable  after  hot  baths, 
the  bed  being  warmed  by  a  hot  bottle. 

In  cold  bathing  we  are  usually  ordered  to  lower  the  patient  in  a 
sheet  into  tepid  water  (75°  F.)  first,  and  to  reduce  the  temperature  by 
adding  cold  water  gradually. 

Of  special  baths  the  following  are  usually  ordered :  — 

(a)  Mustard,  Sij-  to  5iv.  to  every  4  gallons  water. 
(5)  Salt,  1  lb.  to  every  4  gallons  water. 

(c)  Alkaline,  carbonate  soda  or  potash,  5  ij.  to  §  iv.  to  every  4  gallons 
■water. 

(d)  Sulphur,  sulphide  of  calcium,  5  ij-  to  5  vj.  to  every  4  gallons  water. 

The  time  for  which  the  patient  remains  in  the  bath  is  ordered  by 
the  medical  attendant. 

Vapour  and  hot  air  baths  can  be  administered  in  bed,  by  covering  the 
mattress  with  a  waterproof  sheet  and  a  blanket.  The  patient  is  stripped 
and  placed  in  a  blanket,  with  another  over  him.  A  long  cradle  is  then 
placed  in  the  bed,  well  covered  with  blankets,  so  as  to  exclude  all  air 
except  at  the  foot,  where  a  funnel  over  a  special  lamp,  or  from  a  steam- 
kettle  on  a  lamp,  conveys  the  heated  air  into  the  bed.  Hot  drinks, 
such  as  milk,  hot  water,  etc.,  may  be  given  with  advantage  to  promote 
perspiration.  The  temperature  should  be  taken  before,  during,  and 
after ;  and  the  pulse  felt  at  intervals,  in  case  of  faintness.  After  the 
stated  time,  usually  from  twenty  to  thirty  minutes,  the  hot  air  or  steam 
is  withdrawn,  the  patient  wrapped  in  hot  dry  blankets,  and  left  a  while 
before  dressing  him  and  remaking  his  bed. 

If  the  bath  be  given  out  of  bed,  a  lamp,  specially  protected,  is  placed 


NURSING  441 


under  a  cane-chair,  which  is  covered  all  round  by  a  blanket;  the  patient 
is  undressed,  wrapped  in  blankets,  and  placed  on  it  with  a  screen  round. 
The  same  routine  is  followed  after  the  time  has  elapsed,  except  that  the 
bed  should  be  warmed  by  hot  bottles. 

Hot  and  cold  packs  are  given  by  placing  a  patient  on  a  bed  similarly 
prepared  as  for  the  air-bath,  and  enveloping  him  from  head  to  foot  in  a 
thin  blanket  wrung  out  of  hot  water  for  the  hot  pack,  or  a  sheet  wrung 
out  of  cold  for  the  cold  pack.  If  the  latter  be  to  reduce  the  temperature 
it  may  need  renewing  after  an  interval,  the  temperature  being  taken  in 
rectum  or  mouth,  before  and  at  frequent  intervals  during  the  process. 
A  cold  towel  should  be  on  the  head.  The  patient  in  both  cases  is  to  be 
left  for  a  time  before  being  dressed. 

Icebags  should  be  filled  with  small  pieces  of  ice,  and  have  a  piece  of 
lint  or  linen  between  them  and  the  skin.  If  for  the  head  they  must  not 
be  too  heavy,  and  may  be  tied  to  the  top  of  the  bed  to  support  them. 
They  must  never  be  left  until  the  ice  is  all  melted. 

A  tent  and  steam  kettle  are  often  ordered  for  bronchitis,  tracheotomy, 
etc.,  and  can  be  made  of  folding  screens  covered  by  quilts  or  blankets 
so  as  to  exclude  all  draught,  and  enable  the  space  to  be  filled  with 
steam.  The  kettle  must  not  be  too  high  above  the  patient,  or  in  a 
position  to  allow  it  to  drop  or  spurt  on  him;  especially  with  young 
children  an  equable  temperature  must  be  maintained,  and  the  supply 
of  steam  be  constant. 

Inhalations  are  given  in  an  inhaler,  or  in  a  jug  with  a  towel  placed 
round  it  so  that  the  patient  breathes  only  the  steam.  Water  at  140°  F. 
must  always  be  used,  and  care  taken  that  a  weak  patient  does  not  be- 
come faint  by  bending  over  too  much  in  a  crouching  attitude.  The 
nurse  should  be  familiar  with  the  use  of  asthma  powders,  nitrite  of 
amyl  capsules,  etc. 

Sick  Cookery.  —  Gruel.  —  A  nurse  should  understand  the  making  of 
gruel  by  mixing  the  fine  oatmeal  or  grouts  into  a  smooth  paste  with  a 
little  cold  milk  or  water,  and  then  pouring  it  into  the  boiling  milk  or 
water,  and  letting  it  boil  some  minutes  after  thickening,  stirring  mean- 
while to  keep  it  smooth.  Arrowroot  and  cornflour  are  prepared  in  the 
same  way.  White  wine  whey  is  made  by  adding  ^iv.  sherry  to  a  pint 
of  milk  just  as  it  boils,  and  then  straining  through  muslin. 

Junket  is  made  by  adding  a  few  drops  of  rennet  to  a  pint  of  luke- 
warm milk,  and  letting  it  stand. 

Peptonising  milk,  gruel,  etc.,  is  the  nurse's  duty,  and  is  conveniently 
done  by  means  of  the  various  powders  or  peptonising  fluids,  according 
to  printed  rules.  The  food  must  not  stand  too  long,  or  it  will  become 
bitter;  the  process  is  checked  either  by  boiling  for  a  few  minutes,  or 
placing  in  ice. 

The  preparation  of  raw  beef  tea,  scraped  raw  beef  (given  with  brown 
sugar  in  certain  cases),  raw  meat  juice,  beef  tea,  mutton  broth,  veal 
tea,  chicken  broth,  chickf^n  jclly,  custards,  etc.,  are  all  necessary.  The 
nurse's    duty   is    to    give    the  nourishment  in  an  appetising  manner. 


442  SYSTEM  OF  MEDICINE 

Dainty  arrangements,  small  quantities,  served  regularly  and  punctually, 
with  as  much  variety  as  possible,  and  absolute  cleanliness  of  every  detail, 
are  essential.  The  nurse  must  never  touch  the  food  with  the  finger,  or  taste 
it  with  the  patient's  spoon  to  test  its  temperature.  In  feeding  a  patient 
whose  head  is  on  the  pillow,  the  nurse's  hand,  raising  the  head,  must  be 
put  under  the  pillow.  The  food  must  be  cautiously  given,  but  the  food 
must  not  be  dribbled  ineffectually  or  too  slowly  into  the  mouth. 

The  disinfection  of  sputa  from  phthisical  patients  is  a  necessary  pre- 
caution. The  best  spittoons  are  white  mugs  with  an  inverted  conical 
lid.  A  disinfectant,  such  as  "-g-V  carbolic"  or  3ij.  creoline  in  5j.  water 
can  be  used,  and.  the  whole  utensil  is  easily  cleansed.  Stiff  paper  may 
be  folded  for  the  same  use,  but  it  is  not  so  sightly,  and  does  not  allow 
the  sputa  to  pass  readily  into  the  disinfectant.  All  handkerchiefs  used 
by  such  patients  should  be  placed  in  Jy  carbolic  at  once. 

Typhoid  stools  must  be  freely  covered  by  strong  carbolic,  or  a  solu- 
tion of  sulphate  of  iron,  and  allowed  to  stand,  if  possible,  about  twenty 
minutes  before  being  emptied  into  the  drain.  The  utensil  must  be 
closely  covered. 

It  is  usual  to  have  a  sheet  wrung  out  of  J„  carbolic  or  creoline  (  §  iv. 
to  0  vj.  to  1  gallon  of  water)  over  the  door  of  a  room  in  which  there  is  an 
infectious  case.  Sheets  on  folding  screens  may  be  placed  round  a  septic 
case  in  a  ward  until  it  can  be  removed.  The  carbolic  spray  is  sometimes 
ordered  also.  All  bed-linen,  and  whatever  has  been  worn  by  an  infec- 
tious patient,  must  be  immersed  in  carbolic  or  other  disinfectant  at  the 
bedside ;  they  must  not  be  carried  across  the  ward  first.  Special  cups, 
glasses,  etc.,  must  be  kept,  and,  if  necessary,  boiled  or  heated  in  the 
oven  before  using  again. 

Bedding,  outer  garments,  etc.,  are  best  purified  by  the  special  appa- 
ratus which  is  provided  in  most  hospitals,  and  in  connection  with  the 
vestries. 

A  nurse  in  attendance  on  infectious  cases  must  take  a  carbolic  bath, 
(not  forgetting  her  hair),  change  every  article  of  clothing,  have  all  gar- 
ments worn  in  the  room  disinfected,  and  if  possible  have  some  days' 
interval  before  returning  to  general  work.  She  must  not  eat  in  the 
room  of  an  infectious  case,  her  hands  must  be  thoroughly  cleansed  after 
contact  with  the  patient,  and  she  must  rinse  the  mouth  and  gargle  with 
Condy's  fluid  (§j.  to  Oj.)  at  intervals. 

The  nursing  of  children  calls  for  special  watchfulness,  and  that  keen 
and  sympathetic  power  of  observation  which  can  distinguish  between 
fretf ulness  and  pain,  hunger  and  temper,  caprice  and  loss  of  appetite, 
etc.  In  nursing  fretful  children  kindness  is  essential.  I  need  scarcely 
say  that  corporal  punishment  should  never  be  administered. 

One  very  common  error  is  moving  sick  children  about  too  much.  A 
nurse  who  would  not  dream  of  giving  unnecessary  exertion  to  an  adult 
with  acute  bronchitis  or  pneumonia,  will  not  realise  there  is  harm  in 
raising  a  child  similarly  affected  into  a  sitting  position  to  change  linen, 
poultices,  and  so  forth ;  and  will  even  take  it  out  of  bed  to  wash  it  on 


NURSING  443 


her  knee  by  the  fire,  forgetting  that  if  easy  to  her  to  lift  and  move  a 
child,  it  by  no  means  follows  that  it  is  easy  to  the  child.  Sick  children 
should  be  handled  as  nearly  like  adults  as  possible.  Special  care  is 
necessary  to  keep  them  dry  and  clean ;  every  two  hours  by  day  they 
should  be  attended  to  except  Avhen  sleeping  soundly  —  when  four  hours 
may  elapse  —  and  twice  at  least  during  the  night.  Attention  after  each 
meal  is  desirable,  and  the  habit  of  regularity  taught  as  far  as  may  be. 
Careful  washing  and  powdering  are  essential.  Flannel  or  flannelette 
night-gowns  made  long,  and  even  to  button  below  the  feet,  prevent  chill 
when  a  restless  child  throws  off  the  bed-clothes  in  its  sleep.  When 
dressing  wounds,  the  attention  of  the  child  should  be  diverted  as  much 
as  possible,  half  the  crying  is  from  fright  rather  than  pain.  Also  chil- 
dren should  never  be  deceived  with  regard  to  pain,  the  taste  of  medi- 
cine, and  the  like ;  if  they  find  they  have  been  told  what  is  untrue  the 
power  of  the  nurse  is  gone. 

In  clothing  infants,  whose  ribs  are  very  yielding,  there  should  be 
nothing  tight  round  the  chest  or  waist ;  and  the  legs  and  thighs  should 
always  be  covered  with  flannel  or  wool,  not,  as  is  usual,  left  naked  while 
the  chest  is  swathed  in  layers  of  useless  clothing. 

In  feeding  children  they  must  be  induced  to  take  the  amount 
ordered ;  firmness  and  kindness  go  far  to  succeed  in  this. 

When,  in  whooping-cough,  food  is  rejected  from  the  stomach,  it  is 
well  to  give  more  as  soon  as  a  paroxysm  is  well  over,  to  ensnre  that  some 
be  assimilated  before  the  next  fit  of  coughing.  In  convulsions,  when  a 
bath  is  ordered,  it  ought  to  be  from  90°  to  95°,  deep  enough  to  immerse 
the  child  up  to  the  neck,  and  the  thermometer  kept  steady  by  adding 
more  hot  water  from  a  can,  not  from  a  tap;  a  blanket  is  thrown  over 
the  bath,  and  cold  or  iced  applications  may  be  placed  on  the  head. 

It  is  essential  to  remember  that  the  stomach  of  an  infant  a  few 
weeks  old  only  holds  a  small  quantity  of  fluid,  and  no  more  than  §  j. 
to  Sij.  should  be  given  at  one  time  or  vomiting  will  follow. 

In  feeding  infants  by  hand  the  bottles  must  be  scrupulously  clean ; 
those  with  the  teat  on  the  bottle  are  the  best ;  the  tubes  of  the  ordinary 
shape  are  difficult  to  clean.  In  either  case  two  must  be  kept,  one  being 
soaked  in  cold  water  after  a  thorough  cleansing  in  hot  soda  and  water 
while  the  other  is  in  use. 

In  cases  of  diphtheria  great  care  must  be  taken  that  none  of  the 
discharge  or  mucus  is  coughed  or  spat  into  the  nurse's  eyes  or  face, 
especially  during  feeding,  and  the  nurse  must  not  put  her  face  close  to 
that  of  the  child. 

In  cases  of  tracheotomy  the  nurse  must  keep  the  temperature  of  the 
room  perfectly  equable,  and  the  steam  kettle,  usually  charged  with  a 
disinfectant,  always  going.  A  small  piece  of  moist  sponge  over  the 
.  tube  is  generally  used,  and  is  frequently  changed.  The  tube  must  be 
kept  clean  from  membrane  and  mucus  by  means  of  feathers,  which 
should  stand  in  a  solution  of  carbonate  of  soda.  The  nurse  must  under- 
stand the  use  of  the  tube,  so  that  in  an  emergency  she  could  replace  it, 


444  SYSTEM  OF  MEDICINE 

or  at  the  worst  keep  the  tracheal  incision  open  with  her  forceps  till  the 
doctor  can  arrive.  The  child  must  be  regularly  fed,  kept  dry  and  clean, 
and  notice  taken  if  there  be  any  regurgitation  of  liquid  through  the  nose. 

Private  Nursing.  —  This  branch  of  the  profession  affects  the  general 
public  more  closely  than  any  other,  as  both  doctors  and  patients  depend 
almost  entirely  on  the  trustworthiness  and  experience  of  the  nurses ; 
and  yet  it  is  the  one  most  open  to  women  of  little  or  no  pretensions  to 
knowledge.  That  this  is  possible  is  due  to  the  ignorance  of  the  com- 
munity at  large,  the  apathy  or  mistaken  kindness  of  medical  men,  and 
the  cupidity  of  speculators.  If  women  can  be  engaged  at  low  salaries, 
with  little  or  no  investigation  of  their  antecedents,  and  sent  out  as 
"  trained  nurses  "  at  fees  calculated  to  yield  a  handsome  profit,  who  can 
wonder  that  things  are  as  they  are  ?  The  remedy  lies  in  the  hands  of 
those  whose  work  has  called  trained  nurses  into  existence  —  the  mem- 
bers of  the  medical  profession.  As  long  as  they  accept  such  arrange- 
ments so  long  only  will  they  continue. 

If  every  medical  man  would  but  ask  a  few  leading  questions  of  the 
nurse  supplied  to  him  from  an  institution,  concerning  her  length  of 
training,  where  obtained,  her  experience  of  cases  similar  to  the  one  in 
hand,  her  method  of  carrying  out  certain  orders,  meeting  any  emergency 
that  may  arise,  etc.,  semi-trained  incapable  women  would  be  detected. 
No  feelings  of  pity  or  wish  to  avoid  trouble  should  be  allowed  to  screen 
an  incompetent,  unsatisfactory  nurse.  The  issues  involved  are  too 
great,  and  nursing  is  too  responsible  a  calling  to  be  placed  in  prentice 
or  untrustworthy  hands;  neither  for  sentiment  nor  economy,  both 
equally  false,  should  life  be  endangered  or  unnecessary  pain  and  dis- 
comfort inflicted. 

The  manner  and  dress  of  a  nurse  serve  as  guides  to  the  thoroughness* 
of  her  training.  A  woman  who  is  scrupulously  neat,  in  a  suitable  incon- 
spicuous uniform,  businesslike  in  manner,  yet  bright  and  pleasant,  who 
takes  her  orders  quietly  yet  intelligently,  and  who  keeps  strictly  to  her 
own  position,  is  likely  to  be  suitable.  Nurses  need  a  "  professional " 
manner  as  much  as  physicians,  and  the  latter  would  add  to  the  dignity 
of  both  professions  by  recognising  and  encouraging  the  fact.  Flippancy 
and  familiarity  are  especially  unworthy  of  those  whose  work  involves 
such  grave  responsibilities.  Mutual  respect  is  the  groundwork  of  the 
confidence  which  must  exist  if  the  patient  is  to  receive  the  full  benefit 
of  the  treatment.  The  medical  man  must  feel  able  to  trust  the  nurse's 
ability  and  trustworthiness  in  carrying  out  his  instructions  to  the 
smallest  detail ;  and  the  nurse  must  prove  herself  deserving  of  such 
trust,  and  add  to  her  other  duties  an  absolute  loyalty  towards  the 
doctor.  By  her  manner  of  obeying  orders  she  can  also  inspire  the 
patient  with  wholesome  confidence.  If  at  any  time  the  nurse  cannot 
be  present  at  the  doctor's  visit,  a  ivritten  report  must  be  left  for  him, 
and  his  orders  for  her  should  also  be  in  writing  so  as  to  avoid  any 
misunderstanding.  Orders  should  be  given  directly  to  the  nurse,  not 
through  the  friends;   and  care  taken  that  she  really  understands  them. 


NURSING  445 


Her  report  also  should  be  given  to  the  medical  man,  if  necessary  before 
he  sees  the  patient,  or  after,  if  not  desirable  in  the  sick-room. 

The  nurse  should  never  take  the  friends  into  confidence  about  the 
case,  nor  express  her  own  opinion  to  them.  Infinite  harm  is  done  in 
this  way,  and  often  remarks  are  quoted  to  the  medical  attendant  in  a 
different  manner  from  that  in  which  they  were  originally  sjioken. 

The  vice  of  gossiping  is  a  very  grave  one,  and  unfits  a  nurse  for.  her 
office  almost  as  much  as  the  vice  of  intemperance.  If  a  woman  persist 
in  thus  offending  she  should  not  be  employed.  Criticism  of  the  medical 
treatment,  suggestions  of  further  advice,  or  even  of  a  change  of  the 
medical  man,  should  never  be  tolerated;  such  behaviour  is  unconscien- 
tious in  the  highest  degree,  opens  the  door  to  suspicions  of  touting  for 
special  doctors,  and  might  lead  to  the  gravest  results  to  the  patient.  If 
a  nurse  cannot  conscientiously  continue  to  work  for  a  certain  medical 
man  she  must  have  the  courage  of  her  convictions,  and  leave  the  case 
without  reflecting  on  him  in  any  way. 

When  sending  for  a  nurse  the  medical  attendant  can  do  much  to  put 
her  on  a  right  footing  with  the  household  she  is  to  enter.  Too  often 
training  is  supposed  to  render  a  nurse  indifferent  to  sleep,  exercise,  or 
regular  food.  It  should  be  clearly  explained  that  eight  continuous  hours 
for  sleep,  at  least  one  hour  for  exercise,  and  time  for  each  meal,  are 
necessary  as  a  rule,  though  a  good  nurse  will  make  exceptional  efforts 
in  case  of  emergency.  Her  meals  should  not  be  served  in  the  sick-room  ; 
and  if  on  night  duty,  her  bedroom  should  be  in  a  quiet  part  of  the  house. 
Necessary  sleep  and  exercise  are  essential  to  keep  a  nurse  fit  for  the 
duties  and  responsibilities  which  devolve  upon  her.  The  medical  at- 
tendant generally  knows  something  of  the  household,  and  can  give  the 
nurse  some  valuable  hints  which  may  enable  her  to  avoid  friction. 

A  private  nurse  needs  special  neatness  and  refinement,  so  as  to 
keep  both  the  patient  and  his  surroundings  in  pleasant  order.  The 
toilet  of  the  patient  calls  for  scrupulous  nicety ;  nails,  hair,  etc.,  being 
carefully  attended  to.  The  housemaid's  work  will  depend  upon  the 
domestic  arrangements,  and  is  generally  done  by  a  servant,  but  the 
nurse  is  responsible  for  the  room  being  in  order.  She  can  do  much  to 
comfort  her  patient  by  avoiding  all  unnecessary  noise  in  remaking  the 
fire  (using  housemaid's  gloves  to  lift  the  coal,  which  should  be  in 
lumps)  ;  shading  his  eyes  from  too  strong  light,  either  from  lamp  or 
window  ;  arranging  flowers  ;  finding  out  any  particular  like  or  dislike, 
and  if  possible  attending  to  it ;  avoiding  all  whispered  conversations, 
creaking  doors  or  windows,  flapping  blinds,  creaking  shoes,  rustling  or 
rattling  dress  or  ornaments,  not  shaking  the  bed  in  passing,  in  fact, 
feeling  with  as  well  as  for  the  patient.  When  her  services  are  not 
needed  the  nurse  is  better  out  of  the  patient's  sight,  though  close  at 
hand;  and  this  is  especially  desirable  if  the  nurse  be  reading  to  herself 
as  in  some  long  watches  she  may  lest  she  sleep.  Needlework,  however, 
is  never  resented  by  a  patient.  A  nurse  should  invariably  wear  her 
uniform  when  on  duty  whether  by  day  or  night. 


446  SYSTEM  OF  MEDICINE 

Mtich.  depends  on  the  way  in  wMch  the  nourishment  is  presented  as 
to  whether  the  patient  will  take  it  or  not.  This  is  entirely  the  nurse's 
province,  and  she  should  have  a  sufficient  knowledge  of  sick  cookery 
to  supply  any  deficiency  in  this  respect  in  the  household.  Everything 
should  be  served  as  daintily  as  possible,  glasses,  spoons,  etc.,  perfectly 
clean  and  jjolished,  clean  tray-cloth,  if  possible  a  few  flowers,  small 
portions,  and  any  particular  fancy  as  to  sweetness,  etc.,  remembered. 
Every  particle  of  fat  should  be  removed  from  broths  and  beef  tea,  toast 
should  be  thin  and  crisp,  bread  and  butter  thin  and  lightly  spread, 
nothing  spilled  on  plate  or  saucer.  The  patient  should  not  be  told  as  a 
rule  what  is  coming,  as  an  unexpected  thing  is  often  more  readily  taken. 
Rigid  punctuality  is  necessary,  nothing  spoils  an  invalid's  appetite  like 
delay.  No  stimulant  should  ever  be  given  or  allowed  to  be  given  with- 
out direct  medical  orders,  and  the  kind  and  quantity  must  be  entered 
in  the  diary.  Food  should  never  be  tasted  or  cooled  by  being  blown 
upon,  it  disgusts  the  patient.  Food  should  never  be  kept  in  the  sick- 
room, and  plates,  glasses,  etc.,  are  to  be  removed  as  soon  as  possible. 
Ice  may  be  kept  much  longer  if  wrapped  in  flannel  and  placed  on  a 
colander  to  let  the  water  drain  away. 

A  private  nurse  needs  great  tact  in  so  dealing  with  the  friends  and 
relations  that  orders  may  be  carried  out  without  offending  them.  If  in 
any  difficulty  they  will  not  yield  to  her  persuasions  she  must  appeal  to 
the  doctor  for  advice.  Thoughtfulness  for  their  natural  feelings,  and 
also  for  the  household  arrangements,  so  as  to  avoid  giving  unnecessary 
trouble,  will  do  much  to  promote  friendly  relations.  The  present  sys- 
tem of  private  nursing  leaves  much  to  be  desired,  but  valuable  reforms 
can  only  be  obtained  by  those  most  interested,  the  medical  men  them- 
selves. The  nurses  are  too  often  isolated  units,  without  a  centre  or 
standard,  and  so  are  apt  to  put  themselves  before  the  needs  of  patient 
or  doctor.  After  their  time  of  training  and  agreement  is  over  they  are 
inclined  to  think  they  know  all  that  is  necessary;  they  have  no  system 
on  which  to  arrange  their  Avork,  and  unless  they  are  specially  fortunate 
no  one  to  give  aid  or  advice.  Half  the  troubles  that  occur  are  due  to 
inexperience  in  adapting  themselves  to  the  altered  conditions  in  which 
they  have  to  work ;  and  it  needs  both  tact  and  disciplined  training  to 
enable  them  to  adjust  themselves  satisfactorily  to  the  new  circum- 
stances. 

Those  interested  in  nurses  as  a  class  may  give  material  help  to 
individuals  by  advising  and  helping  them  in  habits  of  thrift.  The 
Eoyal  Pension  Fund  for  trained  nurses  and  similar  schemes  offer 
unusual  advantages  for  old  age  pensions,  sick  pay,  etc.,  and  grateful 
patients  may  do  much  for  the  nurses  by  helping  them  to  become  mem- 
bers of  such  associations. 

District  Nursing.  —  Nursing  the  sick  poor  in  their  own  homes  is  now 
a  recognised  branch  of  the  profession,  though  it  is  not  equally  realised 
that  this  work  requires  specially  trained  women.  The  cases  are  as 
varied  and  critical  as  any  to  be  met  with  in  hospital  or  private  work, 


NURSING  447 


with  none  of  their  favourable  surroundings.  In  many  places,  manufac- 
turing centres  for  instance,  where  the  population  has  rapidly  outgrown 
the  hospital  accommodation,  or  in  scattered  country  districts,  where  the 
nearest  hospital  or  infirmary  may  be  many  miles  distant,  the  most  seri- 
ous cases  must  perforce  be  nursed  at  home.  There  are  innumerable 
instances  where  removal  would  probably  cause  a  fatal  termination  to  the 
illness,  and  is  only  attempted  as  a  lesser  evil  than  leaving  the  patient 
to  suffer  untended.  If  a  parent,  especially  the  mother,  is  removed  to 
hospital,  the  whole  family  may  be  broken  xip,  and  the  worst  moral 
results  ensue.  Where  there  are  young  children,  also,  the  anxiety  about 
them  in  her  absence  is  a  serious  drawback  to  the  mother's  recovery. 
There  are  also  many  cases  unsuitable  for  hospital,  such  as  chronic 
rheumatism,  paralysis,  cancer,  phthisis,  children  with  hip  and  spine 
disease,  etc.,  who  can  perfectly  well  be  attended  in  their  own  homes 
by  a  trained  nurse.  It  has  a  good  moral  effect  in  many  cases  for 
children  thus  to  support  aged  parents,  or  for  brothers  and  sisters  to 
keep  a  delicate  member  of  the  family  at  home,  instead  of  sending 
them  into  the  poor-law  infirmaries  at  the  expense  of  the  ratepayers. 
Therefore  a  district  nurse  needs  full  hospital  experience  if  she  is  to 
carry  out  medical  orders  efficiently ;  and  in  addition  she  requires 
special  training  to  meet  the  difficulties  of  the  work. 

Ignorance,  prejudice,  dirt,  foul  air,  and  often  the  want  of  the 
commonest  necessaries,  have  all  to  be  met ;  and  nursing  knowledge 
alone  is  of  little  value  if  it  cannot  be  used  to  the  best  advantage  under 
the  circumstances.  Still  less  can  a  woman  who  has  only  given  three  or 
six  months'  time  to  accjuire  both  nursing  and  district  experience  prove 
a  satisfactory  district  nurse. 

The  method  of  work  usually  accepted  is  for  the  nurse  to  have  a 
certain  number  of  cases  within  reasonable  distance  under  her  care, 
which  she  visits  once,  twice,  or  even  oftener,  every  day,  taking  entire 
charge  of  each  patient  with  regard  to  washing,  bed-making,  changing 
linen,  applying  poultices,  dressing  wounds,  etc.  She  also  is  responsible 
for  the  sick-room  and  all  its  appliances  being  kept  as  far  as  possible  in 
a  cleanly,  tidy  condition,  and  fresh  and  sweet.  It  has  been  objected 
that  unless  the  nurse  remain  with  the  patient  no  real  good  can  result 
from  her  attendance.  But  part  of  a  district  nurse's  duty  is  to  teach 
the  friends  the  right  way  to  wait  upon  the  sick  person.  They  are 
generally  anxious  to  help,  and  a  sensible  man  or  woman  can  be 
educated  to  be  an  intelligent  assistant  who  can  be  trusted  to  administer 
nourishment,  medicine,  etc.,  at  the  proper  intervals  between  the  nurse's 
visits.  Too  frequently  some  benevolent  person,  feeling  the  need  of 
nursing  in  a  special  district,  forms  a  committee,  selects  a  nurse,  and 
sets  her  to  work  without  thinking  it  necessary  to  consult  those  most 
concerned,  the  medical  men  of  the  place.  Even  when  they  are  con- 
sulted and  their  views  considered,  there  is  doubt  as  to  how  and  Avhere 
the  nurse  is  to  be  procured;  generally  she  is  obtained  by  means  of 
advertising,  and  even  then  a  lay  committee  is  apt  to  select  an  unskilled 


448  SYSTEM   OF  MEDICINE 

or  unsuitable  worker,  because  the  real  needs  of  the  work  are  not  under- 
stood. 

Good  hospital  training,  two  years  at  least,  and  six  months'  experi- 
ence in  a  district  home,  should  be  the  minimum  standard.  To  put 
women  Avith  no  more  than  six  months'  experience  of  nursing  the  sick, 
and  often  of  limited  education  and  intelligence,  in  the  position  of 
district  nurse,  is  a  form  of  cheap  philanthropy  that  cannot  be  too 
strongly  condemned.  A  half-trained  Avoman  is  worse  than  one  with 
no  pretensions  to  knowledge,  and  to  place  such  responsibility  in  her 
hands  (too  often  because  she  asks  less  remuneration  than  a  fully-trained 
nurse),  is  an  injustice  to  her,  the  patients,  and  the  doctor  who  attends 
them.  However  sensible  and  willing,  no  woman  could  attain  in  the 
time  even  sufficient  practical  dexterity  to  do  the  best  for  the  cases,  and 
for  lack  of  the  special  training  faults  of  inexperience  must  greatly  limit 
her  usefulness. 

No  nurse,  however  well  trained,  should  ever  be  expected  or  allowed 
to  treat  or  prescribe  for  any  case  whatever  beyond  rendering  first  aid  in 
emergencies.  She  should  never  undertake  the  nursing  of  a  case  that  is 
not  under  a  medical  man,  nor  initiate  £»r  alter  any  treatment  without  his 
direct  orders  or  permission:  as  in  private  work,  all  suggestions,  criti- 
cisms and  discussions  of  his  methods  are  utterly  inexcusable.  Gossip 
is,  if  possible,  even  a  more  fatal  fault  in  district  than  in  private  work. 
Besides  not  talking  of  one  patient  to  another,  the  nurse  should  be 
reticent  concerning  her  cases  to  those  above  them  in  the  social  scale. 
The  respectable  poor  resent  their  private  affairs  being  made  known  to 
district  visitors,  committee  ladies,  etc.,  and  a  nurse  who  thus  betrays 
confidence  will  lose  all  influence  over  her  patients  and  their  friends. 

A  district  nurse  is  generally  sent  to  cases  by  medical  men,  clergymen, 
district  visitors,  or  the  friends  of  the  patient.  If  not  sent  by  the  medical 
man  in  charge  of  the  case,  it  is  more  courteous  for  the  nurse  to  ask  his 
permission  before  beginning  her  Avork,  though  in  an  urgent  case  she  might 
help  the  friends  to  carry  out  orders  at  her  first  visit,  and  then  ascertain 
if  he  Avishes  her  to  continue.  A  ivritten  daib/  report  should  be  left  for 
the  medical  man,  and  in  acute  cases  twice  daily,  or  even  oftener,  with 
the  record  of  temperature,  pulse  and  respiration,  action  of  bowels  and 
bladder,  amount  of  sleep,  food,  stimulants,  etc.  In  chronic  cases  a  writ- 
ten report  once  or  tAvice  a  Aveek  may  be  sufficient,  stating  the  general 
state  of  health,  condition  of  wound,  such  as  an  ulcerated  leg,  etc.  By 
thus  keeping  in  full  communication  mistakes  and  misunderstandings  are 
avoided.  One  rule  Avould  save  many  difficulties,  viz.,  that  both  doctor 
and  nurse  invariably  communicate  in  Avriting,  never  giving  or  receiving 
verbal  messages  from  patients  or  their  friends.  By  implicitly  carry- 
ing out  medical  orders,  and  by  exact  obedience,  she  will  impress  the 
friends  with  the  importance  of  following  directions.  The  nurse  must  aim 
at  being  the  friend,  not  the  supplanter,  of  the  wife  or  mother,  who  may 
resent  a  stranger's  intrusion  until  experience  teaches  hoAV  much  more 
can  be  done  by  skilled  hands.     It  is  generally  much  easier  to  put  the 


NURSING 


449 


patient  than  the  room  in  nursing  order.  But  by  degrees  the  most 
disorderly  room  can  be  rearranged,  and  whenever  possible  this  should 
be  done,  not  by  the  nurse  personally,  but  by  the  friends  acting  on  her 
advice.  The  lesson  is  more  permanent  if  they  realise  themselves  that 
they  can  make  and  keep  things  tidier  and  more  orderly.  They  prefer 
themselves  to  put  away  the  extra  garments  that  have  accumulated,  to 
remove  the  family  linen  "airing"  between  the  bed  and  mattress  of  the 
sick-  person,  to  clear  out  boxes,  sacks,  and  other  rubbish  that  may  be 
under  the  bed.  Still,  if  there  be  no  one  else  available,  the  nurse  must 
ensure  cleanliness  herself,  for  she  is  responsible  that  all  the  appliances 
and  surroundings  are  in  order.  She  must  be  prepared  to  extemporise 
many  kinds  of  contrivances.  If  it  be  not  possible  to  move  the  bed  from 
a  draughty  position  a  screen  can  be  made  from  a  clothes-horse  and  the 
family  shawl,  if  a  quilt  or  blanket  are  not  available ;  or  the  same  gar- 
ment may  be  fastened  as  a  curtain  on  a  clothes-line.  A  roll  of  news- 
paper or  brown  paper  will  convert  a  common  kettle  into  a  steam  one  for 
the  time.  A  sheet  of  the  latter  material  is  an  excellent  substitute  for 
mackintosh.  A  small  teapot  forms  a  good  feeder,  a  chair  can  be  con- 
verted into  a  bed-rest ;  in  fact,  a  good  district  nurse  is  rarely  nonplussed 
for  ways  and  means. 

A  stock  of  necessary  appliances,  such  as  water-pillows  (more  gen- 
erally useful  than  the  large  w^ater-beds),  mackintoshes,  bedpans,  etc., 
should  be  kept  for  lending;  also  sheets,  bed-garments,  etc.  Flannel 
shirts,  open  down  one  side,  are  particularly  useful  for  rheumatic  cases. 
A  free  use  of  Keating's  powder,  carbolic  acid,  or  Jeyes'  fluid  for  bed- 
steads, floors,  etc.,  with  carbolic  soap  and  turpentine  are  useful  in  dimin- 
ishing insect  life. 

Except  under  special  circumstances  night  duty  is  the  exception  for 
a  busy  district  nurse,  as  it  prevents  the  other  work.  Trustworthy  women, 
working  under  orders,  can  generally  be  found  to  relieve  the  friends  at 
night. 

The  nursing  of  infectious  cases  depends  entirely  upon  the  local 
medical  men.  Except  in  epidemics,  scarlet  fever,  typhus,  and  small-pox 
are  not  usually  attended. by  the  nurse.  With  due  precautions,  most 
careful  disinfection  of  hands,  hair  and  instruments,  and  the  use  of  sepa- 
rate sleeves  and  aprons,  enteric  fever,  measles,  whooping-cough,  diph- 
theria, and  erysipelas  may  be  attended  without  risk  to  other  patients. 
Care  would  necessarily  have  to  be  taken  not  to  go  straight  to  a  child 
after  visiting  measles,  nor  to  a  surgical  case  when  attending  erysipelas ; 
but  ordinary  chronic  cases  might  easily  be  nursed  at  the  same  time,  also 
acute  rheumatism,  pneumonia,  etc. 

Whatever  may  be  the  local  attitude  with  regard  to  midwifery,  it  is 
most  desirable  that,  although  the  nurse  may  possess  the  requisite  train- 
ing to  act  in  that  capacity,  she  should  not  do  so  except  at  the  request  of 
the  medical  men,  when  she  must  only  attend  a  limited  number  of  non- 
surgical cases,  or  in  an  emergency.  But  whenever  possible  she.  should 
act  as  monthly  nurse  under  the  medical  men,  and  by  their  orders,  visit- 

VOL.    I  2   G 


450  SYSTEM   OF  MEDICINE 


ing  the  cases  twice  daily  for  seven  days,  and  once  daily  for  another  weekj 
taking  the  mother's  temperature,  pulse,  etc.,  and  keeping  her  absolutely 
clean ;  washing  the  baby,  taking  care  of  its  eyes,  etc.,  and,  by  inculcat- 
ing cleanliness  and  uprooting  traditional  prejudices,  help  to  lessen  the 
mortality  amongst  mothers  and  infants  so  largely  due  to  neglect  at  these 
times. 

District  nursing  should  be  entirely  distinct  from  any  form  of  alms- 
giving. All  relief  should  be  obtained  from  the  proper  local  sources, 
never  given  directly  by  the  nurse.  Also  the  work  should  be  unsectarian 
if  it  is  to  reach  those  most  in  need  of  its  help.  When  arranging  for . 
a  district  nurse  in  any  locality  it  is  helpful  to  obtain  information  from 
one  of  the  established  systems  of  this  work.  A  nurse  fully  trained  is 
supplied,  with  every  detail  of  cost  worked  out,  and  definite  rules  on 
which  she  must  act.  She  is  bound  to  send  a  monthly  report  of  her 
work,  with  full  particulars,  to  headquarters,  in  addition  to  that  furnished 
to  the  local  committee ;  and  she  is  visited  and  her  work  inspected  at 
regular  intervals  from  the  centre.  The  same  holds  good  for  homes, 
only  there  the  superintendent,  herself  a  trained  nurse,  is  held  responsible 
for  those  working  under  her.  Xo  interference  with  local  arrangements 
takes  place  under  this  scheme ;  it  does  but  ensure  a  supply  of  properly- 
qualified  women,  and  a  uniform  standard  of  work.  Experience  has  also 
shown  that  refined,  well-educated  women  exercise  a  stronger  influence 
and  produce  better  results  than  those  drawn  from  the  same  class  as  the 
patients.  One  they  instinctively  recognise  as  their  superior  can  do  more 
in  combating  their  prejudices  than  one  who  is  rather  inclined  to  share 
them. 

Whenever  possible  it  is  well  to  make  the  people  help  to  support  the 
,  nurse,  on  the  lines  of  a  provident  club.  A  monthly  payment  of  4d.  for 
a  family  (or  less  if  local  wages  are  low),  and  a  charge  of  ^d.  or  Id.  per 
head  for  those  over  fourteen  years  of  age  is  conveniently  spared,  and  is 
better  than  the  giving  of  skilled  labour  for  nothing.  Cases  in  receipt 
of  poor-law  relief  would  not  be  expected  to  join  such  a  club,  but  the 
guardians  should  contribute  towards  the  nurses'  fund. 

Puerperal  Nursing.  —  The  fact  needs  wider  recognition,  that  though 
the  puerperal  state  is  naturally  a  normal  one  calling  for  little  beyond 
cleanliness  and  ordinary  attention,  yet  from  constitutional  or  accidental 
causes  the  gravest  complications  may  arise,  which  require  trained  skill  if 
the  case  is  to  be  nursed  successfully.  Therefore  maternity  work  should 
only  be  undertaken  by  women  with  general  as  well  as  special  nursing 
knowledge.  Even  in  the  most  straightforward  case  much  depends  upon 
the  nurse  to  ensure  a  good  recovery  for  the  mother  and  a  contented,  well- 
cared-f or  infant.  It  is  not  possible  for  a  woman  unaccustomed  to  attend- 
ing sick  people  or  young  children,  ignorant  of  the  rudiments  of  anatomy 
or  physiology,  and  often  of  the  simplest  laws  of  hygiene,  to  become 
acquainted  with  all  that  is  essential  for  a  monthly  nurse  in  three  months, 
much  less  in  six  weeks,  the  time  considered  suificient  for  this  training 
in  most  of  the  lying-in  hospitals  and  training  schools. 


NURSING  451 


It  is  often  stated  that  tlie  modern  nurse  falls  short  of  her  untrained 
predecessor  in  the  management  of  infants  after  the  first  ten  days.  It 
cannot  be  otherwise  if  the  nurse  have  not  seen  anything  of  a  baby  after 
the  first  fortnight,  and  is  as  much  at  a  loss  as  the  inexperienced  mother 
in  dealing  with  it.  Then  the  child  becomes  the  victim  of  the  ignorant 
advice  of  zealous  friends  as  to  feeding,  qixack  remedies  for  infantile 
ailments,  etc.,  and  the  seeds  are  sown  of  rickets  and  other  diseases  for 
which  medical  aid  is  sought  too  late.  The  mere  handling  of  mother 
and  infant  needs  time  and  experience  to  do  it  well,  and  with  comfort 
to  the  patient;  and  in  the  washing  and  bed-making  of  a  lying-in 
woman  great  care  is  necessary  to  avoid  exposure  and  risk  of  chill. 
Also  it  frequently  happens  that  the  doctor  does  not  arrive  until  after 
delivery  has  taken  place.  The  safety  of  mother  and  child  depends  then 
upon  the  nurse ;  fortunately,  in  the  majority  of  cases,  masterly  inactivity 
carries  her  safely  through.  But  a  smattering  of  knowledge,  or  the 
audacity  of  inexperience,  will  often  cause  undue  meddling,  and  injuries 
to  both  mother  and  infant  may  ensue. 

The  more  highly  trained  the  nurse,  the  less  danger  is  there  of  her 
taking  too  much  upon  herself;  she  realises  the  risk,  and  is  more  willing 
to  depend  upon  medical  aid  and  instruction. 

Absolute  cleanliness  is  the  secret  of  successful  puerperal  nursing.  A 
nurse  attending  confinement  cases  should  always  wear  dresses  of  washing 
material,  and  large  white  aprons  and  sleeves  that  will  turn  up  above  the 
elbows.  She  must  be  scrupulously  clean  in  person,  especially  having 
her  hands  free  from  roughnesses  and  scratches,  with  short  nails  kept 
absolutely  clean.  Her  hair  should  be  frequently  washed  and  neatly 
arranged.  She  should  be  quite  free  from  any  wounds  or  sores ;  many  a 
case  of  puerperal  septicaemia  might  have  been  traced  to  the  unsuspected 
ulcerated  leg  of  the  old  nurse  in  attendance. 

The  nurse's  duty  is  to  prepare  the  patient  and  bed,  to  have  all  in 
readiness  for  the  infant,  to  wait  upon  the  doctor,  to  put  mother  and  child 
comfortably  back  to  bed  when  all  is  over,  and  to  nurse  the  case  under  the 
medical  orders.  It  is  advisable  for  her  to  ascertain  beforehand  if  her 
patient  has  the  necessary  appliances,  so  as  to  avoid  confusion  at  the  time. 
The  room  should  be  bright  and  cheerful,  as  quiet  as  possible,  not  near 
any  closet  or  sink,  and  easily  ventilated.  The  bed  should  be  in  such  a 
position  that  it  can  be  approached  on  both  sides.  The  fire  should  be 
lighted,  plenty  of  hot  and  cold  water  in  the  room,  two  or  three  basins,  a 
quart  jug  (in  which  to  warm  the  forceps  if  needed),  a  slop  pail,  towels, 
napkins,  infant's  clothes,  dressing  for  the  cord,  dusting  powder,  olive  oil, 
threaded  needles,  thimble,  safety  pins,  blunt-pointed  scissors,  linen 
thread  ligatures,  flannel  receiver,  antiseptic  lubricant,  flannel,  plain  soap, 
etc.  If  possible  sanitary  towels  should  be  used  for  the  patient;  these 
can  be  inexpensively  made  of  carbolised  tow  or  oakum  in  butter  muslin ; 
but,  if  preferred,  ordinary  napkins  may  be  wrung  out  of  hot  antiseptic 
lotion  (2^^  carbolic  or  -^\~^  perchloride)  and  applied. 

Brandy,  hypodermic  syringe,  irrigator,  Higginson's  syringe,  glass 


452 


SYSTEM  OF  MEDICINE 


nozzle,  catheter,  and  a  receiver  for  tlie  placenta  should  be  at  hand. 
Glass  catheters  can  readily  be  cleansed,  but  require  very  careful 
handling. 

The  nurse  should  recognise  the  stage  of  labour  by  the  pains,  the 
short  "  grinding "  ones  of  the  first  being  distinct  from  the  propulsive 
"  bearing  down  "  ones  of  the  second  stage. 

If  the  bowels  have  not  been  well  relieved  a  small  soap  and  water 
enema  may  be  given  in  the  first  stage,  especially  if  the  membranes  have 
not  ruptured,  which  can  be  ascertained  by  external  evidence.  The 
patient  should  be  desired  to  empty  the  bladder  also  at  this  stage,  and  if 
in  accordance  with  the  wishes  of  the  medical  attendant,  a  warm  anti- 
septic douche  (Condy,  or  -^^-^  perchlor.)  is  often  given;  but  this  must 
not  be  done  without  permission.  A  glass  nozzle  (without  a  terminal 
hole)  should  be  used,  jjreviously  boiled  and  soaked  in  a  disinfectant. 
It  is  well  in  any  case  to  bathe  the  vulva  with  a  warm  antiseptic  lotion, 
and  creoline  (3j.  to  Oj.)  is  especially  useful,  as  plenty  of  soap  can  be 
used  with  it,  a  desirable  feature  in  district  maternity  cases. 

The  nurse  should  always  thoroughly  cleanse  her  hands  with  hot  soap 
and  water  and  nail  brush,  and  then  immerse  them  in  "  -^^-^  perchlor." 
or  "  -Jjj-  carbolic  "  before  touching  her  patient,  and  it  is  well  for  her  to 
keep  a  basin  of  antiseptic  lotion  at  hand,  so  that  she  may  dip  her  hands 
in  it  each  time  she  attends  to  the  case. 

Preparation  of  Bed.  —  A  convenient  arrangement  of  the  bed  is  made 
by  spreading  a  mackintosh  sheet  over  the  mattress,  covered  by  a  blanket 
and  under-sheet.  In  district  cases  sheets  of  strong  brown  paper  will 
keep  moisture  from  penetrating  to  the  bed.  Over  the  under-sheet 
another  piece  of  mackintosh  is  laid,  covering  the  lower  half  of  the  bed 
on  the  right  side.  This  is  covered  by  a  small  blanket,  a  folded  sheet, 
and,  if  procurable,  an  accouchement  sheet.  In  poor  homes  clean  old 
quilts  or  any  thick  material  can  be  used,  over  brown  paper  or  an  oilcloth 
table  cover.  The  bed-hangings  should  also  be  moved  from  the  side  of 
the  bed.  The  mackintosh,  etc.,  may  be  kept  in  position  by  safety  pins 
at  each  corner.  The  upper  sheet,  blankets,  and  quilt  are  folded  back 
to  the  left  side  of  the  bed,  ready  to  be  replaced,  and  a  sheet  or  small 
blanket,  as  preferred,  is  placed  over  the  patient.  A  clean  draw-sheet 
and  the  binder  are  rolled  up  and  placed  at  the  head  of  the  bed,  with  six 
strong  safety  pins.  A  pulley  is  firmly  fastened  to  the  foot  of  the  bed 
(an  ordinary  round  towel  is  a  useful  one),  and  if  necessary  a  piece  of 
board  or  a  flat  stone  is  placed  against  the  foot-rail  for  the  patient's 
feet. 

Toilet  of  Patient.  —  She  is  dressed  in  clean  night-clothes  turned  up 
and  secured  on  each  shoulder  by  a  safety  pin.  A  couple  of  clean  petti- 
coats are  worn,  stockings  without  garters,  and  bedroom  slippers,  and  a 
dressing-gown,  which  latter  garment  is  removed  and  a  shawl  put  across 
the  shoulders  when  the  patient  has  to  lie  in  bed  at  the  last. 

Food. — Warm  milk,  tea,  beef  tea,  etc.,  may  be  given  from  time  to 
time — the  last  being  a  valuable  stimulant  to  under-fed,  ill-nourished 


NURSING  453 


women.  The  nurse  must  be  prepared  for  vomiting  during  the  first  stage 
of  labour,  and  sometimes  a  shivering  fit,  without  a  notable  rise  of 
temperature,  announces  its  termination. 

Second  Stage.  —  When  the  pains  become  decidedly  propulsive,  the 
patient  must  lie  on  her  left  side  with  her  spine  on  a  line  with  the  edge 
of  the  bed,  her  head  supported  by  a  pillow  or  pillows,  the  knees  flexed, 
and  the  feet  pressing  against  the  foot  of  the  bed.  The  nurse  can  materi- 
ally assist  the  patient  in  the  second  stage  by  supporting  the  lower  part 
of  the  back  during  each  pain.  She  may  also  be  ordered  to  apply 
hot  fomentations  to  the  perinaeum  if  there  be  rigidity;  these  consist 
of  wool  or  flannel  wrung  out  of  hot  antiseptic  lotion,  and  must  be 
frequently  renewed.  When  the  child  is  born  the  nurse  will  hand 
scissors  and  ligatures  to  the  doctor,  and  if  desired  hold  the  uterus 
while  the  child  is  being  separated.  She  has  the  flannel  receiver  ready 
warmed,  in  which  she  wraps  up  the  infant,  and  puts  it  away  in  a  warm 
place. 

If  animation  be  suspended,  she  must  quickly  prepare  basins  of  hot 
and  cold  water,  and  help  as  directed  with  artificial  respiration,  rubbing 
with  brandy,  dipping  into  hot  and  cold  water,  etc.  A  small  basin  and 
pieces  of  wool  will  also  be  ready  for  the  doctor  to  bathe  the  infant's  eyes. 
After  the  expulsion  of  the  placenta  the  nurse  will  take  the  orders  of  the 
doctor  as  to  when  the  mother  is  to  be  made  comfortable,  generally  after 
the  child  is  dressed. 

First  Toilet  of  Infant. — The  water  for  the  infant's  first  bath  must 
be  from  90°  to  95°  F.,  the  child  is  quickly  soaped,  placed  in  the  water, 
and  gently,  yet  firmly,  rubbed  to  remove  all  the  adherent  deposit  from 
its  skin.  It  is  carefully  dried,  especially  in  the  folds  of  the  skin.  Until 
the  meconium  ceases,  oiling  the  buttocks  and  thighs  will  be  found  use- 
ful. Before  dressing  the  cord,  the  ligature  must  be  carefully  examined, 
and  if  not  firm,  or  there  be  oozing,  it  must  be  retied;  the  genitals  and 
anus  should  also  be  noticed  in  case  of  malformation.  The  cord  may  be 
wrapped  in  antiseptic  gauze,  and  placed  in  a  square  of  linen  with  a  slit 
in  the  centre,  through  which  it  is  drawn,  and  then  neatly  folded  in ;  or 
it  may  be  well  powdered  with  a  mixture  of  1  part  starch-powder,  1 
boracic  powder,  and  1  oxide  of  zinc,  and  enveloped  in  the  linen.  This  is 
kept  in  place  by  the  flannel  binder,  which  may  be  firmly,  but  not  tightly 
applied.  No  pins  must  ever  be  used  to  fasten  the  several  garments ;  they 
must  be  neatly  sewn  on,  except  the  napkins,  which  are  secured  by  a 
safety  pin,  and  the  ends  of  the  long  flannel,  which  are  turned  up  over 
the  feet,  are  similarly  secured  at  each  corner. 

Toilet  of  Mother, — When  the  child  is  dressed,  the  mother,  having 
rested,  is  made  comfortable.  The  soiled  skirts  are  drawn  down  over  the 
feet  and  removed.  A  basin  of  hot  disinfectant,  ^77-0,  or  creoline  and 
water  being  ready,  the  vulva,  thighs,  and  buttocks  are  thorough  cleansed 
from  every  particle  of  discharge,  well  dried,  and  warm  sanitary  towels 
applied.  The  soiled  draw-sheet  and  mackintosh  are  rolled  tightly  up 
against  the  patient,  wlio  turns  towards  the  nurse,  on  to  the  clean  draw- 


454  SYSTEM  OF  MEDICINE 

sheet,  also  rolled  close  to  her.  The  soiled  sheet  is  drawn  away,  the  other 
side  of  the  patient  washed  and  dried,  the  clean  sheet  spread  out,  and  the 
patient  turned  gently  on  it.  She  lies  on  her  back  with  the  legs  extended 
for  the  binder  to  be  applied. 

Application  of  Binder.  —  When  this  duty  falls  to  the  nurse,  she  puts 
the  rolled-up  strip  of  material,  which  is  better  than  any  shaped  bands, 
under  the  patient,  bringing  one  end  across  the  abdomen,  so  that  the  end 
overlap  on  a  line  with  the  right  hip.  The  lower  edge  should  be  well 
below  the  great  trochanter,  and  the  ends  pulled  tightly  together,  the 
left  hand  holding  the  under,  the  right  hand  the  upper  side,  securing 
them  by  a  strong  safety  pin.  This  is  repeated  until  the  whole  abdomen 
is  firmly  bound,  and  at  the  fourth  and  last  pin  a  fold  is  made  in  the 
under  side  of  the  binder  to  make  it  fit  better,  and  it  is  left  rather  looser 
than  lower  down  to  avoid  compressing  the  ribs. 

Two  people  then  gently  lift  the  patient  to  the  top  of  the  bed;  one 
raises  the  buttocks  by  grasping  both  sides  of  the  draw-sheet,  while  the 
other  raises  the  head  and  shoulders  of  the  patient,  and  gently  lifts  her 
into  position.  Onl}^  one  pillow  is  wanted  at  first.  The  draw-sheet  and 
mackintosh  may  be  pinned  at  each  corner  if  desired,  and  an  accouchement 
sheet  placed  under  the  patient.  These  are  easily  made,  in  the  same  way 
as  sanitary  towels  for  poor  people,  by  placing  carbolised  tow  or  tenax 
between  butter  muslin.  Or,  if  preferred,  ordinary  napkins  may  be 
wrung  out  of  hot  disinfectant  lotion  (say  perchloride  toVo)?  ^^^^  applied. 
The  night-dress  is  unpinned  from  the  shoulders,  and  drawn  down,  the 
covering  blanket  removed,  the  bed-clothes  replaced,  and  the  child  given 
to  its  mother. 

The  pulse  should  be  now  taken,  also  the  temperature ;  any  rise  over 
100  in  the  pulse  should  be  reported  at  once,  and  the  nurse  must  be  on 
her  guard  for  heemorrhage. 

The  placenta  is  placed  in  clean  cold  water  for  medical  examination, 
and  then  is  burned  by  the  nurse. 

Tidying  of  Room.  —  All  soiled  clothes  must  be  removed  from  the 
room  as  soon  as  possible,  and  put  to  soak  in  cold  water  containing  car- 
bolic or  other  disinfectant.  The  room  must  be  kept  quiet,  and  the 
patient  left  to  rest.  Nourishment  will  be  as  medically  ordered,  but 
usually  milk,  egg  and  milk,  or  a  cup  of  tea  with  much  milk  in  it,  are 
allowed  almost  at  once.  The  nurse  must  obtain  full  medical  instruction 
as  to  douches,  use  of  the  catheter,  record  of  pulse  and  temperature,  etc. 

The  room  must  be  warm,  but  well  ventilated,  and  the  jjatient  kept 
quiet  for  the  first  week. 

After-Care  of  Mothers.  —  The  mother  must  be  kept  scrupulously 
clean,  the  vulva  being  bathed  at  least  twice  daily,  as  after  an  action  of 
the  bowels.  Douches  will  be  given  as  ordered  by  the  doctor  —  in  every 
ordinary  case  the  bed-pan,  sanitary  towels,  sheets,  night-dress,  etc.,  should 
be  warm  when  given  to  the  patient. 

The  nipples  must  be  well  bathed  and  carefully  dried  before  and  after 
suckling  and  the  breasts  should  be  alternately  relieved.     If  the  nipples 


NURSING  455 


become  tender  the  doctor  must  be  informed,  as  special  applications,  such 
as  glycerine  and  tannin,  eau  de  Cologne  and  water,  etc.,  may  be  ordered, 
or  a  nipple  shield.  The  child  should  never  be  allowed  to  go  to  sleep 
with  the  nipple  in  its  mouth ;  this  is  a  fruitful  source  of  cracks  and 
tenderness.  If  the  breasts  are  very  full  and  tense,  with  more  milk 
than  the  child  can  take,  they  may  be  supported  by  a  binder,  and  the 
medical  attendant  told,  as  the  breast-pump  may  be  needed.  In  district 
work  one  may  be  extemporised  by  filling  a  bottle  with  rather  a  wide 
neck  with  very  hot  water,  emptying  it  quickly,  and  applying  at  once 
over  the  nipple  —  a  soda-water  bottle  is  very  convenient  for  the  purpose. 
If  hardness  still  continue,  hot  fomentations  and  support  should  be 
applied  until  the  doctor  has  seen  the  breast ;  the  nurse  must  never  use 
friction  unless  ordered  to  do  so.  The  child  may  be  put  to  the  breast 
occasionally  until  lactation  is  established,  usually  on  the  third  day.  If 
it  seem  very  hungry,  a  teaspoonful  or  two  of  milk  and  water,  1  to  4, 
warmed  and  sweetened,  may  be  given.  After  the  milk  has  come,  the 
infant  should  be  suckled  every  two  hours  daring  the  day,  and  every 
four  during  the  night,  for  the  first  fortnight  or  three  weeks,  gradually 
lengthening  the  intervals,  especially  at  night. 

Should  a  mammary  abscess  form  the  breast  must  be  well  supported ; 
usually  the  patient's  arm  is  fastened  to  her  side.  A  convenient  support, 
if  poultices  are  ordered,  is  a  square  of  linen  with  tapes  at  each  corner, 
two  of  which  tie  round  the  waist,  and  the  other  two  round  the  neck, 
holding  up  the  breast.  The  square  may  be  folded  to  fit  the  breast,  and 
secured  by  a  safety  pin. 

Light  diet  is  usually  given  to  the  mother  until  the  bowels  have  acted, 
and  then  ordinary  digestible  food.  Stimulants  are  never  to  be  given 
Avithout  orders.  It  is  wise  for  her  to  avoid  cheese,  pickles,  uncooked 
vegetables,  etc.,  at  any  time  while  suckling,  as  they  are  apt  to  disagree 
with  the  child. 

Torn  Perinaeum.  - —  If  the  perinseum  has  been  torn  and  stitched,  the 
nurse  may  be  desired  to  pass  the  catheter  for  some  days,  and  this  is 
most  conveniently  done  as  the  patient  lies  on  her  side  to  avoid  stretch- 
ing the  parts.  The  wound  needs  constant  care  to  keep  it  as  clean  and 
dry  as  possible,  the  dressing  being  frequently  changed.  If  douches  are 
given  the  tube  mast  not  touch  or  rest  upon  the  lacerated  part.  The 
binder  should  be  put  on  as  low  as  possible,  and  the  knees  tied  together, 
the  patient  being  kept  strictly  recumbent. 

If  allowed  to  micturate  naturally  it  should  be  as  the  patient  lies  on 
her  face,  and  the  parts  well  bathed  directly  afterwards. 

White  Leg.  —  Should  the  patient  complain  of  pain  in  the  calf  or 
tliigh  the  leg  must  be  kept  perfectly  quiet  until  the  doctor  comes.  If 
the  pain  be  severe  hot  wool  may  be  applied,  but  no  friction  or  move- 
ment of  any  kind  attempted  imtil  orders  are  received  for  treatment.  A 
cradle  should  be  placed  over  the  limb  to  take  off  the  weight  of  the 
bed-clothes,  and  the  patient  must  be  moved  as  little  as  possible  — 
special  attention  is  to  be  paid  to  the  back,  ankles,  etc.,  as  sores  are  very 


4S6  SYSTEM   OF  MEDICINE 

liable  to  form.  The  patient  must  never  raise  herself  suddenly,  or  sit 
up  while  the  leg  is  affected. 

Should  shortness  of  breath  occur  the  doctor  must  be  summoned  at 
once,  the  patient  kept  as  quiet  as  possible,  and  a  stimulant  given. 

Should  septicemia  arise,  the  nurse's  duties  are  similar  to  those  in 
a  case  of  peritonitis.  Any  abdominal  tenderness,  offensive  lochia, 
scanty  flow  of  milk,  or  rise  of  temperature  must  be  reported  at  once. 
A  strict  course  of  disinfection  for  the  nurse,  and  for  every  garment 
taken  by  her  into  the  house,  must  be  carried  out;  and  some  weeks' 
interval  must  elapse  before  she  attends  another  lying-in  case. 

The  Infant.  —  Much  depends  upon  the  nurse  in  training  an  infant  in 
regularity  of  feeding  and  sleeping,  and,  if  well  managed,  both  mother 
and  child  benefit.  The  baby  should  not  sleep  in  the  bed  with  the 
mother,  but  in  a  cot  at  the  side ;  the  heat  may  be  maintained  by  hot 
bottles.  Many  infants  are  killed  by  suffocation  among  the  poor  for 
lack  of  this  precaution.  The  eyes  should  be  thoroughly  cleansed  every 
day  with  warm  water;  any  redness  or  discharge  must  be  at  once 
reported,  and  the  lotion  ordered  applied.  A  separate  piece  of  wool  or 
soft  linen  should  be  used  for  each  eye,  and  burned  at  once ;  also  the 
soft  linen  for  cleansing  the  mouth  and  nostrils.  The  mouth  should  be 
washed  after  taking  the  breast.  The  cord  is  dressed  daily,  and,  after  it 
separates,  a  folded  pad  of  linen  and  powder  should  be  applied  to  the 
umbilicus  for  a  few  days.  If  the  navel  be  inclined  to  protrude  after 
the  cord  is  off,  the  doctor  may  order  a  counter  covered  with  lint  or 
linen  to  be  fastened  over  it  with  a  strip  of  strapping  two  inches  wide 
and  four  long,  under  the  flannel  binder. 

Clothing.  —  The  binders  and  the  clothing  should  not  be  tight,  as 
both  digestion  and  circulation  suffer,  and  the  support  to  the  umbilicus 
is  insignificant.  The  mother  should  be  advised  not  to  dress  her 
baby  in  gowns  with  low  necks  and  short  sleeves,  but  to  keep  its  limbs 
covered. 

The  child  is  bathed  (90°  temperature)  daily,  though  some  prefer  not 
to  put  it  into  the  water  until  the  cord  separates.  If  the  bowels  and 
bladder  are  not  relieved  within  twelve  hours  after  birth  the  doctor  must 
know.  Often  a  hot  bath  will  have  the  desired  effect.  After  the  stools 
become  yellow  in  colour,  any  green  motions,  constipation,  straining,  or 
distension  of  the  abdomen  due  to  wind  must  be  reported.  Constant 
cleanliness  and  dryness  are  necessary,  and  care  should  be  taken  that 
the  napkins  are  not  washed  in  soda  and  water,  as  this  chafes  the  skin. 
Any  rash,  sore,  discharge,  or  persistent  snufiiing  must  be  reported  at 
once.  If  the  child's  breasts  become  tender  and  swollen,  they  must  be 
protected  from  pressure  by  a  piece  of  wool  and  shown  to  the  doctor. 
The  nurse  must  never  squeeze  or  rub  them. 

In  bringing  up  a  child  by  hand  the  food  will  be  ordered  by  the 
medical  attendant,  but  the  nurse  must  prepare  it,  and  see  it  is  always 
perfectly  fresh,  sweetened,  and  warm,  and  not  given  in  too  large  quan- 
tities at  a  time. 


THE   HYGIENE    OF   YOUTH  ArSl 

The  bottles  must  be  scrupulously  clean  —  the  boat-shaped  are  the 
most  coavenieut,  also  Timpe's  (according  to  Prof.  Escherich),  which 
possess  the  advantage  of  having  inscribed  on  the  glass  a  scale  of  quan- 
tities to  be  prepared  daily  in  proper  proportions,  and  the  amount  for  an 
infant's  meals  from  three  days  old  to  twelve  months.  Other  bottles 
can  be  kept  clean  with  constant  care.  Two  should  alv/ays  be  in  use : 
one,  well  scalded  with  hot  soda  and  water,  and  rinsed  in  cold  water,  is 
left  in  boracic  lotion  until  needed,  when  it  is  washed  out  with  hot  water 
before  being  used.  The  hole  in  the  teat  should  not  be  too  large,  and 
tubes  should  be  cleansed  each  time  with  a  brush,  though  it  is  undesir- 
able this  kind  of  bottle  should  be  used  at  all. 

No  stimulant  or  medicine  should  ever  be  administered  without  orders 
or  permission.  Warmth  and  dryness  keep  a  child  contented ;  many  an 
attack  of  screaming  attributed  to  "  wind  "  is  really  due  to  cold  feet.  In 
obstinate  flatulence  dill  water  may  be  ordered,  and  a  small  teaspoonful 
of  warmed  olive  oil,  if  given  daily,  prevents  constipation. 

A  monthly  nurse  can  do  much  by  thoughtfulness  to  avoid  giving 
additional  trouble  in  the  household. 

In  thus  sketching  the  duties  of  modern  trained  nurses  and  their 
position  as  regards  the  medical  profession,  I  would  urge  that  more 
rather  than  less  training  and  discipline  is  needed  in  every  branch,  and 
it  is  entirely  in  the  hands  of  the  medical  men  to  raise  and  insist  upon 
the  maintenance  of  a  high  standard.  Both  callings  would  profit  by  it, 
and  the  sick  of  every  rank  in  life  would  reap  the  benefit.  In  no  other 
work  are  Browning's  words  so  true  — 

Oh,  the  little  more,  and  how  much  it  is  — 
Oh,  the  little  less,  and  what  worlds  away. 

Amy  Hughes. 


THE  HYGIENE   OE  YOUTH 

I.  Introduction.  — Efficiency  for  the  accomplishment  of  the  work  of  life 
is  a  result  both  of  the  character  and  direction  of  the  training  received, 
and  of  the  physical  and  mental  vigour  to  which  that  training  has  led. 
And,  surveying  the  question  from  a  practical  point  of  view,  it  is  obvious 
that  greater  '^ staying  power"  and  less  training  is  better  than  excessive 
training  with  consequent  diminution  of  vigour. 

Two-thirds  of  the  period  of  youth  are  spent  in  the  process  of  educa- 
tion, and  in  proportion  to  the  care  and  thought  expended  by  parents  and 
teachers  will  growth'  and  development  reach  their  highest  expression, 
or  ill-health  and  disease  result.     I  have  no  hesitation  in  saying,  from  a 


458  SYSTEM   OF  MEDICINE 

wide  experience,  that  a  due  amount  of  care  has  never  yet  been  bestowed 
upon  the  young  human  being. 

In  the  training  of  the  young  the  individual  must  be  regarded  as  a 
whole,  so  that  mind  may  not  be  developed  at  the  expense  of  body,  or 
vice  versd,  but  a  harmonious  dual  development  secured. 

In  the  process  of  education,  which  in  its  proper  sense  necessarily  im- 
plies both  physical  and  mental  development,  the  teacher  too  frequently 
ignores  the  former  factor.  It  is  the  physician's  province  to  point  out 
that  education  must  not  be  pursued  at  the  expense  of  physical  welfare. 
Though  his  advice  may  be  too  generally  ignored  or  contemned,  he  must 
yet  insist  that  his  office  is  to  guide  the  schoolmaster  in  his  duties  so 
far  as  they  concern  the  health  of  the  pupils ;  nay,  even  in  respect  of 
the  teaching  itself —  so  disastrous  is  the  assumption  that  teaching  needs 
no  technical  training  —  less  serious  consequences  would  ensue  to  the 
young  were  the  physician's  advice  more  frequently  sought  and  adopted. 

The  proper  aim,  therefore,  of  parents  and  teachers  being  the  attain- 
ment of  the  highest  development  of  mind  and  body,  it  must  be  impressed 
upon  them  in  every  Avay  that  this  result  is  dependent  upon  an  appro- 
priate training  in  youth. 

In  order  to  secure  the  highest  physical  growth  it  is  necessary  that  an 
approximately  accurate  estimate  should  be  formed  of  each  child's  constitu- 
tion.    Those  who  should  receive  the  most  careful  forethought  are :  — 

1.  Children  who  are  delicate  or  sickly. 

2.  Children  who  have  had  an  ailment  which  may  recur  under 
unfavourable  circumstances. 

3.  Children  who,  though  healthy  as  yet,  come  of  an  ailing  or  dis- 
eased stock,  a  stock  in  the  offspring  of  which,  as  the  physician  knows, 
hereditary  ailments  and  diseases  are  apt  sooner  or  later  to  appear.  If 
these  children  be  surrounded  by  favourable  conditions  during  the  period 
of  growth,  the  tendency  to  such  disease  might  be  eradicated  or  miti- 
gated. Partly  through  ignorance,  but  mainly  from  pure  thoughtlessness, 
parents  flatter  themselves  that,  as  their  children  seem  healthy  during 
youth,  they  have  escaped  the  parental  tendency  ;  whereas  if  they  would 
but  admit  that  these  children  are  likely  to  be  stamped  Avith  their  own 
die,  and  set  themselves  diligently  to  counteract  the  hereditary  taint,  the 
children  would  often  have  to  bless  this  wise  forethought  for  a. healthy 
manlrood. 

It  is  incumbent  on  parents  to  bear  in  mind  what  is  so  Avell  expressed 
by  Dr.  John  Harley,  that  "  within  certain  limits  the  healthy  body  can 
accommodate  itself  with  facility  to  considerable  variations  in  the 
external  conditions,  and  those  are  the  delicate  who  cannot  readily  do 
this,  and  who,  in  the  transition  process,  are  liable  to  develop  abnormal 
action,  or,  in  other  words,  disease."  To  ignore  such  tendencies  to  dis- 
ease may  hamper  the  child  throughout  life,  and  bring  misery  not  only 
to  himself,  but  possibly  again  also  to  his  descendants,  by  entailing 
disease  and  premature  death,  or,  still  worse,  that  deterioration  of 
character  which  ill-health  so  often  engenders. 


THE  HYGIENE    OF   YOUTH 


459 


Table  showing  the  average  and  mean  height  and  weight,  and  the  annual 
rate  of  increase,  of  7855  boys  and  men,  between  the  ages  of  10  and 
30,  of  the  artisan  class  —  town  population :  — 


Ag-e  last 

Heifrht,  without  Shoes. 

Weight,  Including  Clothes  of !»  lbs. 

day. 

Average. 

Growth. 

Mean. 

Growth. 

Average. 

Growth. 

Mean. 

Growth. 

In. 

In. 

In. 

In. 

lbs. 

lbs. 

lbs. 

lbs. 

10 

50-52 

50-50 

66-31 

66-0 

11 

51-52 

1-00 

51-50 

1-00 

69-46 

3-15 

70-0 

4-b 

12 

52-99 

1-47 

53-50 

1-50 

73-68 

4-22 

74-0 

4-0 

13 

55 '93 

2-94 

55-50 

2-50 

78-27 

4-59 

78-0 

4-0 

14 

57-76 

1-83 

58-00 

2-50 

84-61 

6-34 

84-0 

6-0 

15 

60-58 

2-82 

60-50 

2-50 

96-79 

12-18 

94-0 

10-0 

16 

62-93 

2-35 

63-00 

2-50 

108-70 

11-93 

106-0 

12-0 

17 

64-45 

1-52 

64-50 

1-50 

116-40 

7-66 

116-0 

10  0 

18 

65-47 

1-02 

65-50 

1-00 

1-23-30 

6-97 

122-0 

6-0 

19 

66-02 

0-55 

66-00 

0-50 

128-40 

5-08 

128-0 

6-0 

20 
21 
22 

66-31 

0-29 

66-25 

0-25 

130-60 

2-20 

132-0 

4-0 

66-60 

0-29 

66-50 

0-2'5 

135-40 

4-81 

136-0 

4-0 

23-30 

66-68 

0-08 

66-50 

139-00 

3-58 

138-0 

2-0 

Table  showing  the  average  and  mean  height  and  weight,  and  the 
annual  rate  of  increase,  of  7709  boys  and  men,  between  the  ages  of 
10  and  30  years,  of  the  most  favoured  classes  of  the  English  popu- 
lation—  public-school  boys,  naval  and  military  cadets,  medical  and 
university  students :  — 


Ape  last 
Birth- 
day. 

Height,  without  Shoes. 

Weight,  including 

Clothes  of  9  lbs. 

Average. 

Growth. 

Mean. 

Growth. 

Average. 

Growth. 

Mean. 

Growth. 

In. 

In. 

In. 

In. 

lbs. 

lbs. 

lbs. 

lbs. 

10 

53-40 

53-00 

67-4 

67-0 

11 

54-91 

1-51 

54-50 

1-50 

72-9 

5-50 

73-0 

6-0 

12 

56-97 

2-06 

56-50 

2-00 

80-3 

7-39 

80-0 

7-0 

13 

58-79 

1-82 

58-50 

2-00 

88-6 

8-27 

88-0 

8-0 

14 

61-11 

2-32 

61-00 

2-50 

99-2 

10-61 

98-0 

10-0 

15 

63-47 

2-36 

63-50 

2-50 

110-4 

11-21 

110-0 

12-0 

16 

66-40 

2-93 

66-50 

3-00 

128-3 

17-92 

126-0 

16-0 

17 

67-84 

1-46 

68-00 

1-50 

141-0 

12-69 

140-0 

14-0 

18 

68-29 

0-43 

68-50 

0-50 

146-0 

4-97 

146-0 

6-0 

19 

68-72 

0-43 

68-75 

0-25 

148-3 

2-20 

148-0 

2-0 

20 

69-13 

0-41 

69-00 

0-25 

152-0 

3-87 

150-0 

2-0 

21 

69-16 

0-03 

152-3 

0-27 

152-0 

2-0 

22 

68-93 

154-7 

2-44 

23 

68-53 

151-7 

24 

68-95 

149-2 

25-30 

69-06 

69-00 

155-2 

6-42 

154-0 

2-0 

The  lieight  and  vjeight  should  annually  increase,  not,  it  is  true,  with 
steady  regularity,  for  in  autumn  and  winter  the  advance  is  less  than 
during  spring  and  summer.  But  the  weight  always  bears  a  certain 
definite  ratio  to  the  height. 


46o  SYSTEM  OF  MEDICINE 

In  a  child  a  constitutional  disease  is  usually  regarded  as  a  necessary- 
evil,  and  the  parent  never  dreams,  that  a  rational  readjustment  of  the 
circumstances  in  the  light  of  modern  preventive  medicine  might  have 
prevented  the  mischief. 

We  should  never  forget  that  a  vigorous  manhood  is  the  greatest  of 
all  blessings,  and  that  the  vestibule  to  its  attainment  is  a  healthy  child- 
hood; parents  must  be  educated  to  understand  that  the  highest  and 
most  acceptable  endowment  which  they  can  bestow  upon  their  children 
is  good  health,  and  after  that,  a  sound  education ;  these  blessings  by  fore- 
thought and  foresight  may  usually  be  obtained. 

Health  must  depend  largely  upon  two  conditions :  — 

1.  The  inherent  properties  of  each  individual. 

2.  The  environment  in  which  the  individual  is  reared. 

Only  so  long  as  the  individual  organism  is  placed  in  its  appropriate 
surroundings  —  i.e.  grown  on  its  proper  soil  —  can  we  expect  to  produce 
typical  health  and  strength.  Failing  these  necessary  conditions  we  can 
only  anticipate  imperfect  growth,  meagre  health,  an  absence  of  robust- 
ness of  chara'iter  and  manliness,  the  manifestation  of  early  disease,  and 
the  absence  of  vigorous  old  age. 

II,  The  Environment.  —  I  would  first  point  out  the  necessity,  as  far 
as  possible,  of  bringing  up  the  young  in  the  country  rather  than  in  town ; 
and  in  detached  residences,  rather  than  in  the  immense  blocks  which 
constitute  some  of  our  schools  and  asylums.  Where  parents  reside  in 
towns  every  effort  should  be  made  to  arrange  for  education  in  the 
country ;  if  this  be  impracticable,  opportunity  should  be  made  for  spend- 
ing the  vacations  there.  The  importance  of  this  condition  has  repeatedly 
impressed  itself  upon  my  notice,  when  I  have  been  consulted  about  the 
children  of  persons  in  comfortable  and  even  in  affluent  circumstances 
who  (with  apparent  exemption  from  any  hereditary  delicacy  in  the 
family)  enjoyed  all  the  requisites  for  healthy  growth  except  this;  and 
who,  being  brought  up  in  a  town,  or  even  in  a  "  healthy  suburb,"  con- 
tinually suffered  from  tonsillitis,  croup,  bronchitis,  persistent  bronchial 
catarrh  or  pneumonia.  As  soon  as  they  were  removed  to  a  school 
in  the  country  their  ailments  ceased,  education  was  uninterrupted,  and 
healthy  physical  development  succeeded.  In  the  case  of  nervous 
diseases  this  difference  of  effect  between  towii  and  country  is  still  more 
marked. 

Last  summer,  when  I  joined  in  the  inspection  of  a  Volunteer  brigade 
of  five  battalions  comprising  more  than  4000  men,  I  observed  in  passing 
through  the  ranks  of  the  various  "  companies "  that  the  difference  in 
height,  breadth  and  aspect  between  companies  levied  in  the  country  and 
those  mustered  from  towns  was  astounding.  These  facts  are  clearly  ex- 
hibited in  detail  in  the  carefully-prepared  tables  of  Mr.  Charles  Roberts, 
which  should  exercise  a  decided  influence  on  the  modes  of  rearing  the 
young. 

•  The  air  of  town  and  country  is,  of  course,  originally  the  same  in 
composition.     But  town  air  is  rendered  impure,  not  only  by  the  absence 


THE  HYGIENE    OF   YOUTH  461 


of  sunlight,  but,  as  it  would  seem,  by  the  presence  of  some  deleterious 
elements.  Hence  the  exhilarating  feeling  of  breathing  fresh  country 
air  as  a  contrast  to  that  of  the  town.  But  the  utility  of  transferring 
children  to  the  country  vanishes  if  they  are  confined  to  day-rooms  and 
bedrooms  with  so  insufficient  an  extent  of  CAihic  sjoace  that  air  has  to  be 
rebreathed. 

There  is  no  habit  more  common,  and  none  more  deleterious  and 
uncleanly,  than  that  of  living,  working  and  sleeping  in  ill-ventilated 
rooms,  and  breathing  and  rebreathing  the  same  air.  It  causes  ill-health 
a,nd  deficient  growth,  from  the  imperfect  working  of  the  internal  func- 
tions of  the  body ;  and  renders  the  human  being  disposed  to  the  attack 
of  poisons  from  without.  There  can  now  be  little  doubt  that  these 
conditions  pre-eminently  favour  the  development  of  tubercle  bacilli. 
The  effect  of  pure  and  impure  air  on  health  and  mortality,  as  recorded 
by  Parkes,  is  strikingly  shown  in  horses ;  for  in  them  the  question  is 
more  simple  on  account  of  the  similarity  in  different  times  and  places 
of  food,  water,  exercise  and  treatment.  Formerly,  in  the  French  army, 
the  mortality  of  horses  was  enormous.  Rossignol  states  that,  previous 
to  1836,  the  mortality  of  the  French  cavalry  horses  varied  from  180  to 
197  per  1000  per  annum.  The  enlargement  of  the  stables  —  the  in- 
creased quantity  of  the  ration  of  air  —  reduced  the  loss  in  the  next  ten 
years  to  68  per  1000. 

It  is  sometimes  stated  that  nurseries  and  schools  need  only  be 
supplied  with  half  the  amount  of  air-space,  on  account  of  the  size  of 
the  inmates.  No  greater  mistake  can  be  made.  Children  cannot  thrive 
well  without  the  purest  air ;  like  the  young  of  all  animals,  they  are 
peculiarly  sensitive  to  pre-breathed  air.  Yet  parents  will  take  any 
trouble,  and  make  any  complaint,  about  the  quality  and  the  quantity 
of  the  food  at  schools,  but  show  no  concern  about  the  ration  of  air  pro- 
vided. If  they  have  to  find  fault  with  the  appearance  of  their  children 
on  their  return  home  for  the  vacation,  they  immediately  throw  the  blame 
on  the  inferior  quality  or  quantity  of  food.  The  truth  is  that,  in  a  large 
proportion  of  cases,  the  pupils  are  compelled  to  live  and  work  hard  in 
insufficient  air-space,  and  to  sleep  in  still  less.  This  has  been  repeatedly 
proved  by  the  diminution  of  excessive  mortality  on  the  provision  of 
more  air.  The  active  functions  of  children,  together  with  their  quicker 
breathing,  necessarily  produce  more  rapid  tissue  change.  It  was  found 
by  Voit,  that  during  waking  hours  more  carbonic  acid  in  proportion  is 
given  off,  while  during  sleep  more  oxygen  is  absorbed  than  carbonic 
acid  eliminated.  And  in  his  eighth  report  to  the  Privy  Council,  1865, 
Sir  John  Simon  stated,  "that  even  healthy  children,  in  proportion  to 
their  respective  bodily  weights,  are  about  twice  as  powerful  as  adults 
in  deteriorating  the  air  which  they  breathe." 

Place.  —  The  quality  of  the  soil  on  which  the  child  is  reared  is  of 
paramount  importance,  especially  in  relation  to  the  position  of  the 
water-level.  It  is  well  known  that  water  lying  stagnant  on  the  surface 
of  land  is  very  inimical  to  health ;  but  it  is  not  so  well  recognised  that 


462  SYSTEM   OF  MEDICINE 

uELhealthiness  is  also  produced  where  the  subsoil  is  loaded  with  stagnant 
water. 

Drainage  of  Soil.  —  Efficient  surface  and  subsoil  drainage,  so  as  to 
lower  the  water-level  even  a  foot  or  two,  may  remove  consumption  and 
diarrhoea  from  an  entire  district,  and  produce  so  improved  a  state  of 
health  among  the  inhabitants  that  the  development  of  germ  life  in  them 
is  largely  prevented. 

In  the  selection  of  residence  for  a  delicate  child,  other  things  being 
equal,  the  nearer  it  is  to  the  sea  the  more  equable  the  climate;  the 
farther  from  the  sea  the  more  is  the  climate  one  of  extremes.  Hence 
the  child  who  requires  a  moist,  equable  climate,  with  warm  winters  and 
warm  nights,  should  live  at  the  sea^side,  while  those  who  need  a  more 
bracing  air  should  reside  inland.  Children  Avho  possess  that  form  of 
delicacy  which  renders  them  susceptible  to  constant  colds;  those  having 
a  hereditary  tendency  to  rheumcUism,  consumption,  feeble  circulation,  neu- 
ralgia, kidney  disease,  and  other  such  misfortunes,  might  be  saved  much 
misery  could  they  pass  their  period  of  youth  in  a  dry,  warm  situation.  It 
must  constantly  be  borne  in  mind,  that  although  consumption  is  a  para- 
sitic disease  arising  from  the  attack  of  tubercle  bacilli,  yet  these  bacilli 
only  find  a  suitable  soil  for  their  propagation  in  certain  constitutions,  or 
in  feeble  states  of  constitution ;  a  vigorous  condition  of  health  resists  them. 

Further,  where  insanity,  or  even  an  excitable  nervous  condition  — 
which  is  often  exemplified  in  hysteria  only  —  is  known  to  have  occurred 
in  members  of  the  family,  the  child  should  be  educated  where  he  can 
be  out  of  doors  most  of  his  time,  on  fine  days,  so  that  vigour  of  consti- 
tution may  be  produced,  for  in  this  development  the  brain  itself  largely 
participates.  Such  a  child  should  not  be  allowed  to  work  at  night,  or 
for  any  examination,  until  his  brain  is  mature  in  its  growth.  Above  all 
he  should  be  taught  that  immorality  in  any  form  is  especially  detrimental 
to  the  stability  of  his  brain. 

It  is  also  imperative  that  a  child  born  with  this  hereditary  dis- 
position should  be  educated,  from  his  earliest  years  to  manhood,  away 
from  home,  and  apart  from  the  management  of  his  parents  or  any  rela- 
tives who  are  tainted  with  the  nervous  constitution,  in  a  place  where 
a  regular  life  will  be  maintained  under  watchful  discipline,  where  all 
waywardness  will  be  dealt  with  by  a  firm  but  kind  hand,  and  where  he 
will  work  and  play  with  those  of  his  own  age  who  are  more  robust  in 
health  and  in  character.  By  such  means  the  nervous  tendency  may  be 
eradicated :  yet  these  very  children  are  too  often  kex^t  at  home,  where 
they  are  petted  and  pampered,  never  thwarted  or  corrected  lest  the 
nervous  condition  should  be  induced,  and  where  peevishness,  ill-temper, 
and  petty  tyranny  are  allowed  full  sway.  Such  surroundings  make  a 
hotbed  for  the  development  of  the  tendencies  which  it  is  essential  to 
check.  In  the  case  of  girls,  who  spend  so  much  time  at  home,  and 
are  disposed  to  a  nervous  habit,  it  is  still  more  imperative  that 
their  education  should  be  absolutely  freed  from  the  influence  of  such 
surroundings. 


THE  HYGIENE    OF   YOUTH  463 

It  is  most  mischievous  to  tamper  witli  the  emotions  of  the  young,  for 
they  are  so  unstable  during  this  period  of  life  as  to  be  certain  to  run  into 
channels  unforeseen  and  undesired.  Even  religious  fervour,  if  excessive, 
is  often  perverted  into  the  shape  of  sexual  immorality.  In  youth  the 
appetites,  desires  and  passions  awake,  untempered  by  reason,  uninstructed 
by  experience,  so  that  at  no  time  of  life  is  steadfast  guidance  and  help 
more  essential.  Yet  how  few  boys  —  and  still  fewer  girls  —  receive  the 
needful  aid  from  their  home  training ;  a  policy  of  silence  is  substituted 
with  results  frequently  disastrous. 

III.  External  Conditions.  —  As  regards  clothing,  it  must  be  borne  in 
mind  that  the  skin  is  our  most  important  gland,  and  requires  protection 
to  enable  it  to  do  its  duty,  and  to  prevent  its  functions  being  arrested 
by  sudden  chills  or  other  changes  of  temperature.  In  this  country, 
where  the  temperature  of  the  body  is  always  higher  than  that  of  the 
atmosphere,  the  use  of  clothing  is  to  prevent  the  waste  of  the  heat  of 
the  body. 

The  skin  regulates  the  temperature  of  the  body  by  means  of  its 
blood-vessels,  and  these  are  dilated  and  contracted  by  their  vaso-motor 
nerves,  which  turn  on  or  shut  off  the  blood  as  stopcocks  regulate  hot 
water  pipes.  The  equability  of  the  temperature  of  the  body  is  regulated 
by  a  mechanism  now  well  known  to  physiologists.  The  cooling  power 
of  a  sweating  skin  is  enormous,  and  the  chill  arising  from  clothes  damp 
after  exertion  or  getting  wet  are  well  known.  But  no  one  catches 
cold,  or  becomes  chilled,  from  keeping  on  wet  garments  so  long  as  he  is 
warmly  clad,  i.e.  so  long  as  rapid  evaporation  or  icing  is  prevented.  A 
non-conductor  should,  therefore,  be  worn  next  to  the  skin,  so  that  the 
changes  of  its  temperature  may  not  be  too  sudden.  Wool  of  vari- 
ous thickness  is  the  best  covering  of  the  skin  in  summer  as  w^ell  as  in 
winter. 

It  should  be  remembered  that  the  bodies  of  children  are  less  capable 
of  resisting  heat  and  cold  than  of  adults.  But  the  worst  of  all  clothing 
for  children  is  excessive  clothing.  From  time  to  time  I  see  children  who, 
being  considered  delicate,  are  burdened  with  an  inordinate  amount  of 
clothing  which  increases  their  delicacy  —  their  skin  is  never  dry.  By  a 
reduction  of  the  excessive  clothing  the  "  delicacy "  often  disappears. 
Clothing  should  keep  the  skin  warm,  but  not  moist  except  under  active 
exertion.  When  moisture  is  perceptible  on  the  skin  under  ordinary 
circumstances  by  night  or  day,  the  clothing  is  excessive  and  harm  will 
result. 

In  this  country  the  siimnier  season  should  be  well  established  before 
a  change  is  made  in  the  thickness  of  the  underclothing ;  much  illness 
is  occasioned  by  a  premature  change  suggested  by  a  few  warm  days  in 
April  or  May. 

Much  care  should  be  given  to  keep  the  feet  ahvays  warm,  for  neglect 
of  this  entails  unnecessary  ill-health  often  mistakenly  attributed  to  in- 
herent delicacy.  I  continually  see  children,  and  whole  families  too,  who 
are  always  ailing,  and  are  consequently  described  as  very  delicate;  whose 


464  SYSTEM   OF  MEDICINE 

"  delicacy  "  comes  indeed  of  the  mother,  but  only  in  this  that  she  does 
not  know  the  value  of  warm,  dry  socks  and  thick  boots.  That  the  lack  of 
these  is  the  commonest  cause  of  enlargement  of  the  tonsils  I  feel  sure, 
and  I  suspect  that  it  is  answerable  for  a  large  proportion  of  the  cases 
of  post-nasal  growths. 

The  importance  of  warm  feet  in  the  maintenance  of  good  health  has 
so  impressed  itself  upon  the  attention  of  a  shrewd  schoolmaster  who  has 
125  boys  under  his  care,  that  every  boy  is  compelled  daily,  as  soon  as 
he  has  settled  indoors,  not  only  to  change  his  boots,  but  also  to  put 
on  a  pair  of  dry  socks.  The  drying  of  damp  hoots  before  rewearing 
them  has  not  yet  received  the  attention  it  deserves,  and  in  very  few 
schools  are  means  provided  for  this  purpose.  The  miseries  and  deformi- 
ties (such  as  chilblains,  ingrowing  toe-nail,  flat  foot,  anchylosed  toes  and 
corns)  originating  from  out-grown  and  misfitting  boots  —  boots  never 
intended  to  fit  the  foot,  but  only  to  suit  the  fashion  —  I  must  not  here 
discuss. 

IV.  Internal  Conditions.  —  Next  in  importance  to  fresh  air,  sunshine, 
and  locality  in  the  nurture  of  the  young,  is  the  material  — food — necessary 
to  provide  for  existence  and  for  growth  and  development.  Without 
nourishment,  appropriate  in  quantity  and  quality,  bodily  vigour  is  im- 
possible, resistance  to  parasitic  disease  fails,  internal  maladies  arise,  or 
less  specific  general  physical  and  mental  deterioration  are  induced. 

A  large  proportion  of  the  sufferings  of  adult  life  arise  from  the  in- 
appropriate food  and  cooking  and  the  hasty  meals  of  adolescence.  Some- 
times the  diet  of  youth  is  so  nicely  adjusted  to  its  cost  that  illness  is 
barely  averted,  while  growth  and  development  are  frustrated.  A  more 
short-sighted  policy,  even  financially,  it  is  difficult  to  conceive ;  the 
cheapest  policy,  in  the  long  run,  for  the  rearing  of  youths,  is  to  feed 
them  well,  so  that  they  may  be  advantageously  started  for  the  attain- 
ment of  the  maximum  of  size  and  strength.  If  thus  helped  to  reach  a 
vigorous  adult  age  greater  and  better  work  will  be  obtained  from  them, 
with  more  vigorous  brain  power,  higher  character,  and  less  liability  to 
special  incapacities  or  deficient  energies. 

Again,  variety  of  food  is  essential  to  efficient  digestion  and  liveliness 
of  disposition ;  monotony  of  diet  seems  to  produce  monotony  of  character, 
probably  by  way  of  some  defect  of  nutrition. 

The  periodical  use  of  the  scales  —  say,  once  a  month  —  would  indicate 
to  parents  and  teachers  beyond  all  doubt  whether  the  child  was  well 
cared  for  or  gravely  wronged.  It  would  reveal  errors  in  the  mode  of 
life,  —  such  as  inappropriate,  insufficient  or  monotonous  feeding,  over- 
work, or  over-exercise,  —  and  would  also  direct  earlier  attention  to  the 
advent  of  disease.  Periodically  carried  out  it  ivould  show  whether  the 
natural  standard  of  height  to  weight  was  being  maintained. 

In  estimating  the  significance  of  the  measure  and  scales,  it  must  be 
remembered  that  most  children  grow  by  fits  and  starts ;  rapid  growth 
requires  great  care,  ample  food,  more  rest,  and  little  work,  while  on 
loss  of  weight  work  should  be  diminished  or  cease  altogether.     In  some 


THE  HYGIENE    OF   YOUTH  465 

schools  such  a  record  is  already  kept,  and  has  been  found  to  be  of  the 
greatest  assistance  to  the  teacher.  For  instance,  should  the  measure  and 
scales  disclose  that  all  the  pupils  are  deficient  in  height  and  Aveight  for 
their  age,  it  will  be  evident  that  some  radical  defect  of  management 
exists ;  should  they  indicate  that  one  child  here  and  there  is  below  the 
average,  a  reference  to  the  height  and  weight  chart  on  entrance  to  school 
might  show  the  child  to  be  the  offspring  of  a  diminutive  stock ;  on  the 
other  hand,  if  the  original  height  and  weight  were  then  normal,  the 
evidence  would  be  clear  that  the  child  had  been  working  excessively, 
fed  too  sparingly  (perhaps  on  account  of  a  squeamish  stomach),  or  that 
illness  or  disease  was  imminent. 

On  the  other  hand,  it  is  quite  conceivable  that  many  schoolmasters 
and  mistresses  would  dread  the  introduction  of  this  system,  since  it 
would  reveal  the  viciousness  of  many  of  the  present  methods  of  education 
and  treatment,  and  would  involve  (if  its  indications  were  attended  to) 
considerable  thought  and  alteration  in  the  administration. 

No  work  should  ever  be  imposed  upon  boys  or  girls  without  previovis 
sustenance.  Food  first,  work  afterwards,  should  be  the  invariable  maxim. 
To  work  before  food  probably  implies  that  the  material  necessary  for  the 
performance  of  the  work  must  be  absorbed  at  the  expense  of  the  system 
and  to  the  hindrance  of  bodily  growth.  The  meals,  therefore,  should  be 
wisely  arranged  :  a  substantial  meat  meal  should  be  provided  for  break- 
fast and  dinner,  so  that  the  heavy  meals  may  be  consumed  bafore  the 
principal  morning  and  afternoon  work  commences  ;  lighter  meals  may  be 
taken  in  the  after  part  of  the  day  when  the  heavy  work  is  ended.  On 
the  other  hand,  a  meat  meal  three  times  a  day  is  objectionable  and 
injudicious  on  all  grounds,  although  I  continually  hear  of  physicians 
recommending  this  plan  in  the  rearing  of  youth :  it  would  be  found  most 
inappropriate  for  schools  at  all  events. 

The  cooldng  of  food  for  the  young  has  scarcely  received  the  attention 
it  deserves  and  requires ;  this  neglect  and  the  supplementary  stuffings 
at  tuck  shops  are  a  fertile  source  of  feeble  health,  meagre  work,  bad 
temper,  and  permanent  damage  to  the  digestive  organs. 

Insufficient  time,  again,  is  rarely  allowed  to  the  young  for  efficient 
mastication  and  saturation  of  the  food  with  the  secretion  of  the  salivary 
glands.  If  a  child  abstain,  for  any  reason,  from  eating  a  meal  or  meals, 
he  must  not  be  expected  to  perform  his  tasks  as  usual.  Every  child 
who  does  not  eat  his  food  should  be  reported  to  his  master,  careful 
inquiry  made  into  the  cause,  and  the  omission  repaired.  It  must  never 
be  forgotten  that  it  is  during  the  years  of  growth  that  the  delicate  child 
may  overcome  its  feebleness  and  be  made  permanently  strong,  or  the 
strong  child  be  weakened  and  stunted. 

I  would  especially  point  out  the  necessity  of  children  being  taught 
to  use  their  teeth  for  the  purposes  of  mastication,  rather  than  be  allowed 
the  too  frequent  use  of  the  knife,  or  be  provided  with  soft  foods;  in 
this  w^ay  only  will  the  teeth  be  kept  serviceable.  Twice  a  year  at  least 
children's  mouths  should  be  inspected  by  the  dentist. 

VOL.    I  2    II 


466  SYSTEM  OF  AI ED  I  CINE 

Concerning  the  suitable  kinds  of  food  for  youth,  I  would  insist  that 
meat  should  be  provided  twice  a  day,  at  breakfast  and  at  dinner ;  that  the 
crust  of  bread  is  more  suitable  than  the  crumb,  and  whole  meal  than 
white  bread ;  that  porridge  is  an  invaluable  article  of  diet ;  that  sugar, 
so  frequently  denied,  is  an  indispensable  requirement,  forming  as  it  does 
their  main  heat-forming  food,  as  well  as  the  most  important  factor  in 
the  growth  and  work  of  muscles ;  that  milk  should  take  the  place  of  tea 
and  coffee ;  and  that  young  people  are  better  without  alcohol  during  this 
period  of  life. 

Food  implies  waste,  which  results  from  Avear  and  tear,  and  is  removed 
from  the  body  by  certain  excretory  organs.  These  products  of  com- 
bustion must  be  continually  removed  if  health  is  to  be  maintained. 
As  Dr.  Lauder  Brunton  says :  "  As  a  rule,  people  are  now  fully  alive 
to  the  risks  they  run  from  poisoning  by  sewer  gas,  or  to  put  it  more 
widely,  from  poisoning  by  products  of  decomposition  outside  the  body ; 
but  perhaps  we  do  not  all  of  us  keep  so  clearly  before  us  as  we  ought 
the  fact  that  inside  the  body  there  are  all  the  conditions  for  the  for- 
mation of  putrefactive  products,  and  the  most  favourable  arrangement 
for  their  rapid  absorption."  The  need  of  the  daily  removal  of  these 
products  from  the  body  is  not  yet  sufficiently  taught  and  enforced  in 
the  young,  and  as  a  consequence  much  unnecessary  ill-health  ensues, 
and  the  appearance  of  piles  is  facilitated  and  encouraged. 

V.  As  we  have  discussed  the  suitable  environment  for  the  human 
body  during  early  life  and  also  the  material  necessary  for  growth,  we  must 
now  consider  the  purport  of  this  care,  and  we  shall  find  that  the  highest 
attainable  development  is  impossible  without  the  exercise  of  functions. 

As  unused  organs  atrophy,  it  is,  therefore,  essential  that  they  be 
employed  in  order  to  ensure  a  maximum  of  growth  and  usefulness.  But 
it  must  be  borne  in  mind  that  whether  we  consider  the  exercise  of  the 
brain  which,  during  this  period  of  life  we  shall  term  work  or  education, 
or  the  exercise  of  the  body,  which  we  shall  term  play  or  recreation, 
exercise  increases  gi-owth,  while  over-exercise  stunts  it.  This  is  doubly 
true  when  we  are  discussing  immature  but  growing  organs ;  for  strain 
of  any  description  is  detrimental  to  their  efficiency.  And  exercise  of 
function  is  no.t  only  essential  to  growth  and  development,  but  also  to 
the  healthy  maintenance  of  the  brain  and  body  when  normal  growth  is 
attained.  In  the  performance  of  work  energy  is  expended  and  finally 
exhausted  ;  and  this  end  comes  sooner  in  the  young  than  in  those  whose 
tissues  are  matured.  Moreover,  the  young  have  to  tread  unbeaten  tracks, 
which  consumes  more  force  than  the  pursuit  of  more  or  less  accustomed 
studies.  This  opening  up  of  new  ground  necessitates  exertion,  and  un- 
less the  exertion  is  put  forth  with  pleasure,  it  is  apt  to  become  harmful ; 
whereas  information  acquired  by  the  young  with  pleasure  rarely  occasions 
injury.  Hence  the  importance  of  the  study  of  "likes  and  dislikes,"  and 
of  fostering  work  for  which  the  pupil  shows  a  taste,  slowly  adding  that 
which  is  at  first  distasteful.  In  fact,  the  appetite  for  work  is  very 
similar  to  the  appetite  of  eating ;  the  child  will  not  only  thrive,  but  get 


THE   HYGIENE    OF   YOUTH  467 

fat  on  that  which  it  likes,  while  it  will  eat  so  sparingly  of  what  is  dis- 
tasteful that  the  body  will  suffer.  It  is  true  of  mind  as  well  as  of  body, 
if  unsophisticated,  that  we  all  like  what  we  can  readily  digest.  More- 
over, as  variety  of  food  is  essential  for  the  adequate  development  of 
the  body,  so  variety  of  work  is  imperative  for  due  development  and 
nourishment  of  the  brain ;  and  as  slow  and  regular  development  of  the 
body  produces  the  finest  and  most  permanent  results  in  strength  and 
durability  of  other  tissues,  so  it  is  also  with  the  brain  itself. 

The  prime  duty  of  the  teacher  is  to  develop  whatsoever  faculties 
a  pupil  has,  however  rudimentary  they  may  be ;  and  he  alone  is  the 
real  educator  who  knows  how  to  compass  this,  instead  of  passing  all 
pupils,  like  corn,  through  the  same  mill.  Every  faculty  thus-  developed 
becomes  a  stepping-stone  in  educating  other  faculties  which  may  be 
still  dormant;  though  sometimes  special  ability  in  one  direction  may 
coexist  with  utter  incapacity  in  others,  mentally  and  morally.  It  is 
natural  to  all  children  to  desire  knowledge,  —  a  desire  which,  unfortu- 
nately, our  teachers  too  often  succeed  in  extinguishing  outright. 

The  true  aim  of  training  and  of  education  should  be  to  develop  the 
best  type  of  manhood  in  mental,  moral,  and  physical  well-being,  —  an 
aim,  I  regret  to  say,  too  frequently  disregarded,  especially  in  the  train- 
ing of  girls,  who  should  receive  the  greater  consideration  on  account  of 
the  peculiarity  of  their  growth  and  the  demands  to  be  made  upon  them 
in  early  motherhood.  The  young  are  allowed  insufficient  time  for 
sleep;  they  are  often  deprived  of  fresh  air  and  exercise  by  faulty 
school  regulations,  or  unwisely-assigned  punishments ;  they  have  little 
time  to  masticate  their  food  owing  to  the  hurry  of  school  customs ;  and 
thefr  hours  of  work  are  usually  too  prolonged,  extending  throughout  the 
evening  and  too  far  into  the  night,  to  permit  either  of  good  work  or  a 
healthy  development  of  the  brain.  An  intimate  friend  of  mine,  and  a 
born  educator  of  the  young,  has  informed  me  that  since  he  abolished 
evening  preparation  of  work  in  his  school  of  considerably  over  a  hun- 
dred young  boys,  not  one  case  of  sleep-walking  has  occurred,  although 
many  cases  happened  before  this  reform. 

The  worst  feature  in  this  prevalent  method  of  education  is  that  the 
long  hours  and  clumsy  educational  methods  compel  the  work  to  be  per- 
formed under  a  sense  of  fatigue,  so  that  the  work  itself  is  not  of  lasting 
value,  and  the  brain  may  be  damaged  in  the  process.  These  imperfect 
methods  of  education  are  likely  to  continue  until  teachers  receive  a 
technical  training  in  their  duties,  or  at  any  rate  till  they  cease  to  despise 
and  abhor  it.  The  education  of  the  youth  of  the  upper  a,nd  middle 
classes  in  England  is  the  only  business  for  which  a  man  is  not  trained. 

The  successful  educator  considers  his  pupil  as  a  whole ;  it  is  the 
disregard  of  this  unity  that  leads  to  harmful  results.  Each  child  pos- 
sesses but  its  own  proportionate  stamina  and  mental  ability,  inherited 
and  acquired.  The  ability  may  exist  potentially  in  abundance,  but  of 
what  avail  unless  the  stamina  be  sufficient  to  provide  a  ])lontiful  supply 
of  good  red  blood  for  the  sustenance  of  the  brain.     This  brain  nourish- 


468 


SYSTEM  OF  MEDICINE 


inent  is  the  product  of  an  efficient  digestion  of  food,  appropriate  in 
quantity  and  quality,  of  fresli  air  and  exercise,  and  of  ample  sleep,  for 
the  nutrition  of  the  brain  takes  place  mainly  during  sleep. 

In  the  regulation  of  the  hours  ofivork  will  any  sane  man  uphold  the 
invariable  custom  which  prevails  of  assigning  the  same  number  of  hours 
of  work  to  a  young  child  when  he  enters  school  and  to  a  senior  pupil 
at  the  point  of  leaving  ?  It  would  be  as  reasonable  to  expect  him  to 
undertake  work  of  a  similar  order  of  difficulty.  To  some  extent  it  is 
recognised  that  one  of  the  chief  functions  of  the  competent  educator  is 
to  graduate  the  training  of  the  brain  from  short  and  easy  tasks  to  more 
rigorous  and  strenuous  exercise ;  but  the  length  of  the  hours  of  work 
should  be  similarly  gauged,  as  the  young  are  without  that  power  of 
sustained  endurance,  which  comes  only  with  the  completion  of  educa- 
tion. If  sterling  and  lasting  work  is  to  be  accomplished  during  youth, 
and  the  brain  is  to  be  benefited  in  the  process,  teachers  must  learn  that 
the  work  of  the  immature  brain  must  be  proportioned  in  difficulty  and 
duration  to  its  age  and  capacity.  Yet  the  work  assigned  is  sometimes 
so  disproportionately  severe  that  progress  is  arrested,  or,  too  often,  con- 
verted into  retrogression;  at  other  times  the  work  is  too  prolonged,  and 
tells  its  tale  in  weakened  brain,  body  and  interest ;  the  character  also 
suffers,  in  consequence  of  the  temptation  to  employ  illegitimate  means 
for  its  accomplishment,  or  to  avoid  punishment  on  account  of  failure. 
A  scale  of  icork  should  be  adapted  to  each  age ;  and  this  again  will 
require  revision  and  remission  in  certain  cases  and  under  special  cir- 
cumstances of  age  and  sex.  In  this  scale  should  also  be  included  any 
work  assigned  as  punishment. 


Table  of  the  Scale  of  Work. 


Ages. 

Hours  of  work  per  week 

From    5  to    6            .            .            .            .            .            .              6 

„        6  „     7 

9 

7  „     8 

12 

8  „  10 

15 

„      10  „  12 

20 

,,      12  „  14 

25 

„       14  „  15 

30 

„      15  „  16 

35 

„      16  „  17 

40 

,,      17  ,,  18 

45 

„      18  „  19 

.     50 

Each  faculty  of  the  brain  —  such  as  thought,  memory,  special  sense, 
muscular  co-ordination,  and  other  functions  —  requires  its  own  special 
stimulation  for  purposes  of  development.  Every  brain  has  its  natural 
high-water  mark  of  effort  and  capacity.  The  systemic  circulation  of 
the  blood  affects  the  central  circulation  so  intimately  that  on  it  depend 
not  only  the  growth  of  the  brain  itself,  but  its  functions  also  during  the 
process  —  a  full  circulation  aiding  a  flow  of  ideas  and  the  retention  of 
facts.  The  debility  of  more  rapid  growth  —  occasionally  seen  in  boys, 
and  habitually  in  girls  —  like  that  ensuing  on  illness,  causes  a  feebleness 


THE  HYGIENE    OF   YOUTH  469 

of  circulation,  and  in  consequence  apathy  and  incapacity  for  mental 
exertion,  however  eager  the  pupil  may  previously  have  been  in  the 
acquisition  of  knowledge. 

The  quality  of  the  blood,  like  feebleness  of  circulation,  dulls  the  mental 
faculties,  as  in  anaemia,  whether  arising  from  deficient  food,  loss  of  blood 
or  overwork.  ISTo  less  injurious  are  the  impurities  which  may  circulate 
in  the  blood,  and  so  irritate  the  brain  matter  as  to  give  rise  to  all  the 
symptoms  of  overwork,  as  is  seen  in  the  case  of  constipation,  biliousness, 
albuminuria  and  so  forth.  It  is,  therefore,  manifest  that  brain  capacity, 
although  in  part  it  depends  upon  progenitors,  depends  also  in  part  on 
environment.  The  bounds  of  safety  can  easily  be  overstepped  where. 
graduation  of  the  amount  and  difficulty  of  work  is  not  provided  for. 

It  is  not  always  the  bright  and  promising  pupil,  but  frequently  the 
dull,  feeble,  but  conscientious  one  who  is  overpressed.  Moreover  there 
are  grades  of  overwork,  from  poor  health  and  loss  of  weight  to  a  com- 
plete and  often  permanent  breakdown ;  here  it  is  that  the  scales  tell  so 
genuine  a  tale.  Loss  of  weight  —  and  even  a  stationary  weight  —  during 
the  years  of  growth  means  overwork,  underfeeding,  incipient  disease,  or 
recent  illness.  Yet  children,  while  suffering  from  illnesses  or  well- 
marked  functional  disturbances,  are  often  kept  fully  at  work  as  if  in 
robust  health. 

The  converse  case  is  only  too  common,  in  which  a  brilliant  pupil  from 
too  early  pressure  becomes  a  nonentity,  with  an  impoverished  and  incom- 
petent brain. 

It  is,  consequently,  incumbent  on  those  who  have  the  welfare  of  the 
young  at  heart  to  gauge  the  material  with  which  they  have  to  deal ;  and 
we  repeat  that  it  is  essential  for  teachers  to  be  adequately  equipped  with 
the  requisite  judgment,  the  necessary  technical  skill  in  teaching,  the  tact 
and  force  of  disciplinarians,  and  a  knowledge  of  the  physiological  factors 
concerned.  The  circulation  of  blood  in  the  young  brain  is  always  in 
excess  of  that  which  exists  when  maturity  has  been  attained,  and  thus 
provision  is  made  for  the  more  rapid  repair  and  growth.  Moreover,  all 
mental  work  makes  the  blood-vessels  distended  and  the  brain  hyperaemic. 
If  during  this  period  of  life  work  be  too  prolonged,  and  this  pressure 
too  frequently  repeated,  the  blood-vessels  do  not  recover  during  the  brief 
periods  of  rest.  In  this  way  the  brain  becomes  congested,  and  oedema 
of  the  cerebral  tissue  follows  with  alteration  of  function,  symptoms  of 
headache,  sluggishness  and  perversion  of  thoughts,  absence  of  mind, 
irritability,  inability  to  fix  the  attention,  which  may  lead  even  to  organic 
diseases  of  the  brain  of  various  kinds. 

It  behoves  the  physician  of  the  present  day,  however,  to  be  exceed- 
ingly cautious  in  suggesting  to  schoolmasters  that  a  certain  brain  is 
incapable  of  bearing  the  strain  imposed,  for  the  demand  for  our  public 
schools  being  greater  than  the  supply,  the  unfortunate  pupil  who  may 
only  require,  in  order  to  enable  him  to  compass  his  duties,  a  little  con- 
sideration in  easing  or  lessening  his  hours  of  work  and  increasing  his 
sleep,  may  not  receive  the  required  sympatliy,  but  may  be  told  that  if  he 


470  SYSTEM  OF  MEDICINE 

cannot  keep  in  the  running  his  place  must  be  filled  by  another  eager 
applicant ;  his  future  career  may  thus  be  compromised.  The  brain  wastes 
in  all  illness,  and  this  atrophy  renders  it  totally  unfit  for  work,  or  even 
for  reading  a  difficult  book  for  a  considerable  time.  I  have  not  yet 
succeeded  in  impressing  upon  parents  and  teachers  that,  so  far  as  one 
can  judge  from  the  apathy  exhibited  in  these  cases,  and  the  easily 
induced  fatigue,  as  well  as  from  observation  of  nature,  the  brain  wastes 
in  equal  proportion  to  the  waste  of  the  body. 

It  must  also  be  remembered  that  knocks  on  the  head,  to  which  boys 
are  liable  from  various  causes,  may  alter  the  nervous  structure,  possibly 
from  bruising  and  minute  ruptures,  and  that  prolonged  cessation  from 
work  should  be  enforced  even  when  the  blow  may  have  been  of  a  com- 
paratively trivial  nature.     [  Vide  art.  on  "  Concussion  of  the  Brain."] 

But  overwork  is  yet  more  pernicious  in  its  effects  when  the  necessity 
of  an  ample  allowance  of  sleep  is  not  recognised.  It  is  a  well-established 
fact  that  more  sleep  is  required  for  the  formative  than  for  the  intel- 
lectual activity  of  the  cerebral  centres  ;  yet  what  a  record  do  our 
schools  furnish  in  this  respect !  It  must  not  be  supposed  that  the 
deleterious  effects  of  overwork  during  youth  can  be  compensated  by  an 
additional  amount  of  sleep,  for  nature  will  not  permit  a  forced  brain  to 
rest  —  one  of  the  most  manifest  symptoms  of  undue  pressure  being  wake- 
fulness. The  over-exercise  of  the  animal  functions  nature  does  not  resent, 
for  the  more  the  muscles  are  used  the  moi'e  the  brain  will  rest.  Teachers 
should  know  that  deficient  sleep  means  stunted  brain  and  body,  and  must 
not  forget  that  it  is  only  by  graduated  exercise  of  the  mental  faculties 
that  the  highest  condition  of  brain  development  may  be  secured  for  work 
in  after  years.  Yet  the  child  on  entering  school  is  only  allowed  the 
same  number  of  houi*s  of  sleep  as  the  big  boy  who  is  leaving,  whereas 
two  hours  more  should  be  allotted  as  the  following  table  shows :  — 

The  Amount  of  Sleep  required  during  Youth. 

Hours  of  sleep. 
11 

10 

9 

But  while  the  child's  brain  may  be  perfectly  satisfied  on  this  scale 
until  the  advent  of  puberty,  yet  for  some  time  before  and  after  that 
date,  perhaps  a  year  —  when  the  growth  is  enormous,  especially  in  the 
case  of  girls,  and  the  development  of  new  organs  entails  a  severer 
stress  upon  the  system  —  this  amount  is  insufficient,  as  much  more 
sleep  is  required  for  growth  than  for  repair. 

VI.  The  Exercise  of  the  body  is  necessary  to  attain  a  maximum  of 
growth  and  vigour.  —  But  the  brain  can  never  attain  its  largest  growth 
nor  its  highest  quality  of   nervous  tissue  from   the   exercise  simply 


Age. 

Under  10  years 

11 

13      „           . 

15      ,,            . 

11 

17      „           . 

19      „           . 

THE  HYGIENE    OF   YOUTH  471 

of  its  own  functions,  for  it  is  dependent  to  a  large  extent  upon  the 
vigour  of  the  body,  which  is  the  manufacturer  of  the  material  on 
which  it  lives.  As  I  have  already  pointed  out,  the  growth  of  the  brain 
depends  upon  the  condition  of  its  blood-supply  ;  and  the  condition  of  the 
blood  is  dependent  upon  the  state  of  the  circulation,  respiration,  and  the 
muscular  and  digestive  systems.  Hence  the  importance  to  the  young 
of  sufficient  exercise.  This  exercise  should  take  the  form  of  games  or 
recreation,  in  which  refreshment  the  brain  participates,  rather  than  tht; 
form  of  a  set  lesson  in  the  hands  of  a  gymnasium  instructor  or  the 
drill  sergeant.  These  latter  modes  of  exercise  are  desirable  enough, 
but  they  should  be  an  addition  to,  rather  than  a  substitute  for  school 
games. 

Exercise  during  youth  is  excellent :  games  are  invaluable.  We,  as  a 
nation,  owe  our  success  chiefly  to  our  mental  and  bodily  vigour,  —  a 
vigour  which  is  irrepressible,  and  dependent  mainly  upon  the  games  of 
boyhood,  which  render  possible  our  sports  of  manhood.  What  other  na- 
tion would  dream  of  playing  football  in  India  and  polo  in  Burmah  ?  The 
physical  education  of  the  young  trains  them  in  perception  and  judgment, 
as  well  as  in  adroitness  and  courage.  Even  yet,  however,  the  influence 
of  physical  education  on  mental  and  moral  growth  is  not  sufficiently 
regarded,  nor  is  it  yet  fully  recognised  that  bodily  and  mental  culture 
must  be  concurrent  if  the  highest  development  is  to  be  attained.  The 
sportsman  precedes  the  trader  in  new  countries,  and  the  trader  the 
statesman.  Their  qualities  can  be  developed  in  our  school  playing- 
fields  :  let  them,  therefore,  be  encouraged  in  every  possible  way.  No 
question  in  the  training  of  the  young  is  of  more  general  importance  than 
the  mode  of  occupying  out-of-school  hours.  This  freedom  from  work 
should  be  a  period  of  cheerful  recreation  and  constant  lively  occupation, 
otherwise  it  becomes  a  time  of  weariness  and  idle  lounging,  and  the 
character  and  tone  of  the  young  must  consequently  deteriorate. 

In  physical  exercise  all  the  functions  of  the  body  are  engaged ;  the 
circulation  of  the  blood  is  quickened,  more  oxygen  is  inhaled,  and  the  im- 
purities of  the  blood  are  thereby  oxygenated  and  destroyed,  so  that  the 
excretory  organs  of  the  body  may  remove  the  detritus  from  the  system. 
Observe  the  young  boy  who  is  keen  in  games,  and  compare  his  physical 
condition  with  that  of  the  dawdler.  Notice  his  healthy  complexion,  good 
wind,  elastic  gait,  splendid  muscles,  increased  stature,  and  sure  promise 
of  vigorous  manhood.  Consider,  again,  how  boys'  games  tend  to  develop 
a  well-balanced  mind  and  character;  how  they  instil,  as  nothing  else  can, 
glowing  spirits  from  the  robustness  of  health,  quick  response  to  calls  of 
duty,  frankness  of  disposition,  good  temper  often  under  trying  circum- 
stances, love  of  justice  and  fair-play,  self-reliance,  endurance,  confidence 
in  comrades,  desire  to  excel,  quick  judgment,  aptness  to  act  with  others 
for  the  good  of  all,  courage  under  pain  or  difficulties,  self-control,  and 
last,  but  not  least,  how  they  check  morbid  desires  and  sensations  by  the 
exyKmditure  of  superfluous  energy,  which  ensures  purity  of  life.  If 
scliool  gaines  had  no  other  salutary  influence  than  that  of  affording  a 


472  SYSTEM   OF  MEDICINE 

wholesome  topic  of  conversation  in  out-of-school  hours,  they  would  be 
worth  the  infinite  trouble  Avhich  should  be  bestowed  upon  them. 

In  the  regulation  of  the  games  of  the  young,  where  healthy  rivalry 
may,  in  the  inexperienced,  lead  to  excessive  competition,  I  think  the 
physician  should  have  a  voice.  I  would,  therefore,  suggest  the  following 
precautions  which  are  reasonable,  without  the  unnecessary  fuss  which 
pupil  and  teacher  alike  resent :  — 

1.  The  physical  examination  of  all  children  when  they  first  enter 
school.  In  this  way  only  can  the  healthy  be  safely  compelled  to  play 
all  games. 

2.  The  proper  apportionment  of  exercise  consequent  on  this  exam- 
ination, in  order  that  the  physically  weak,  diseased  or  deformed  may  be 
restricted  to  that  exercise  which  is  suitable  to  each.  In  this  way  only 
should  any  boy  be  excused  from  the  ordinary  school  games. 

3.  The  medical  control  of  all  severe  exercise,  so  that  even  those  who 
are  physically  fit  to  undergo  it  may  not  be  permitted  to  do  so  without 
prior  and  suitable  training  for  the  prolonged  exertion.  It  is  excess  of 
exercise,  or  exercise  imprudently  taken,  which  is  so  deleterious  to  those 
who  are  growing;  exercise  in  proper  measure  promotes  health  and 
strength. 

Exercise  should  be  gradiial  in  its  increase,  or  harmful  results  may 
follow.  Those  who  think  that,  because  they  have  excelled  at  some  exer- 
cise during  one  season  they  can  resume  it  in  the  next  season  without 
fresh  training,  are  likely  to  overstrain  and  injure  themselves.  If  we  do 
not,  therefore,  wish  to  hear  of  the  dangers  of  rowing,  of  running,  and  of 
football,  of  the  golf  arm  and  of  the  tennis  leg,  the  muscles  necessary  to 
these  exercises  must  be  trained  by  degrees  at  the  commencement  of  each 
season.  All  muscles  may  be  educated  to  any  strain  within  reason,  but 
unused  muscles  are  unable  to  bear  sudden  or  prolonged  efforts. 

Syncope  in  boys  during  exertion  is  usually  attributed  to  exhaustion, 
but  my  experience  has  shown  that,  while  it  may  in  some  cases  be  occa- 
sioned by  the  physiological  condition  of  the  heart  and  vascular  system 
at  puberty,  or  be  due  to  a  temporary  dilation  of  the  heart  resulting  from 
active  physical  exertion  in  an  unfit  state  of  body,  it  is  more  frequently 
toxsemic,  the  excreting  organs  being  inadequate  to  the  new  and  sudden 
call  upon  them. 

Physical  education  requires  as  much  forethought,  method,  and  appli- 
cation as  mental,  whereas  too  much  routine  is  involved  in  both. 

For  all  games  entailing  exex'tion  the  player  should  be  clothed  in 
flannel,  which  should  be  changed  immediately  afterwards  and  dried ; 
where  this  care  is  not  observed,  chills  and  even  dangerous  illnesses  are 
apt  to  arise. 

It  is  customary  for  the  young  to  undergo  training  for  boating  and 
other  athletic  sports.  The  purpose  of  training  is  to  place  the  body  in 
such  a  condition  as  to  enable  it  to  perform  the  hardest  physical  work 
rapidly,  or  for  a  prolonged  period;  it  is,  in  fact,  to  produce  the  highest 
possible  state  of  health  for  hard  physical  work.    The  essence  of  training 


THE  HYGIENE    OF   YOUTH  473 

is  that  the  heart  aud  lungs  should  become  accustomed  to  sustained 
exertion,  and  this  is  effected  by  degrees. 

In  training  to  obtain  good  "  wind,"  it  is  of  the  highest  importance 
to  avoid  indigestion,  for  nothing  more  thoroughly  defeats  that  end. 
Food,  therefore,  as  I  have  said,  should  be  eaten  slowly  and  masticated 
thoroughly,  and  no  food  should  be  taken  between  meals.  There  is  a 
fallacious  opinion  among  all  trainers,  be  they  trainers  of  mankind  or 
of  horses,  that  to  those  under  training  the  smallest  quantity  of  fluid 
should  be  allowed ;  hence  these  persons  often  suffer  from  actual  thirst. 
Many  people  do  indeed  drink  more  than  is  requisite  to  satisfy  thirst, 
man  being  the  only  animal  which  resorts  to  this  mischievous  practice. 
It  should  be  a  rule  with  every  one,  in  order  that  the  highest  condition 
of  health  may  be  attained,  to  take  only  a  sufficiency  of  fluid,  say  from 
two  to  three  pints  daily,  except  in  hot  weather  or  under  great  exertion 
and  sweating.  Water  sufficient  to  satisfy  thirst  should  be  freely  allowed, 
but  in  small  quantities  at  a  time ;  thus  the  athlete  never  becomes  actu- 
ally thirsty,  —  for  every  ounce  of  fluid  which  leaves  his  body  another 
is  supplied  in  its  place.  Dry  tissues  and  unnaturally  thickened  thirsty 
blood  are  unfit  for  the  highest  functional  activity.  To  suffer  thirst  for 
minutes  or  hours,  and  then,  when  the  exercise  is  over,  to  take,  as  many 
do,  an  excessive  quantity  of  fluid,  may  well  cause  discomfort,  take  away 
appetite,  and  entail  indigestion  and  loss  of  sleep. 

Again,  change  of  work  and  change  of  play  are  as  important  as  variety 
in  diet.  At  the  present  time  the  games  of  the  young  are  too  monoto- 
nous, and  insufficient  attention  is  paid  to  natural  tastes  and  aversions. 
This  is  not  the  place  to  discuss  the  merits  of  the  several  games  suitable 
for  boys  and  girls  during  their  growth ;  but  I  would  point  out  that  the 
exercise  adapted  to  boys  is  also  compatible  with  the  health  and  physique 
of  girls  up  to  the  age  of  puberty  ;  after  that  age  the  games  of  girls  should 
gradually  pass  year  by  year  into  exercise  of  a  quieter  character. 

The  exercise  obtainable  from  games,  as  well  as  that  from  hand-culture, 
should  be  various,  not  only  for  the  better  development  of  bones  and 
muscle,  but  also  for  the  development  of  the  brain  itself,  as  every  com- 
plex movement  has  its  brain-centre,  which,  in  its  turn,  is  developed  by 
the  exercise  of  its  functions  ;  so  that  we  want  not  only  football,  cricket, 
rowing  and  running,  but  in  addition,  walking,  brook-jumping,  high- 
jumping,  skipping,  swimming,  skating,  racquets,  fives,  lawn-tennis,  la 
Crosse,  golf,  hockey,  baseball,  wrestling,  fencing,  boxing,  gymnastics, 
physical  drill,  cycling,  rifle-corps  drill,  rifle-shooting,  camping-out,  work- 
shops, natural  history  excursions,  gardening,  music  and  drawing.  With 
such  variety  of  exercise,  and  mountaineering,  riding,  shooting  and  fish- 
ing in  the  holidays,  the  brain  and  body  will  be  formed  as  a  complete 
and  harmonious  whole. 

The  physical  education  of  girls  is  seriously  neglected,  and  little  or  ho 
attention  is  paid  to  their  bodily  development.  Why  do  girls  so  fre- 
quently fail  in  health  directly  they  undergo  hard  mental  work,  some- 
times becoming  incapacitated  for  life,  physical  wrecks,  and  the  victims 


474  SYSTEM  OF  MEDICINE 

of  hysteria  and  other  neuroses  ?  Simply  because  they  and  their  friends 
attempt  the  impossible.  If  we  are  to  have  the  higher  mental  education 
in  girls,  of  which  they  are  quite  capable  without  injury,  they  must  not 
be  pressed,  as  they  are  at  present,  during  these  years  when  their  growth 
and  development  are  enormous,  viz.,  from  11  to  14,  when  they  leap,  as 
it  were,  from  childhood  to  womanhood  at  a  bound,  for  all  their  nervous 
force  is  expended  in  this  direction.  Teachers  must  not  fail  to  recog- 
nise the  ditference  in  constitution  between  the  boy  and  girl.  Continual 
application  to  work  from  day  to  day,  from  week  to  week,  and  from 
month  to  month,  should  never  be  enforced  on  girls  ;  nor  should  they  even 
be  allowed  to  make  such  efforts ;  cessation  and  rest  at  menstrual  periods 
should  not  only  be  encouraged,  but  even  enforced.  Their  mental  edu- 
cation, again,  must  proceed  %)ari  passu  with  a  thorough  physical  educa- 
tion, otherwise,  with  rare  exceptions,  it  must  end  in  failure;  perhaps 
in  serious  or  life-long  misery.  If  in  Great  Britain  we  cannot  yet 
manage  both,  let  the  mental  education  remain  as  it  was,  and  the  physi- 
cal education  be  undertaken  more  completely,  so  that  girls  may  by 
degrees  be  prepared  for  the  higher  intellectual  education,  and  become 
better  suited  for  their  womanhood. 

At  the  present  time  a  girl's  education  is  effeminate,  whereas  it  should 
he  feminine.  Why  has  it  been  considered  unladylike  for  girls  at  school  to 
be  allowed  any  other  outdoor  exercise  than  a  formal  walk  in  the  street  ? 
There  is  no  conceivable  reason  for  this  restriction.  The  lady  who  has 
the  courage  to  break  through  the  spell  and  establish  a  good  school  for 
girls,  in  which  their  physical  education  shall  be  as  well  organised  as 
their  intellectual  and  moral  education,  will  deserve  well  of  her  country, 
and  will  carry  out  one  of  the  greatest  and  most  needed  reforms  of  the  age. 

Girls  are  naturally  more  subject  than  boys  to  nervous  excitement,  but 
this  could  be  more  elfectually  restrained  by  a  sounder  physical  develop- 
ment. Our  girls  are  so  often  what  they  are — "  nothing  but  nerves," 
or  ''nothing  but  emotions,"  ready  to  faint  on  any,  or  without  any  provo- 
cation—  because  they  are  suffering  from  their  faulty  training  and  con- 
ditions unnatural  to  them ;  these  evils  will  disappear  when  girls  are 
reared'  under  a  reasonable  system. 

The  absence  of  daily,  regular  and  sufficient  exercise  renders  girls  list- 
less and  apathetic,  entails  pallor  and  anaemia,  constipation  with  its  sal- 
loAvness,  foul  breath,  and  depressed  spirits,  crooked  and  stooping  backs, 
and  knock-knee  and  flat  foot  with  characteristically  awkward  gaits. 

It  should  be  the  aim  of  parents  and  teachers  to  instil  into  girls'  minds 
the  fact  that  it  is  their  duty  to  try  to  be  physically  strong,  and  to  pro- 
vide for  its  attainment  by  adequate  means.  They  should  be  taught  the 
necessity  of  being  vigorous  as  well  as  graceful,  and  naturally,  instead 
of  artificially  shapely.  But  this  perfection  of  body  can  only  be  reached 
during  the  period  of  youth,  and  by  physical  exercise,  which,  duly  regu- 
lated, promotes  not  only  muscular  development,  but  also  a  vigorous 
nervous  tissue  and  brain  capacity,  and  above  all,  that  strength  of  char- 
acter which  curbs  irregular  nervous  expenditure.     I  repeat,  if  girls  are  to 


THE  HYGIENE    OF   YOUTH  475 

receive  a  higher  culture  their  physical  education  must  precede  any 
increase  in  their  mental  education.  Without  this  the  process  cannot  be 
safely  effected,  for  the  mental  powers  are  developed  in  woman  at  a  high 
physiological  cost,  which  her  feminine  organisation  will  not  sustain  with- 
out more  or  less  profound  injury  if  bodily  vigour  go  not  hand  in  hand 
with  it.  It  is  more  essential  for  a  nation  to  produce  strong,  vigorous 
offspring  than  to  educate  girls  to  the  highest  standard.  By  the  highest 
physical  education  girls  can  be  made  strong,  comely  and  well-propor- 
tioned ;  while  by  the  highest  mental  education  (without  this  physical 
basis)  they  may  be  made  into  "  blue-stockings,"  or  neurotics,  or  both 
together.  By  physical  education  I  mean  games  and  recreation  which 
cheer  and  elate,  not  merely  gymnastics  and  physical  drill,  which  afford 
exercise  without  elation.  These  latter  exercises  are  mainly  for  the 
sickly  and  deformed ;  and  curative  rather  than  animating.  By  physical 
exercise,  too,  I  mean  exercise  taken  out  of  doors ;  without  this  condition 
at  least  half  of  its  value  is  lost.  In  wet  weather  dancing  should  be 
encouraged ;  graceful  movements  and  carriage  are  only  to  be  attained 
by  means  of  well-develoi^ed  springy  muscles.  Every  educator  of  girls 
should  feel  disgraced  by  the  lounging  attitudes  and  awkward  gaits  which 
prevail  at  most  girls'  schools,  with  their  lop-sided  shoulders  and  crooked 
backs,  for  in  these  is  manifest  the  vicious  system  of  education  in  vogue. 
Symmetry  is  of  paramount  importance  in  women  for  ensuring  the  pro- 
duction of  healthy  offspring. 

While  I  hold  that,  subject  to  the  restrictions  I  have  laid  down,  girls 
may  safely  receive  a  higher  education  than  has  hitherto  been  accorded 
to  them,  I  would  urge  that  their  moral  education  is  of  more  consequence 
to  themselves  and  the  nation  than  their  purely  intellectual  development. 
With  a  physical  education  such  as  is  their  due,  we  should,  almost  in  a 
generation,  eradicate  the  neuroses  and  anaemia  to  which  at  present  girls 
are  so  prone ;  in  their  place  we  should  perceive  more  even  spirits  and 
more  stability  of  character,  and  the  aping  of  man  would  give  way  to  a 
more  dignified  respect  for  the  qualities  of  their  own  sex. 

I  trust  I  have  made  it  manifest  that  to  produce  a  sound  human 
being,  it  is  imperative  that  there  should  be  a  concurrent  development  of 
mind  and  of  its  physical  basis  during  the  period  of  youth.  It  is  during 
these  years  only  that  we  can  educe  faculties,  form  character,  and  invigo- 
rate the  physical  powers  and  functions.  The  school,  where  most  of  the 
years  of  youth  are  passed,  is  an  epitome  of  the  world  at  large,  —  a  place 
in  which  to  prepare  the  young,  and  not  to  unfit  them,  for  their  duties  as 
men  and  women. 

Clement  Dukes. 


476  SYSTEM   OF  MEDICINE 


LIFE  ASSURANCE 

Life  Assurance,  although  scarcely  two  centuries  old,  bids  fair  soon  to 
embrace  the  whole  civilised  world. 

The  casualties  of  life  have  become  matters  of  scientific  prediction ; 
what  seemed  to  be  "  accidents  "  are  seen  to  be  less  and  less  under  the 
dominion  of  "chance,"  which,  indeed,  is  but  a  word  to  express  our  igno- 
rance of  the  laws  in  operation. 

The  likelihood  that  a  confidential  servant  will  betray  bis  trust  can 
be  estimated  and  provided  for  with  the  same  precision  as  the  probability 
of  the  occurrence  of  a  storm,  a  shipwreck,  a  murder,  or  a  suicide. 

The  medical  selection  of  lives  was  not  attempted  in  the  early  days 
of  life  assurance.  The  first  life  assurance  society,  "  The  Amicable,"  was 
founded  in  1708,  and  existed  for  years  before  a  medical  officer  was 
appointed.  The  same  premium  was  paid  by  each  applicant,  whatever 
his  age  or  apparent  health.  He  was,  however,  called  upon  to  state  on 
oath  that  he  believed  himself  to  be  a  good  life. 

In  process  of  time  it  was  found  desirable  to  exclude  manifestly  un- 
healthy applicants.  Hence  the  proposer  was  required  to  appear  before 
the  Board.  Some  directors  were  shrewd  in  their  judgment  as  to  the 
value  of  a  life,  but  it  soon  became  apparent  that  a  medical  inspection 
was  required  for  the  selection  of  ''first-class  lives."  The  first  medical 
officer  was  appointed  to  the  "  Amicable  "  in  1855,  and  to  the  "  Equi- 
table "  in  1S58. 

Besides  the  health,  the  age  of  the  life  to  be  assured  needs  considera- 
tion, and  the  duration  of  the  term  of  the  assurance. 

The  premium  required  being  greater  in  proportion  to  the  age  or 
"  expectancy  of  life,"  it  is  customary  for  the  medical  adviser,  in  estimat- 
ing the  necessary  addition,  to  ask  himself  the  question,  "  Will  the  appli- 
cant before  me,  now  30  years  of  age,  live  as  long  as  a  healthy  man  at 
35,  40,  45,  or  50?"  If  he  considers  that  the  "expectancy"  of  the 
invalid  life  before  him  is  as  good  as  that  of  a  first-class  life  at  45,  he 
advises  the  addition  of  fifteen  years  in  estimating  the  annual  premium. 

Other  questions,  besides  the  medical  selection  of  lives,  call  for  the 
attention  of  the  profession ;  although  in  the  domain  of  the  actuary  they 
have  intimate  relations  with  medical  and  medico-legal  science. 

Term  policies  are  issued  for  short  or  long  periods,  of  days,  months, 
or  years  ;  a  life  may  be  accepted  for  a  "  short  term  "  when  uninsurable 
for  a  long  one.  Some  disabilities  that  prevent  the  acceptance  of  the  life 
may,  however,  so  greatly  increase  the  danger  of  speedy  death  as  to 
demand  the  refusal  of  the  risk,  even  for  a  few  weeks ;  this  is  especially 
the  case  if  the  "habits"  are  bad.  The  premium  receivable  for  a  short 
period  being  very  small,  the  loss  involved  in  the  event  of  a  claim  occur- 
ring is  so  great  that  no  ordinar}^  addition  to  the  premium  would  cover 


LIFE   ASSURANCE  477 


the  risk.  In  these  cases  a  large  premium,  say  3  or  4  per  cent,  is 
sometimes  suggested  instead  of  the  usual  addition  of  years. 

Contingent  risks,  or  assurance  payable  only  in  the  event  of  one  person, 
generally  young,  dying  in  the  lifetime  of  another,  are  rendered  unduly 
dangerous  to  the  office  if  the  younger  life  is  a  seriously  damaged  life. 
A  high  extra  rating  may  then  be  insufficient  to  cover  the  risk.  Thus  a 
'■'■  weedy "  youth  at  25,  whose  habits  are  uncertain,  may  be  ineligible 
against  a  healthy  life  at  50,  though  insurable  for  life  with  an  addition. 
The  medical  examiner  thinks  only  of  the  case  before  him ;  the  actuary 
reminds  him  that,  whilst  the  loss  on  a  particular  case  might  be  compara- 
tively large,  the  greater  number  of  the  "  contingent  risks  "  are  never 
heard  of  again  by  the  doctor  or  by  the  Board ;  they  become  void  by 
reason  of  the  death  of  the  older  life,  or  are  dropped,  the  assurance  hav- 
ing been  effected  for  temporary  purposes. 

Furthermore,  the  mortality  among  recently  examined  lives  (say 
within  five  years)  is  less  than  the  tabular  rate;  consequently,  for  all 
forms  of  assurance  where  the  period  (five  years)  forms  a  considerable 
portion  of  the  risk,  the  calculated  premium  is  slightly  in  excess  of  the 
true  net  premium,  and  the  ''  loading  "  in  contingent  cases  is  usually  heavy. 

Issue  risks  are  often  affected  when  the  "heir  presumptive"  wishes 
to  raise  money  on  his  expectations,  there  being  no  "  heir  apparent ; " 
also  when  it  is  desired  to  quash  a  trust  in  favour  of  children,  a  marriage 
having  been  childless.  In  such  a  case  the  risk  to  be  considered  is  not 
so  much  of  issue  by  the  existing  marriage  as  of  the  death  of  the  wife 
and  remarriage  of  the  husband ;  the  chief  considerations  being  the  health 
of  the  wife,  and  the  prospect  of  the  man  marrying  again  late  in  life  and 
having  children.  If  the  wife's  health  be  uncertain,  the  prospects  of  a 
second  fertile  marriage  by  the  man  may  be  considerable. 

The  cause  of  sterility  in  the  woman  often  needs  consideration.  If 
this  be  rem^ovable  the  risk,  of  course,  is  greatly  enhanced.  Sometimes  the 
issue  risk  to  be  covered  is  not  only  the  birth  of  an  heir,  but  his  attaining 
the  age  of  21.  A  variety  of  issue  risks  has  been  proposed  in  which  the 
probability  of  a  woman,  known  to  be  pregnant,  giving  birth  to  viable 
twins  has  to  be  considered.  In  certain  families  and  with  certain  indi- 
viduals the  probability  of  twin  births  is  enhanced. 

Endowment  assurances  payable  during  life,  say  on  reaching  the  age 
of  50, 55,  or  60,  have  tended  to  modify  the  work  of  a  medical  examiner  by 
increasing  markedly  the  proportion  of  "  first-class  lives."  A  proposer 
having  a  shrewd,  perhaps  well-grounded  suspicion  that  his  life  will  be  a 
short  one,  in  his  natural  endeavour  to  pay  as  little  as  may  be  for  his 
privileges,  is  likely  to  select  a  whole  life  "  without  profits  "  policy,  rather 
than  a  short  term  endowment  which  would  double  the  annual  premiums. 

It  is  on  this  account  that  the  medical  examiner  should  scrutinise  with 
especial  care  the  "  without  profits  "  whole  life  policies,  and  look  with  a 
favourable  eye  on  the  short  term  endowments. 

Members  of  the  medical  profession,  who  feel  that  Life  Assurance  is 
a  business  of  which  they  have  some  special  knowledge,  tend  more  and 


478  SYSTEM  OF  MEDICINE 

more  to  regard  endowment  assurances  as  a  safe  and  remunerative  form 
of  investment  in  which  they  can  obtain  3,  4,  or  even  5  per  cent  compound 
interest  on  tlieir  yearly  savings,  besides  tlie  security  of  an  ordinary  life 
policy  in  case  of  premature  death.  A  man  ast.  25  may,  for  annual  pay- 
ments of  £28,  secure  an  endowment  of  £1000  which,  on  attaining  the 
age  of  60,  amounts  with  bonus  additions  to  about  £2000.  At  set.  35, 
his  practice  having  increased,  he  may  take  out  another  policy  for  £2000 
at  an  annual  payment  of  £83,  so  that  on  reaching  60  (when  perhaps  his 
powers  are  waning  and  his  professional  income  diminishing)  he  receives, 
say  £5500,  and  has  no  further  premiums  to  pay. 

The  claims  on  this  class  of  assurance  are  exceedingly  small.  When 
any  cause,  hereditary  or  personal,  leads  to  the  anticipation  that  the  life 
will  not  be  prolonged  much  beyond  set.  60,  although  normally  secure  up 
to  that  time,  it  is  becoming  customary  to  advise  "endowment"  of  such 
cases ;  thus,  perhaps,  the  remarkable  absence  of  claims  in  this  class  may 
be  somewhat  modified. 

The  relative  duties  of  chief  medical  officer,  medical  referee,  and 
medical  attendant  need  definition. 

It  is  undesirable  that  the  ordinary  medical  attendant  should  act  as 
medical  examiner  for  an  office,  although  occasionally  there  is  no  alterna- 
tive. If  he  undertakes  to  report,  and  accepts  the  fee,  he  is  bound  to 
consider  the  interest  of  the  office  first,  and  that  of  his  patient  as  of 
secondary  importance ;  motives  of  personal  friendship  must  not  influence 
his  report. 

The  medical  examiner  is  the  adviser  retained  by  the  office,  and  is 
bound  to  consider  the  interest  of  the  office  as  paramount.  He  must  not 
allow  himself  to  be  swayed  by  the  arguments  pressed  upon  him,  often 
with  undue  insistence,  by  the  "agent,"  whose  interest  it  is  to  carry 
through  business,  however  insecure.  The  facts  which  the  agent  will 
supply  may  be  valuable,  but  are  apt  to  be  one-sided  and  to  need  dis- 
criminating interpretation. 

In  some  offices,  where  the  desire  to  get  business  is  great,  the  actuary 
may  also  try  to  put  undue  pressure  on  the  medical  referee,  who  must 
then  remember  that  he  is  responsible  to  the  directors,  and  is  bound  to 
consider  first  the  well-being  of  the  office.  Whilst  it  is  the  function  of  the 
agent,  and  in  a  measure  also  of  the  actuary,  to  "carry  through"  every 
proposal,  it  is  for  the  doctor  to  separate  the  wheat  from  tlie  chaff,  and 
to  refuse  insecure  lives. 

When  an  agent  finds  it  difficult  to  mould  the  medical  examiner,  he  is 
apt  to  try  to  take  the  proposer  to  some  medical  friend  whose  opinion  he 
can  dominate  ;  hence  it  is  important  not  to  accept  the  report  of  an  un- 
authorised examiner  without  full  and  satisfactory  expTanation.  A  large 
number  of  bad  lives  are  thus  insured  in  offices  which  do  not  insist  upon 
reports  from  a  medical  referee  of  their  own  selection. 

In  his  personal  examination  of  an  applicant  each  medical  man  should 
follow  the  methods  of  diagnosis  to  which  he  is  accustomed. 

He  should  take  note  of  the  condition  of  the  heart  and  great  vessels, 


LIFE  ASSURANCE  479 


■  the  lungs,  the  kidneys,  etc.  He  will  probably  learn  much  from  the 
character  of  the  pulse  and  cardiac  rhythm,  and  still  more  from  the 
aspect,  the  morale,  and  general  physical  condition. 

Whilst  taking  pains  to  investigate  the  case  and  estimate  exactly  the 
probabilities  of  life,  the  medical  examiner  should  avoid  over-examination. 
Would-be  insurers  are  frightened  away  by  too  elaborate  an  investigation 
and  too  exacting  an  air.  It  is  not  necessary  in  every  case,  as  some 
morbidly  conscientious  tiros  seem  to  think,  to  use  sphygmograph,  laryn- 
goscope, ophthalmoscope,  and  so  forth.  When  the  office  is  represented 
by  a  competent  and  carefully  selected  medical  adviser,  the  end  sought  is 
best  obtained  without  insisting  on  the  registration  of  pulse,  respiration, 
temperature,  and  quality  of  heart  and  lung  sounds  in  various  situations. 
Such  formal  inquiries  tend  to  draw  away  attention  from  essential  points, 
and  vitiate,  if  they  do  not  destroy,  the  value  of  the  report.  Even  if 
now  and  then  an  obscure  point  be  missed  the  office  gains  on  the  whole 
by  not  exacting  too  minute  an  investigation  asking  too  many  questions. 

An  experienced  medical  man  should  not  take  very  long  in  deciding 
"  yes  "  or  "  no,"  and  he  should  not  look  too  critical  or  "  difficile." 

If  he  himself  has  to  labour  through  an  endless  series  of  questions, 
many  of  them  trivial  {e.g.  colour  of  hair  and  eyes),  and  nonsensical  {e.g. 
"  of  what  temperament  is  the  applicant  ?  "),  he  has  little  time  or  spirit 
left  for  forming  an  independent  opinion,  or  for  the  exercise  of  that 
sagacious  and  comprehensive  judgment  which,  after  all,  is  the  thing 
sought. 

Some  offices  receive  reports  from  medical  men  having  little  experience 
of  assurance  practice,  as  is  seen  by  their  conclusions  which  have  little 
relation  to  the  observations  on  which  they  are  based.  Thus  cardiac 
imperfections  or  albuminuria  are  mentioned,  and  yet  the  case  recom- 
mended at  ordinary  rates,  or  perhaps  with  an  addition  of  three  years : 
or  a  high  loading  is  suggested  with  nothing  in  the  body  of  the  report  to 
justify  it,  except  perhaps  hernia  or  doubtful  family  history. 

Offices  whose  forms  are  filled  up  by  all  sorts  and  conditions  of 
medical  men  may  find  it  of  use  to  try  to  obtain  facts  rather  than  in- 
ferences ;  but  where  competent  men  are  selected  to  make  the  examina- 
tion, the  simpler  the  form  the  more  valuable  the  report.  The  following 
simple  forms  have  been  proved  by  long  experience  to  be  useful  ones. 
They  give  an  opportunity  for  stating  in  order  the  points  likely  to  be  of 
most  importance  for  the  consideration  of  the  chief  medical  officer. 

If  an  application  be  made  to  the  "  medical  attendant,"  Form  No.  2 
is  suitable. 

Form  A.     No.  1 

QiK^Hlions 

Name,  rf.sidfjnce,  occupation,  age. 

Are  you  married  ?  Have  you  visited  the  tropics,  when,  and  for  how  Ions;  ? 
Are  you  now  in  good  healtli  ?  Is  your  health  generally  good  ?  What  medical  or 
surgical  assistance  have  you  required,  and  when  ? 


SYSTEM    OF  MEDICINE 


Have  you  any  reason  to  suspect  yourself  liable  to  any  affection  of  throat,  lungs, 
heart,  or  any  other  organ  ? 

Do  you  know  of  any  hereditary  disease  in  your  family,  such  as  asthma,  con- 
sumption, insanity,  scrofula,  cancer,  or  gout  ? 


Family  History 

Father,  mother,  brothers,  sisters,  age  if  living ;  if  dead,  at  what  age  and  from 
what  cause  ?     Is  your  family  a  healthy  one  ? 

I  declare  foregoing  particulars  to  be  true  (to  the  best  of  my  knowledge  and 
belief).     Signature  of  proposer. 

The  medical  officer  is  then  requested  to  report  the  result  of  his 
examination  and  inquiries  in  the  following  form  :  — 

Height  and  weight  of  applicant  (about).  State  of  lungs,  as  shown  by  physical 
examination.  Haemoptysis.  State  of  heart  (by  physical  examination).  Pulse. 
Gout  or  rheumatism.     Digestion  and  abdominal  organs.     Genito-urinary  system. 

As  to  habits,  whether  regular,  temperate  and  healthy ;  occupation  and 
pursuits,  whether  or  not  detrimental  to  health.  If  a  woman,  state  of  uterine 
functions. 

Is  tliere  any  other  circumstance  calling  for  remark? 

From  examination  do  you  think  he  seems  likely  to  live  as  long  as  any  other 
person  of  his  age,  and  do  you  recommend  his  life  to  be  accepted  ? 

If  so,  whether  at  ordinary  rate  ? 

If  not,  what  addition  to  the  age  do  you  advise  ? 

Signature  of  medical  referee,  address,  qualification,  date. 


Form  No.  2 

Confidential.     How  long  have  you  known  Mr. ?     Are  you  in  the  habit  of 

seeing  him  frequently  ?     For  what  diseases  have  you  attended  him  ? 

When  did  you  last  see  him  professionally,  and  for  what  disease  ? 

Has  he  to  your  knowledge  ever  had  any  serious  illness  for  which  he  has  been 
attended  by  any  other  medical  man  ? 

Has  it  come  to  your  knowledge  that  any  of  his  near  relations  have  suffered 
from  consumption  or  any  other  hereditary  disease  ?  State  what' you  may  know, 
or  are  able  to  ascertain,  of  the  health  and  longevity  of  his  parents  and  other  near 
relations.  Do  you  consider  that  he  is  now  in  good  health,  that  his  cerebral,  tho- 
racic, and  abdominal  organs  are  sound  ?  If  not,  state  in  what  respect  they  deviate 
from  health. 

Is  he  temperate  in  his  habits  ?  What  are  his  pursuits,  and  are  they  detrimental 
to  health  ? 

Is  his  physical  conformation  such  as  is  consistent  with  a  fair  average  life  ? 
Is  he  likely  to  live  as  long  as  any  healthy  person  of  his  age  ?  Do  you  consider  that 
on  the  whole  his  life  is  a  first-class  one  ?  If  not,  state  the  grounds  on  which  you 
form  your  opinion,  and  the  addition  you  think  should  be  made  to  his  age  to  meet 
the  extra  risk. 

A  space  is  left  for  any  "special  question"  which  the  actuary  or 
chief  medical  officer  should,  from  other  information,  deem  important, 
and  a  space  left  for  signature,  qualifications,  and  date. 


LIFE  ASSURANCE 


The  medical  examiner  should  secure  a  private  interview,  for  in  the 
presence  of  the  agent,  or  of  any  friend  or  relation,  people  are  apt  to  be 
less  frank  and  unconstrained.  The  proposer  should  be  placed  as  much 
as  possible  at  ease,  and  the  inquiries  should  be  made  with  quietness, 
courtesy  and  deliberation.  The  proposer  should  realise  that  he  must 
give  honest  answers  to  definite  questions,  which  are  neither  impertinent 
nor  inquisitorial. 

Directors  are  rightly  severe  in  refusing  applicants  found  to  be  tricky 
and  secretive ;  when  a  proposer  is  detected  in  making  a  false  statement 
it  is  right  to  decline  to  accept  him. 

Life  assurance  should  be  an  honourable  transaction  for  mutual  ad- 
vantage, and  an  attempt  to  overreach  should  not  be  lightly  passed  over 
by  either  party. 

Preparation  for  Medical  Inspection.  —  Before  venturing  to  appear  for 
medical  examination  many  candidates  take  a  bath,  visit  the  barber, 
attend  to  the  tongue,  the  teeth,  and  sometimes  consult  their  family 
doctor  that  "  they  may  be  put  in  order  "  and  be  prepared  for  the  ordeal. 
They  also  avoid  giving  any  information  about  family  and  personal  his- 
tory which  might  lead  to  an  extra  rating,  and  dexterously  omit  all 
incriminating  details. 

Tropical  Rating.  — The  practice  of  applying  an  extra  rating  for  resi- 
dence in  the  tropics,  whilst  giving  occasion  to  criticism  on  the  part  of  those 
who  disapprove  of  the  imposts,  has  been  found  to  work  fairly  on  the  whole. 

The  risk  of  death  in  the  early  years  of  tropical  life  is  considerable ; 
it  should  be  also  remembered  that  an  extra  payment  is  demanded  only 
during  residence  in  the  tropics,  and  is  taken  off  when  the  proposer  re- 
turns to  Europe,  with  health  perhaps  broken  by  tropical  disease. 

The  habit  of  "rating-up"  for  tropical  fever,  ague,  dysentery,  etc. 
(those  who  come  for  assurance  after  living  abroad),  is  also  fully  justified 
by  experience,  as  also  are  the  ratings  for  "active  service  in  the  field." 

Ratings  for  dangerous  avocations  call  for  consideration,  among  these 
the  most  frequent  are  occupations  connected  with  the  drink  trade.  It  is 
customary  to  add  a  50  per  cent  extra  to  such  cases,  even  if  classed  as 
"  A  1 "  by  the  medical  examiner ;  but  it  is  probably  wiser  to  follow  the 
rule  of  the  more  cautious  offices,  and  absolutely  to  decline  to  accept  pro- 
posals in  such  cases. 

Extra  risks  arising  from  hunting  and  other  active  sports,  which 
occasionally  lead  to  a  broken  neck  or  concussion  of  the  brain,  may  be 
accepted  at  ordinary  rates  on  the  ground  that  the  improved  health  and 
longevity  secured  by  an  active,  open-air  life  will  more  than  counter- 
balance the  extra  risk. 

Details  regarding  the  diagnosis  and  prognosis  of  well-defined  diseases 
may  be  dispensed  with,  but  there  are  various  conditions  of  imperfect 
health  more  difficult  to  assess  concerning  which  something  must  be  now 
said. 

Susceptibility  to  disease,  whether  catarrhal  or  zymotic,  exhibited  by 
the  proposer  or  his  family  needs  consideration. 

VOL.    I  2    I 


SYSTEM   OF  MEDICINE 


Vulnerability  means  increased  risk  and  therefore  extra  rating. 

Obesity.  —  Among  conditions  which  may  not  be  classiiied  as  "  disease," 
or  even  "  impaired  health,"  undue  stoutness,  or  excessive  weight  in  pro- 
portion to  height,  calls  for  consideration.  If  obesity  do  not  directly 
shorten  life,  it  greatly  increases  the  risks  from  acute  and  chronic  disease. 
When  an  effort  is  needed  to  meet  some  unexpected  strain,  a  large  extent 
of  useless,  cumbersome  tissue,  a  fatty  heart,  loaded  liver,  restricted  lung 
surface,  or  kidneys  prone  to  disease,  become  powerful  allies  of  any  inter- 
current disease  in  the  assault  upon  life. 

As  soon  as  a  man's  weight  increases  much  above  the  average  weight 
(see  table),  and  the  abdominal  girth  exceeds  the  chest  girth,  an  extra 
rating  is  called  for.  Weight  alone,  without  consideration  of  the  build, 
the  size  of  the  bones,  the  conditions  of  the  muscles,  etc.,  is  not  a  sufficient 
guide.  Where  the  muscles  are  flabby,  the  abdomen  pendulous,  exercise 
insufficient,  and  food  excessive,  these  conditions  are  incompatible  with 
prolonged  health. 

A  man,  aet.  40,  who,  since  the  age  of  20,  has  steadily  increased  in 
weight  and  bulk,  and  finds  his  breathing  short  on  exertion,  should  not  be 
accepted  without  an  addition  of  five  years,  even  though  in  all  other 
respects  he  may  seem  well.  Experience  has  shown  (see  Report  on  Invalid 
Lives,  Equity  and  Law  Assurance  Society)  that  cases  rated  upon  the 
ground  of  '•'  stoutness  "  have  proved  a  very  unfavourable  class.  Habits 
of  excessive  eating  and  dtiuking  and  insufficient  exercise  tend  to  shorten 
life,  and  the  very  obese  must  be  declined,  or  accepted  for  short  terms 
with  high  rating. 

Leanness.  —  When  the  weight  is  markedly  beloAv  the  average  careful 
investigation  as  to  the  cause  is  required.  If  loss  of  weight  be  progressive 
the  risk  is  enhanced,  and  the  necessity  for  an  explanation  of  the  cause 
essential.  It  may  be  an  early  indication  of  phthisis,  diabetes,  cancer,  or 
other  progressive  disease  in  the  organs  of  digestion  and  assimilation. 


Table  of  Height  and  Weight 


Feet  Inches 

stones  Lbs. 

Feet 

Indies 

Stones  Lbs. 

5        3 
5         5 
5         7 
5        9 

8  13 

9  11 

10  10 

11  10 

5 
6 
6 
6 

10 
0 
2 
4 

12  4 

13  5 

14  7 

15  9 

If  due  to  unusual  slimness  this  need  not  necessarily  imply  delicacy 
or  vulnerability,  for  the  thin  and  "  wiry  "  are  (proverbially)  long  lived, 
or  at  least  have  so  great  an  aptitude  of  recovery  from  disease  as  to  justify 
their  acceptance  without  extra  rating,  if  careful  inquiry  elicit  nothing 
against  the  life. 

Leanness  associated  with  feeble  physique  calls  for  considerable 
"extra."  A  man,  5  ft.  7  in.  in  height  (see  table),  whose  weight  is  but 
8  St.  10  lbs.  instead  of  the  normal  10  st.  10  lbs.,  is  probably  a  better  life 


LIFE  ASSURANCE  483 


than  a  man  of  the  same  age  who  weighs  12  st.  10  lbs. ;  or  a  man, 
aet.  40  5  ft.  10  in.  in  height,  weighing  10  st.  4  lbs.,  instead  of  the  nor- 
mal 12  st.  4  lbs.,  is  a  more  favourable  life  —  other  things  being  equal  — 
than  if  his  weight  were  14  st.  4  lbs. 

Two  stone  above  or  below  the  normal  need  in  neither  case  necessi- 
tate extra  rating,  but  demand  extra  caution.  Note  should  always  be 
taken  of  such  deviation,  and  if  no  explanation  be  forthcoming  adequate 
ground  exists  for  extra  rating. 

Heredity. — Longevity  is  hereditary  in  some  families,  as  is  prema- 
ture death  in  others  (see  Analysis  of  Peerage  Mortality,  Sprague),  and 
this  without  noticeable  strength  or  feebleness  of  physique. 

When  a  tendency  exists  in  the  line  of  both  parents  to  any  special 
disease  the  heredity  is  intensified,  notably  in  phthisis,  cancer  and 
insanity.  The  mother's  power  of  transmitting  disease  to  sons,  who 
form  the  majority  of  insured  lives,  is  greater  than  that  of  the  father. 

As  with  phthisis,  hereditary  gout  is  manifested  earlier  than  the 
acquired  form.  If  a  tendency  to  gout  or  asthma  exist  on  both  sides  a 
considerable  extra  rating  is  called  for ;  where  cancer  is  doubly  inherited 
it  is  safer  to  decline,  or  to  require  all  premiums  to  be  paid  by  the  age 
of  fifty.  Where  one  parent  only  has  suffered  from  gout,  rheumatism, 
heart  disease,  diabetes  or  cancer,  this  may  be  overlooked  if  the  case  be 
otherwise  unexceptionable. 

An  investigation  into  the  life  and  health  of  grandparents,  aunts, 
cousins,  is  usually  supererogatory,  but  the  medical  referee  may  be  often 
aided  by  such  an  inquiry ;  he  should  never  omit  to  report  on  the  brothers 
and  sisters  of  the  proposer. 

Phthisis.  —  As  one  death  in  eight  is  attributed  by  the  Registrar- 
General  to  this  cause,  its  early  detection  is  of  primary  import;  and  as 
the  mortality  from  phthisis  among  assured  lives  is  but  eight  per  cent, 
it  is  evident  that  medical  selection  has  proved  of  great  value.  Half  the 
mortality  from  phthisis  among  the  assured  occurs  before  the  age  of  40, 
and  three-quarters  before  50.  (A  large  proportion  of  proposers  have 
passed  the  most  dangerous  years  from  15  to  25.) 

The  occurrence  of  haemoptysis  needs  careful  consideration ;  if  follow- 
ing strain,  and  there  be  no  evidence  of  inheritance,  of  heart  or  lung 
defect,  of  wasting  or  constitutional  disorders ;  and  if  the  applicant  have 
passed  the  age  of  30,  the  life  may  be  accepted  with  a  slight  addition. 
Where  hereditaxy  tendency  exists,  the  chest  is  long  and  narrow,  the 
weight  light,  and  the  pulse  quick,  the  life  should  be  refused.  Indeed, 
the  coexistence  of  haemoptysis  with  a  history  of  hereditary  phthisis 
would  call  for  refusal.  Full  consideration  of  physical  signs,  etc.,  will 
be  found  in  other  articles. 

In  insurance  practice,  where  the  opportunities  for  complete  examina- 
tion of  a  case  are  limited,  it  may  not  be  easy  to  make  a  prognosis  with 
adequate  confidence  to  justify  the  acceptance  of  a  life  with  serious 
organic  disease;  but  every  life  has  its  value  and,  with  advancing  patho- 
logical knowledge,  accurate  clinical  methods  and  acquaintance  with  the 


484  SYSTEM   OF  MEDICINE 

natural  history  of  disease,  a  prognosis  may  be  made  with  sufficient 
precision  to  justify  the  acceptance  of  the  risk.  This  is  certainly  the 
case  with  the  varieties  of  valvular  disease  of  the  heart,  and  in  some  cases 
of  chronic  ^&roicZ  change  in  the  hing  the  life  may  be  assessed  with  equal 
confidence  and  accepted  with  extra  rating  for  short  periods,  or  under  the 
"endowment"  or  "limited  payment"  system.  In  cases  of  this  class, 
however,  the  chief  medical  ofiicer  would  probably  require  to  see  the  case 
himself,  and  would  not  recommend  it  to  the  acceptance  of  the  Board 
on  any  second-hand  information. 

Emphysema,  when  associated  with  chronic  or  recurrent  bronchitis, 
especially  if  any  signs  exist  of  commencing  cardiac  dilatation,  must  be 
refused.  If  a  somewhat  inelastic  chest  wall,  a  prominence  of  thoracic 
venules,  and  tendency  to  dyspnoea  on  exertion,  alone  mark  the  emphy- 
sematous tendency,  or  if  only  occasional  asthmatic  attacks  are  recorded, 
an  extra  rating  will  suffice.  Liability  to  bronchial  attacks,  whether  of 
gouty,  syphilitic,  or  phthisical  origin,  renders  the  life  precarious  even 
for  very  short  terms. 

Pleurisy.  —  Where  traces  of  pluerisy  exist,  if  the  proposer  be  young, 
and  if  family  and  personal  history,  aspect,  pulse,  etc.,  should  point  to  a 
possible  tubercular  origin  or  complication,  the  case  should  be  declined. 
If  the  evidence  indicate  no  more  than  the  local  contraction  consequent 
upon  old  pleurisy  of  non-constitutional  origin,  a  small  extra  rating  will 
suffice. 

Heart  Disease.  —  The  diagnosis  and  prognosis  of  cardiac  disorders 
are  fully  discussed  in  other  places ;  I  can  only  say  here  that  cases  in 
which  indications  of  muscular  failure  exist  are  uninsurable.  Where 
compensatory  hypertrophy  conceals  all  evidence  of  circulatory  defect 
the  case  may  be  considered,  and  acceptance  advised  on  condition  that 
all  premiums  be  paid  before  degenerative  changes  are  likely  to  occur. 
Aortic  disease  is  jnore  perilous  than  mitral.  Cases  of  mitral  stenosis 
and  aortic  regurgitation  can  but  seldom  be  accepted.  Less,  however, 
depends  on  the  situation  and  character  of  the  murmur  than  on  the 
history  and  constitutional  state. 

Irregular  action,  with  feebleness  of  impulse  and  confused  rhythm,  is 
of  evil  portent. 

Intermission  of  the  pulse  and  apex  beat  may  not  prove  the  existence 
of  serious  defects,  but  calls  for  close  investigation,  and  often  leads  to  the 
discovery  of  gouty,  dyspeptic,  or  nervous  disorder. 

The  rapid,  nervous,  ]3alpitating  "insurance  heart,"  so  constantly 
observed  among  candidates  for  life  assurance,  requires  skill  and  experi- 
ence for  its  estimation.  The  beat  is  so  rapid,  tumultuous,  bouncing  and 
diffused  that  it  suggests  the  idea  of  serious  disease,  and  may  indeed  mask 
organic  defect.  Its  variability  and  manifest  association  with  general 
nervous  perturbation  will  generally  enable  the  physician  to  assess  its 
import  at  the  first  interview;  if  not,  a  second  should  be  arranged. 
Some  proposers  faint  when  thus  examined,  and  may  justly  be  regarded 
as  too  unstable  to  be  accepted  as  first-class  lives.    These  are  persons  who 


LIFE  ASSURANCE  485 


are  morbidly  sensitive  to  a  refusal  or  an  extra  rating,  and  it  is  important 
by  firmness  and  kindness  of  manner  to  give  them  confidence  and  self- 
reliance.  A  medical  referee  cannot  be  too  careful  to  avoid  causing 
distress  or  anxiety  in  an  applicant,  even  if  he  be  obliged  to  decline  the 
proposal. 

Gout.  —  The  bearing  of  gout  on  life  assurance  is  important.  Experi- 
ence proves  that  a  high  extra  rating  is  necessary.  Gout  was  regarded  in 
the  early  days  of  life  assurance  as  conducive  to  longevity.  The  free 
imbibition  of  port  was  followed  by  occasional  explosions  recurring  for  a 
quarter  or  perhaps  half  a  century,  and  leading  to  no  marked  deterioration. 
In  recent  years  the  wide  extent  of  gout,  as  a  constitutional  affection  leading 
to  heart,  kidney,  liver,  and  more  general  tissue  change,  has  been  recog- 
nised even  when  no  joint  affection  has  occurred.  Gout,  as  we  know  it 
now,  calls  for  rejection  in  a  large  number  of  instances ;  and  an  average 
addition  of  20  to  25  per  cent  in  cases  recommended  for  acceptance. 

It  must  be  remembered,  too,  that  while  phthisis  is  a  "  diminishing 
risk,"  gout  is  an  ''  increasing  "  one.  The  mortality  from  phthisis  falls 
mainly  iu  early  manhood,  whilst  that  from  gout  falls  in  the  years  when 
life  assurances  are  most  usual,  namely,  between  50  and  60. 

The  close  relation  often  existing  between  gout  and  intemperance,  in 
eating  and  drinking  must  not  be  forgotten ;  and  the  extra  rating  applied 
for  "  gout "  might  in  some  cases  be  more  accurately  entered  under  the 
heading  "habits." 

No  part  of  insurance  medical  practice  calls  for  so  much  discrimination 
as  this.  Intemperance,  often  markedly  hereditary,  may  show  itself  in 
occasional  craving  for  drink  or  other  forms  of  nerve  excitement,  and  lead 
to  early  tissue  degeneration ;  the  man  who  indulges  freely  and  continu- 
ally because  he  is  never  drunk  being  in  the  greater  danger.  Tact  to 
discern  habits  of  life,  and  skill  to  interpret  indications  (which  have 
been  perhaps  carefully  masked),  are  essential  here. 

Among  the  indications  are  the  hurried  manner,  loud  voice,  foetid 
breath,  bloodshot  sallow  eye,  flushed  face,  red  nose,  tremulous  cold  damp 
hand,  tremulous  tongue  (often  clean,  especially  in  women),  engorged 
fauces,  carelessness  of  dress,  etc.  Where  such  signs  exist  no  laboured 
proof  in  "  friends'  reports,"  or  in  the  statement  of  the  applicant,  must  be 
allowed  to  shake  the  conclusion  of  the  medical  examiner.  If  he  be  thus 
beguiled  into  accepting  a  life  he  was  disposed,  on  personal  examination, 
to  reject  for  "  habits,"  he  is  nearly  sure  to  hear  of  the  case  "  as  a  claim  " 
in  a  time  distressingly  short  for  his  reputation  and  for  the  office.  The 
evidence  as  to  the  "  temperance,  soberness,  and  chastity  "  of  a  suspected 
applicant  must  not  always  be  estimated  by  the  weight  or  volume  of  the 
letters  supplied  in  ''  friends'  reports  "  ! 

It  is  not  customary  to  regard  hernia,  if  a  suitable  truss  is  worn, 
as  a  reason  for  extra  rating.  Neither  need  piles  nor  varicose  veins 
be  80  regarded,  except  in  so  far  as  they  give  evidence  of  hepatic 
engorgement. 

A  history  of  fistula,  if  connected  with  piles  which  have  been  cured, 


486  SYSTEM  OF  MEDICINE 

does  not  call  for  surcharge  ;  but  when  there  is  any  evidence  of  phthisis 
or  constitutional  weakness  the  proposal  should  be  declined. 

History  of  gonorrhoea  justifies  an  extra  rating ;  even  when  not  fol- 
lowed by  stricture,  etc.,  it  often  brings  in  its  train  prostatic  and  vesical 
troubles  which  shorten  life. 

Syphilis.  —  During  the  existence  of  this  disease  in  any  primary  form 
the  proposal  must  be  postponed. 

If  any  secondary  symptoms  exist  in  a  quiescent  state  an  addition  of 
five  or  seven  years  is  required.  When  these  symptoms  have  been  in 
abeyance  for  two  or  more  years  only  the  case  is  not  eligible  at  ordinary 
rates ;  it  should  be  rejected  if  any  lesion  of  brain,  spinal  cord,  artery, 
liver,  lung  or  kidney  have  occurred. 

Albuminuria,  whether  present  or  not  at  the  time  of  examination,  if 
connected  with  kidney  disease,  with  gouty,  rheumatic,  or  cardiac  dis- 
order, or  excess  in  eating  or  drinking,  must  be  declined. 

If  the  albumin  be  reported  after  scarlet  fever  or  exposure,  and  to 
have  disappeared  for  years,  the  health  being  perfect,  acceptance  may 
be  recommended.  Where  it  has  been  known  to  exist  for  many  years 
without  detriment  (such  cases  have  fallen  under  my  observation)  the 
case  may  be  accepted,  as  a  case  of  mitral  disease  or  emphysema  might 
be  accepted,  with  a  high  rating  or  for  a  short  term.  When  a  trace  only 
is  to  be  detected,  after  food,  and  recurring  at  intervals,  after  several 
examinations  at  sufficient  intervals,  and  with  full  knowledge  of  the  case, 
acceptance,  with  five,  seven,  or  ten  years  added,  may  be  advised. 

Glycosuria,  while  it  exists,  should  forbid  the  acceptance  of  the  pro- 
posal. It  is  often,  however,  a  temporary  condition,  and  may  leave  no 
ill  effects ;  unless  manifestly  due  to  some  transient  state  it  should  be  re- 
garded as  a  ground  for  refusal,  and  in  any  case  for  addition.  In  every 
form  of  diabetes  the  risks  are  too  great  to  justify  acceptance.  It  must 
not  be  forgotten  that  some  urines  not  containing  sugar  may  nevertheless 
cause  a  turbidity  with  Fehling's  solution. 

In  cases  of  ataxia,  and  other  forms  of  paralysis  of  a  central  kind, 
refusal  is  called  for.  In  cases  of  old  infantile  paralysis,  in  diphtheritic 
paralysis,  and  in  facial  paralysis,  a  moderate  extra  should  suffice  (three 
to  five  years). 

Pregnancy. — Recently  married  ladies  often  insure  for  very  large 
sums,  and  the  risk  during  the  first  year  of  married  life  is  great. 

The  mortality  in  first  pregnancies  is  high(l  in  74,  Matthews  Duncan) 
and  it  is  wise  to  defer  a  proposed  insurance  until  after  confinement.  It 
is  usual  to  charge  a  small  10s.  per  cent  addition  to  the  first  premium  for 
a  multipara,  20s.  for  a  primipara.  If  the  age  is  above  30,  and  the  risk 
thus  enhanced,  an  addition  of  30s.  is  often  justly  made. 

Claims.  —  Certificates  as  to  the  cause  of  death  should  always  be  con- 
sidered carefully  by  the  medical  officer,  and  it  would  be  advantageous  if 
a  medical  report  on  each  claim  could  be  forwarded  to  the  referee  upon 
whose  report  the  life  had  been  accepted.  Information  to  the  chief 
medical  officer  would  become   the  common   property  of  the   medical 


LIFE  ASSURANCE  487 


referees,  whose  experience  would  thereby  be  increased,  as  an  autopsy  is 
invaluable  to  the  physician  who  had  charge  of  the  case  during  life. 

The  wording  of  the  death  certificate  should  be  clear  and  definite. 
Thus  syncope  may  refer  only  to-  the  mode  of  death  and  have  no  bearing 
on  the  nature  of  disease.  ''  Childbirth  "  may  mean  phthisis,  and  should 
be  limited  to  fatal  incidents  immediately  connected  with  confinement. 
"  Gastritis  "  may  be  a  term  used  to  conceal  death  from  intemperance  or 
irritant  poisoning.  "  Dropsy,"  without  evidence  of  dependence  on 
heart,  kidney,  liver,  should  not  be  allowed  to  pass  without  investigation. 

If  the  disease  certified  as  the  cause  of  death  existed  prior  to  the 
completion  of  the  assurance,  a  question  arises  as  to  the  bona  fides  of  the 
transaction.  If  the  statements  made  can  be  proved  false  the  claim  could 
not  be  maintained. 

As  a  matter  of  fact  ofiices  are  most  unwilling  to  refuse  any  claim ; 
but  they  have  and  ought  to  exercise  the  power  to  refuse  claims  mani- 
festly unjust. 

E.  Symes  THOMPSOisr. 


DIVISION  II 

FEVERS 

PAET  I.  — mSOLATION 
PAET  II.  — THE   INFECTIONS 


PART   I 

INSOLATION   OR   SUNSTROKE 

Under  the  designation  of  sunstroke,  heat-stroke,  insolation,  thermic 
fever,  calenture,  heat  apoplexy,  heat  asphyxia,  ictus  solis,  and  other 
synonyms,  a  variety  of  morbid  conditions,  from  the  simplest  to  the 
gravest,  are  included.  However  these  conditions  may  be  modified  by 
personal  susceptibility,  local  surroundings  and  climatic  influences,  they 
are  all  essentially  due  to  heat,  and  are  the  result  of  direct  exposure  to 
the  rays  of  the  sun  or  to  a  high  atmospheric  temperature  in  the  shade. 
Great  heat  may  cause  — 

1.  A  state  of  exhaustion  leading  to  syncope. 

2.  An  overheating  of  the  nervous  centres,  blood  and  tissues  ;  with  a 
tendency  to  produce  vaso-motor  paralysis,  hyperpyrexia  (thermic  fever), 
and  subsequent  asphyxia  through  the  action  upon  the  respiratory  centres. 
Therewith  lesions  may  take  place,  such  as  cerebral  tissue  change  and 
haemorrhage,  and  meningitis  in  various  degrees.  The  symptoms  in  such 
cases  are  varied,  and  depend  upon  the  portions  of  the  cerebro-spinal 
centres  affected. 

The  effect  of  heat  upon  the  human  body  in  tropical  climates  or  else- 
where is  a  subject  of  considerable  importance  and  interest.  Man,  of  all 
animals,  possesses  the  greatest  power  of  adapting  himself  to  changes 
of  climate  and  temperature,  and  maintaining  health  under  them.  His 
body,  under  favourable  circumstances  of  climate,  food  and  habits,  has  the 
power  of  maintaining  an  almost  constant  temperature  under  extremes  of 
heat  and  cold.  Vigorous  healthy  persons,  who  lead  temperate  and  well- 
regulated  lives,  can  tolerate  a  very  much  higher  temperature  than  others 
not  so  conditioned ;  and  the  natives  of  tropical  climates  —  especially  the 
coloured  races  —  can  tolerate  an  amount  of  heat  to  which  the  European 
would  succumb :  even  they,  however,  suffer  at  times  if  the  heat  rise 
above  a  certain  point,  and  natives  of  India  frequently  die  from  "loo 
marna,"  hot  wind  stroke. 

The  action  of  heat  is  much  influenced  by  the  hygrometric  condition 
of  the  atmosphere.  A  dry  hot  air  is  better  tolerated  than  a  moist  one  at 
a  lower  temperature,  because  it  favours  perspiration  and  keeps  the  body 
cool ;  while  damp  air  diminishes  evaporation  and  the  refrigerating  proe- 


492  SYSTEM  OF  MEDICINE 

esses  of  the  body.  When,  from  any  cause,  perspiration  fails,  or  the 
natural  eliminative  functions  are  interfered  with,  especially  when  the 
air  temperature  exceeds  that  of  the  normal  heat  of  the  body,  suffering 
soon  ensues,  and  danger  from  ardent  fever  or  heat  asphyxia  becomes 
imminent.  That  these  evil  consequences  are  not  due  to  the  direct  action 
of  the  sun  alone  is  shown  by  the  fact  that  many  of  the  fatal  cases  take 
place  in  rooms,  tents  or  hospitals,  at  night,  or  in  the  early  hours  of  the 
morning  before  sunrise,  especially  if  the  air  be  vitiated  as  well  as  hot : 
previous  disease,  debility,  or  irregular  and  intemperate  habits,  dispose 
to  insolation. 

The  effects  of  all  the  conditions  of  hot  climates,  including  heat,  are 
not  yet  sufficiently  determined,  and  we  must  look  for  further  information 
to  medical  men  practising  abroad.  Continued  exposure  to  great  heat 
cannot  long  be  endured,  even  by  the  healthy  human  body,  with  impunity. 
Parkes  and  others  have  shown  its  injurious  effects  on  the  nervous  system, 
on  secretion  and  elimination,  and  on  the  digestive  and  assimilative  proc- 
esses. It  causes  fever  from  the  simplest  to  the  most  ardent  form;  and 
it  is  often  combined  with  pernicious  miasmatic  poisoning,  extreme  cases 
of  which  may  be  confounded  with  or  pass  into  the  most  aggravated  forms 
of  thermic  fever  or  asphyxia. 

Insolation  generally  takes  place  in  the  hottest  months  of  the  year. 
April,  May,  June,  and  July  give  the  highest  returns  in  India ;  but  when- 
ever the  temperature  is  high  enough  in  other  countries  the  same  results 
obtain.  For  example,  it  is  very  frequent  in  jSTorth  America  every  year. 
In  1894  it  proved  very  destructive  in  New  York;  and  in  1892  many 
places  in  Europe  suffered  with  a  severity  unsurpassed  even  in  India  or 
other  tropical  countries.  Reports  from  Vienna  in  1894  show  many  cases 
of  heat-stroke ;  on  the  25th  of  July  twenty-seven  people  were  conveyed 
to  the  hospitals. 

It  has  been  stated  that  sunstroke  seldom,  if  ever,  occurs  at  sea ;  but 
this  is  negatived  by  the  records  of  the  vessels  passing  through  the 
Red  Sea,  Indian  Ocean,  Persian  Gulf,  and  other  tropical  seas.  I  have 
myself  witnessed  death  on  board  steamers  in  the  Red  Sea  from  insola- 
tion. 

Maclean  tells  us,  among  other  examples  of  insolation  occurring  on 
board  ship,  that  Boudin  relates  that,  while  at  Rio  Janeiro,  the  French 
war-ship  Duquesne  (Statistiques  Medicales)  had  100  cases  of  insolation 
out  of  a  crew  of  600.  Most  of  the  men  were  attacked,  not  when  exposed 
to  the  direct  rays  of  the  sun,  but  at  night  when  in  the  recumbent  posi- 
tion—  that  is,  when  breathing  not  only  a  hot  and  suffocating,  but  also 
an  impure  air. 

M.  Bassier,  a  French  naval  surgeon,  gives  an  account  of  18  cases 
out  of  a  crew  of  78  men,  which  happened  on  board  the  man-of-war 
brig  Le  Lynx,  cruising  off  Cadiz  in  August  1823.  The  heat,  aggra- 
vated by  calms,  was  excessive  —  33°  to  35°  C;  the  vessel  small  and 
overcrowded. 

It  is  hardly  possible  to  fix  any  particular  degree  of  external  tempera- 


INSOLATION  OR   SUNSTROKE  493 

ture  as  one  of  excessive  danger,  because,  as  before  stated,  the  tolerance 
of  heat  is  very  great  in  persons  in  perfect  liealth  in  a  pure  atmosphere, 
and  also  in  the  dark-skinned  races ;  but,  under  the  conditions  before 
mentioned,  the  danger  is  great  when  the  temperature  is  equal  to  or 
higher  than  that  of  the  body.  A  temperature  of  110°  or  115°  F.  or 
higher,  in  very  dry  air  in  motion,  would  be  better  tolerated  than  one 
of  90°  or  95°  F.  in  an  atmosphere  laden  with  moisture ;  especially  if  it 
be  vitiated,  as  in  barracks  or  rooms,  by  human  respiration,  or  telluric 
or  other  miasmata. 

All  who  suffer  do  not  die ;  some  perfectly  recover,  but  many  are 
permanently  injured,  and  made  unfit  for  service  in  a  hot  climate,  or 
even  become  permanent  invalids  at  home. 

In  1891  the  numbers  of  the  European  army  in  India  were  67,030. 
Of  these  there  were  228  admissions  from  heat-stroke  and  65  deaths. 

In  1892  the  numbers  were  68,162.  There  were  223  admissions  from 
heat-stroke  and  61  deaths. 

In  1891  there  were  3137  women  with  the  European  army.  Among 
these  there  Avere  2  admissions  and  2  deaths  from  heat-stroke. 

In  1892  there  were  3101  women  with  the  army,  but  no  admissions 
for  heat-stroke  ;  one  death  out  of  hospital. 

In  1891  there  were  5886  children  with  the  European  army.  There 
were  3  admissions  and  2  deaths  from  heat-stroke. 

In  1892  there  were  5762  children  with  the  army.  There  were  4 
admissions  and  4  deaths  from  heat-stroke. 

The  native  army  in  1891  numbered  128,600.  There  were  22  ad- 
missions and  12  deaths  from  heat-stroke. 

In  1892  the  native  army  numbered  145,340.  There  were  43  admis- 
sions and  18  deaths  from  heat-stroke. 

In  1891  the  jail  population  of  India  numbered  101,019.  There  were 
77  admissions  and  40  deaths  from  heat-stroke. 

In  1892  the  numbers  were  103,159.  There  were  77  admissions  and 
41  deaths  from  heat-stroke. 

The  above  numbers  show  that  the  admission-rate  per  mille  from 
heat-stroke  in  the  European  army  in  India  was,  in  1891,  3-4 ;  in  1892, 
3-3 ;  while  the  death-rate  in  1891  was  0-97 ;  in  1892,  0-90.  Among  the 
women  with  the  European  army  the  admission-rate  in  1891  was  0-64 ; 
in  1892,  0;  while  the  death-rate  in  1891  was  0-64;  in  1892,  0-32.i 
Among  the  children  the  admission-rate  in  1891  was  0-5;  in  1892,  0-7; 
while  the  death-rate  in  1891  was  0-34;  in  1892,  0-35.  In  the  native 
army  the  admission-rate  in  1891  was  0-2 ;  in  1892,  0-3;  while  the  death- 
rate  in  1891  was  0-09 ;  in  1892,  0-14.  Among  the  jail  population  the 
admission-rate  in  1891  was  0-8 ;  in  1892,  0-7 ;  while  the  death-rate  in 
1891  was  0-40 ;  in  1892,  0-40. 

The  following  statistics  and  tables  are  taken  from  the  reports  of  the 
Sanitary  Commissioner  with  the  Government  of  India  for  1891  and 
1892:  — 

The  one  death  was  out  of  hospital. 


494 


SYSTEM  OF  MEDICINE 


Deaths  from  Heat-stroke  in  the  European  Army  in  India  in  1891 
and  1892  at  the  different  Ages. 


Age. 

1891. 

1S92. 

24  and  under    . 

25  to  29     . 
30  to  34     . 

35  and  upwards 

35  or  1-06  per  mille 
14  or  0-58       ,, 

8  or  1-41 

7  or  3-33 

26  or  0-76  per  mille 
21  or  0-84       ,, 
9  or  1-65       ,, 
5  or  2-40       „ 

Deaths  from  Heat-stroke  in  the  European  Army  in  India  in  1891 
and  1892  at  the  different  periods  of  Residence. 


Length  of  Service. 

1S91. 

1S92. 

First  and  second  years 
Tliird  to  fit'tli  year    . 
Sixth  to  eighth  year  . 
Eleventh  to  fifteenth  year 
Fifteen  years  and  upwards 

36  or  1-74  per  mille 
18  or  0-59       ,, 

5  or  0-43       ,, 

3  or  1-81 

2  or  3-27 

23  or  100  per  mille 
22  or  0-72       „ 
12  or  1-03       ,, 

2  or  1-40 

2  or  3-85 

The  statistics  show  how  the  effects  of  heat  influence  a  certain  class 
of  persons  who  are  under  hygienic  control ;  reliable  data  thus  being 
afforded  on  which  to  determine  the  value  of  this  element  of  the  death- 
rate  of  a  certain  section  of  the  population  whose  vital  statistics  are 
trustworthy.  In  others  less  protected,  as  in  the  scattered  European, 
Eurasian,  and  immense  native  population,  the  incidence  of  the  disease 
is  often  greater.  In  seasons  when  there  are  great  accessions  and  waves 
of  heat  all  over  the  world  the  disease  and  the  mortality  from  it  increase. 
Such  waves  of  high  temperature  recur  at  uncertain  intervals.  No  doubt 
the  same  obtains  in  other  countries  where  the  climatic  conditions  are 
similar ;  it  is  needless,  therefore,  to  produce  further  statistics,  as  these 
sufficiently  illustrate  the  subject. 

A  number  of  cases  of  hemiplegia  are  reported  by  the  Sanitary  Com- 
missioner with  the  Government  of  India,  which  there  is  reason  to  believe 
were  also  due  to  attacks  of  insolation ;  but  as  it  is  not  certain  that  all 
were  so  caused,  I  am  content  to  allude  to  it  generally  as  one  of  the 
possible  results  of  sunstroke. 

Symptomatology  and  Pathology. — In  addition  to  the  general  dis- 
turbance of  health  which  occurs  in  all  who  are  more  or  less  affected  by 
heat  —  such  as  restlessness,  irritability,  sleeplessness  —  the  morbid  con- 
ditions which  are  to  be  attributed  to  the  effects  of  a  high  temperature 
are:  — 

I.  A.  Syncope  from  exhaustion,  caused  either  by  the  direct  rays 
of  the  sun  or  a  heated  atmosphere  in  the  shade ;  especially  when  the 
physical  or  mental  powers  are  depressed :  engine-room  men  in  steamers 
in  hot  climates ;  men  marching,  or  on  parade,  if  oppressed  with  clothes 
or  accoutrements,  or  weakened  by  previous  illness,  or  by  dissipation; 
labourers  or  artificers  ;  men  in  hay -fields  in  England,  or  in  heated  rooms 


INSOLATION   OR   SUNSTROKE  495 

and  factories,  in  barracks,  hospitals,  tents,  or  ships,  may  suffer  in  this 
way.  The  condition  is  one  of  depression;  the  skin  is  cold  and  pale, 
and  the  pulse  feeble.  Death  may  occur  from  failure  of  the  heart,  but 
recovery  is  usual. 

B.  The  exhaustion  above  described  having  passed  away  may  be  suc- 
ceeded by  fever,  which  may  assume  an  ardent  type  \vide  section  on 
Indian  fevers  (thermic  fever)].  The  fever  may,  after  a  certain  dura- 
tion, def  ervesce ;  or  it  may  result  in  changes,  the  consequence  of  damage 
done  by  the  heat  to  the  cerebro-spinal  centres.  Thus  a  variety  of  morbid 
conditions  may  ensue,  depending  upon  the  parts  affected.  Such  cases 
are  often  very  prolonged,  and  the  only  hope  of  recovery  lies  in  removal 
to  a  colder  climate. 

When  death  occurs  rapidly  at  the  time  of  the  exposure  it  may  be 
due  to  sudden  cardiac  failure,  as  shown  in  the  experiments  of  Claude 
Bernard  and  Brunton  (8)  upon  animals  exposed  to  great  heat.  When 
it  occurs  suddenly,  during  great  exhaustion  or  muscular  action  with 
fatigue,  it  may  be  due  to  coagulation  of  the  cardiac  myosin,  which  Dr. 
Wood  of  Philadelphia  has  shown  to  be  likely  to  occur  during  any  great 
muscular  exertion  at  a  much  lower  temperature  than  usually  determines 
it  when  there  is  no  great  muscular  exertion.  For  example,  men  fighting 
in  a  very  high  temperature  may  fall  dead  suddenly;  but  probably 
coagulation  of  myosin  is  most  frequently  a  post-mortem  change. 

II.  The  gravest  and  perhaps  most  fatal  forms  of  sunstroke  occur  as 
a  consequence  of  the  general  heating  of  the  whole  body,  blood  and 
tissues,  which  may  happen  either  from  prolonged  exposure  to  the  sun's 
rays  in  a  heated  atmosphere,  to  a  heated  atmosphere  in  the  shade 
(occurring,  as  it  does,  by  night  as  well  as  by  day),  or  to  an  abnormal 
thermotaxic  state  due  to  vaso-motor  or  other  heat-regulating  disturbance. 

In  the  first  case  the  effect  of  the  high  temperature  tells  upon  the 
brain,  which  becomes  heated  to  a  degree  incompatible  with  due  perform- 
ance of  its  functions:  this  may  result  in  acute  cerebral  symptoms,  and 
sometimes  in  phrenitis,  rapidly  passing  into  a  state  of  asphyxia,  if  the 
respiratory  centres  are  involved :  more  frequently,  perhaps,  the  whole 
body  becomes  overheated,  the  temperature  rising  to  106°,  108°,  or  110°, 
which,  if  not  I'apidly  counteracted,  proves  destructive  to  life  by  asphyxia 
or  sudden  cardiac  failure,  or  even  by  cerebral  haemorrhage  or  meningitis. 

In  heat  exhaustion  the  primary  symptoms  are  those  of  depression. 
The  person  becomes  faint,  pallid,  with  a  pale,  cold,  and  moist  skin  and 
feeble  pulse,  not  unfrequently  attended  with  sickness.  The  soldier  on 
parade  staggers  and  falls  over  in  a  faint;  so  with  the  orator  when  speak- 
ing, or  the  artisan  in  pursuing  his  calling.  This  may  take  place  either 
in  the  sun  or  in  the  shade.  The  condition  is  one  of  syncope,  and  may 
approach  collapse;  if  reaction  be  not  soon  established  death  may  result 
from  cardiac  failure,  but  this  is  rare.  Recovery  is  generally  complete, 
but  when  the  state  has  occurred  from  direct  application  of  intense  solar 
heat  and  glare,  the  mischief  is  not  always  confined  to  the  transient 
shock  or  impression ;  secondary  effects,  such  as  vertigo,  muscular  tremors, 


496  SYSTEM   OF  MEDICINE 

and  temporary  loss  of  power  may  result;  or  a  reaction  may  be  followed 
by  fever,  or  by  symptoms  indicating  lesions  of  the  centres  or  cerebral 
excitement,  and  this  may  end  in  mania. 

In  insolation  proper  the  premonitory  symptoms  may  appear  some 
hours  or  even  days  before  the  dangerous  symptoms  set  in,  as  the  result 
of  continued  exposure  to  a  high  temperature ;  although  they  may  occur 
also  in  a  much  shorter  period,  as  when  men  are  exposed  in  marching  or 
in  other  occupations  to  a  very  high  degree  of  solar  heat,  in  which  case 
some  would  no  doubt  be  affected  by  heat  exhaustion,  whilst  others  would 
pass  into  a  state  of  hyperpyrexia  as  before  described.  These  are  generally 
malaise,  restlessness,  insomnia,  apprehension  of  impending  evil,  precor- 
dial anxiety;  hurried,  gasping,  shallow  breathing;  a  feeling  of  constric- 
tion round  the  thorax ;  vertigo ;  headache,  often  severe ;  nausea,  or  even 
vomiting,  anorexia,  great  thirst,  frequent  micturition,  and  fervent  heat 
of  the  skin.  As  one  or  more  of  these  symptoms  become  aggravated  the 
temperature  rises  to  104°,  106°,  or  even  110°.  Dyspnoea  and  restlessness 
increase ;  the  head,  face,  neck,  and  skin  of  the  body  generally  become 
red,  or  livid,  sometimes  dry,  sometimes  moist;  the  pulse  full  and 
labouring,  carotid  pulsation  very  perceptible,  pupils  contracted,  but 
dilating  widely  before  death.  Unconsciousness  passes  into  complete 
coma,  stertor,  and  epileptiform  convulsions;  finally,  relaxation  of  the 
sphincters  and  suppression  of  urine  precede  death. 

These  symptoms  all  indicate  a  profoundly  disturbed  state  of  the 
cerebro-spinal  centres  and  a  disordered  condition  of  the  blood.  The 
hyperpyrexia  is  incompatible  with  a  due  performance  of  their  functions, 
and  death  will  rapidly  result  unless  prompt  aid  be  given;  indeed,  it 
frequently  does  so  despite  all  treatment.  The  fatal  result  is  due  to 
asphyxia  and  cardiac  failure.  There  may  be  —  though  perhaps  rarely  — 
meningitis  or  cerebral  hseraorrhage  or  effusion,  the  disordered  state  of 
the  blood  not  unfrequently  manifesting  itself  by  petechial  patches  on 
the  body. 

The  earlier  stages  of  this  condition  are  those  of  so-called  thermic  fever. 
A  very  high  temperature  may  be  maintained  for  several  days,  and  finally 
defervescence  takes  place  without  evidences  of  any  structural  lesion ;  but 
unless  active  measures  be  used  and  the  temperature  rapidly  reduced, 
unless,  that  is,  the  causes  which  produce  the  hyperpyrexia  be  mitigated 
or  removed,  the  case  is  apt  to  pass  on  into  the  grave  state,  and  to  ter- 
minate fatally  by  paralysis  of  the  respiratory  centres,  and  in  some 
instances,  though  rarely,  by  cerebral  haemorrhage.  From  the  graver  forms 
some  recover,  but  many  are  permanently  injured,  and  become  invalids  for 
life ;  life  indeed  is  not  unfrequently  shortened  by  obscure  cerebral  or 
meningeal  changes  which  affect  the  sufferer  in  varying  degrees  of  form 
and  intensity,  such  as  epilepsy,  irritability,  impaired  memory,  cephalal- 
gia, blindness,  or  deafness,  partial  or  complete  paralysis,  dementia  or 
even  mania.  In  those  who  have  apparently  recovered  intolerance  of 
the  sun's  rays  or  even  of  the  heat  of  temperate  climates  may  remain; 
or  such  cases  may  after  a  long  time  end  in  dementia,  or  epilepsy,  or 


INSOLATION  OR   SUNSTROKE  497 

both ;  or  in  chronic  meningitis  with  thickening  of  the  calvaria ;  fre- 
quent or  intense  headaclie,  general  functional  derangement  and  dis- 
ordered innervation  being  persistent. 

Morbid  Anatomy.  —  When  death  has  occurred  in  the  syncopal  form 
there  is  not  any  very  obvious  morbid  change.  The  brain  with  its  mem- 
branes and  the  lungs  are  sometimes  but  not  always  congested.  The 
venous  trunks  in  the  abdomen  and  also  the  right  cavities  of  the 
heart  may  be  full  of  blood,  which  is  imperfectly  coagulated  and 
deficient  in  oxygen.  The  abdominal  viscera  are  congested;  lividity 
of  the  body  and  decomposition  come  on  rapidly  after  and  even  before 
death. 

In  death  from  thermic  fever  and  insolation  the  heart  is  sometimes 
found  firmly  contracted  —  it  may  be  from  coagulation  of  the  myosin  — 
and  the  venous  system  generally  is  engorged.  The  blood  is  dark, 
grumous,  fluid,  and  acid  in  reaction ;  the  blood  globules  are  crenated 
and  do  not  rapidly  form  into  rouleaux.  The  body  for  some  time  after 
death  retains  a  high  temperature.  In  early  autopsies,  necessary  in  hot 
climates,  the  body  and  viscera  when  opened  feel  pungently  warm,  dark 
blood  drips  freely  from  the  incision,  rigor  mortis  comes  on  rapidly. 
The  brain  and  membranes  are  often  congested.  There  may  be  some 
cerebral  haemorrhage,  effusion  of  serum  into  the  substance  or  cavities, 
or  incipient  symptoms  of  meningitis. 

A  precise  degree  of  blood  temperature  incompatible  with  life  can- 
not be  defined,  but  the  danger  becomes  very  imminent  at  or  above  108° 
or  109°  F. 

Prophylaxis.  —  Prevention  is  the  great  desideratum.  The  clothing 
should  be  very  light,  and  woollen  material  should  always  be  worn  next 
the  skin,  as  cotton  or  linen  wet  with  perspiration  is  very  injurious. 
The  head  and  spine  should  be  protected  from  the  direct  rays  of  the 
sun  out  of  doors  by  a  pith  hat  and  a  cotton  pad  let  into  the  coat  over 
the  back  of  the  neck  and  spine,  and  by  a  good  white  umbrella  lined 
with  green.  The  clothing  should  be  loose,  not  constricting  the  neck  or 
any  part  of  the  body.  Indoors  the  temperature  should  be  reduced  by 
the  use  of  thermantidotes,  punkahs,  or  other  artificial  means  of  cooling ; 
free  ventilation  should  be  insisted  on,  and  a  sufficient  amount  of  cubic 
space  —  not  less  than  1000  to  1200  cubic  feet  per  head  —  in  sleeping 
rooms,  barracks,  and  so  on.  During  the  hot,  still  nights  —  a  most 
dangerous  time  —  the  foregoing  precautions  are  especially  necessary. 

Overfatigue,  excitement  or  depression  should  be  alike  avoided,^ 
though  a  moderate  degree  of  exercise,  physical  and  mental,  is  desirable 
during  the  cooler  hours  of  the  day.  A  short  sleep  during  the  course  of 
the  day  is  also  to  be  encouraged. 

For  soldiers  all  drills  not  absolutely  necessary  should  be  avoided. 
If  they  must  march  during  the  hot  weather  it  should  be  in  the  early 
hours  of  the  morning.  Frequent  halts  should  be  allowed,  and  coffee 
and  a  biscuit  given  out.  Plenty  of  water  should  be  carried  and  be 
readily  available.     The  dress  should  be  light  and  loose,  and  all  con- 

VOL,.    I  2    K 


498  SYSTEM  OF  MEDICINE 

striction  carefully  avoided.  The  halts  should  be  in  the  most  sheltered 
places  that  can  be  found,  with  plenty  of  fresh  air  —  such  as  open  topes 
of  trees.  The  accoutrements  should  be  as  light  as  possible,  so  as  to  spare 
fatigue  and  exhaustion.  Men  falling  out  should  be  attended  to  immedi- 
ately by  the  medical  officer.  The  marches  and  drills  in  the  great  heat 
should  be  as  short  as  the  exigencies  of  the  service  will  permit. 

Moderation  of  diet  is  especially  to  be  enjoined.  Very  little  animal 
food  should  be  taken ;  the  food,  whilst  sufficiently  nutritious,  should  be 
light  and  unstimulating.  Iced  water  should  be  drunk  freely  and  fre- 
quently, and  the  greatest  moderation  in  the  use  of  stimulants  should  be 
observed.  Excesses  in  eating,  drinking  or  smoking  are  especially  to  be 
deprecated.  The  cold  bath  may  be  freely  used.  In  short,  regulation 
and  moderation  in  all  things,  and  careful  attention  to  the  state  of  the 
bowels,  which  should  never  be  allowed  to  be  confined,  are  essential.  No 
one  is  more  likely  to  suffer  from  the  ill  effects  of  heat  than  he  who  has 
undergone  mental  or  physical  exhaustion,  or  has  suffered  from  intemper- 
ance in  food  or  alcoholic  drinks.  Healthy  persons  who  lead  regular 
lives  and  observe  such  precautions  will  tolerate  a  degree  of  heat  which 
would  hardly  be  deemed  credible. 

Treatment.  —  In  simple  heat  exhaustion,  remove  the  patient  to  a  cool 
place  in  the  shade  or  into  the  open  air,  according  to  circumstances. 
Remove  all  oppressive  or  tight  clothing.  Dash  cold  water  on  the  head 
and  chest  so  as  to  rouse  but  not  depress.  If  necessary,  give  a  stimulant 
and  apply  ammonia  to  the  nostrils.  If  depression  continue,  administer 
stimulants  and  restoratives ;  let  the  patient  avoid  exertion  or  exposure 
to  heat  as  much  as  possible.  In  the  steamers  in  the  Red  Sea  and  Indian 
Ocean  stokers,  usually  Africans,  are  sometimes  brought  up  from  the 
furnaces  unconscious  from  heat  exhaustion,  but  are  generally  quickly 
restored  by  the  fresh  air,  by  dashing  cold  water  on  their  bodies,  or  by 
giving  a  little  stimidant. 

If  a  man  be  struck  down  by  the  beating  of  the  hot  sun  on  his  head, 
apply  the  cold  douche  freely  to  the  head ;  if  there  be  rise  of  temperature, 
apply  ice  to  the  head,  but  not  for  too  long  a  time.  The  object  is  two- 
fold, to  rouse  by  reflex  action  and  to  reduce  temperature. 

At  the  capture  of  Rangoon  in  1852,  numbers  of  men  under  my 
observation  were  struck  down  by  the  sun,  some  simply  from  heat 
exhaustion.  They  were  clad  in  the  thick  red  coats  worn  in  India  in 
those  days.  In  others,  apparently,  the  exhaustion  was  combined  with 
the  direct  effects  of  the  sun  upon  the  head  and  spine.  They  were  all 
douched  with  cold  water  and  placed  in  the  shade  in  the  Field  Hos- 
pital. All  but  two  recovered ;  these  two  were  bled  on  the  field  where 
they  fell,  and  never  regained  consciousness.  By  recovery  is  meant 
a  favourable  reaction  at  the  time ;  in  some  there  were  consecutive 
symptoms  of  fever  and  cerebral  disturbance ;  they  were  sent  away  to  a 
Depot  hospital,  and  if  their  history  could  be  traced,  it  would  probably  be 
found  that  in  some  of  them  complete  recovery  never  took  place.  Exposure 
to  the  sun's  rays  should  be  carefully  guarded  against,  and  unless  recovery 


INSOLATION   OR   SUNSTROKE  499 

be  rapid,  and  complete,  a  colder  climate  should  be  sought,  where  the 
same  precautions  must  be  continued. 

In  thermic  fever  or  insolation  the  object  is  to  reduce  the  tempera- 
ture, before  more  serious  or  fatal  consequences  appear.  For  this  pur- 
pose quinine  in  doses  of  5  grains,  or  even  more  up  to  10  grains  of 
hydrochlorate  or  sulphate,  may  be  given  in  solution  by  the  mouth, 
every  three  hours ;  or  the  equivalent  in  the  form  of  a  hypodermic  in- 
jection \yide  article  on  "Indian  Fevers"],  may  be  given  and  continued 
until  an  impression  is  produced.  Morphia  has  also  been  suggested,  but 
this  practice  seems  questionable.  Bleeding  should  not  be  resorted  to 
except  in  special  cases.  In  asphyxia,  where  the  right  heart  is  over- 
loaded, it  may  be  expedient  in  the  choice  of  evils.  As  a  general  rule 
it  has  been  abandoned,  for  though  it  may  have  appeared  at  first  to  pro- 
duce a  favourable  impression,  subsequent  results  have  not  justified  it 
as  a  general  practice.  No  absolute  canon  of  procedure  can  be  laid  down 
with  reference  to  bleeding  in  this  disease ;  each  case  must  be  dealt  with 
on  its  own  merits.  All  that  can  be  said  here  is  that  it  is  not  desirable 
as  a  general  rule.  Should  the  quinine  not  be  effective  in  reducing  the 
temperature,  antipyrin,  phenacetin,  antifebrin,  aconite,  or  acetate  of 
ammonia  may  be  tried. 

The  cold  bath,  cold  affusions,  and  application  of  ice  to  the  head  — 
which  should  be  shaved  —  and  to  the  body,  should  also  be  resorted  to, 
care  being  taken  not  to  prolong  the  cooling  until  too  great  depression  be 
produced  —  that  is,  not  below  100°  F.  The  bowels  should  be  relieved 
by  calomel,  colocynth  and  saline  purgatives,  and  by  enemata ;  care  being 
taken  that  sufficient  daily  action  be  maintained.  In  the  epileptiform 
convulsions  which  sometimes  occur  the  cautious  inhalation  of  chloroform 
may  be  resorted  to.  I  have  seen  good  results  from  its  use.  Blisters  are 
sometimes  applied  to  the  nape  of  the  neck,  but  it  seems  doubtful  whether, 
in  the  early  stages  at  any  rate,  they  can  be  of  much  use,  if  any.  Light 
and  unstimulating  diet  should  be  given  in  small  quantities  at  tolerably 
frequent  intervals.  This  antipyretic  treatment  must  be  continued  as 
long  as  a  high  temperature  lasts,  to  obviate  the  imminent  risk  of  death 
or  of  tissue  changes  which  may  be  permanently  injurious.  As  the  case 
proceeds,  if  symptoms  of  cerebral  or  meningeal  mischief  supervene, 
iodide  and  bromide  of  potassium  and  counter-irritation  may  be  of  service. 

It  is  essential  that  perfect  rest  of  mind  and  body  should  be  main- 
tained. When  insomnia  is  distressing  hypnotics  may  be  useful ;  they 
must  be  given  with  great  caution,  and  without  opium  if  it  can  be 
avoided.  Kestriction  should  be  imposed  upon  the  use  of  alcoholic 
stimulants.  The  amount,  if  any,  that  may  be  given  must  depend  upon 
the  previous  habits  as  well  as  the  present  condition  of  the  patient.  Here, 
again,  the  physician  must  be  guided  by  the  special  indications  of  the  case 
before  him.  Precautions  should  be  continued,  not  only  when  recovery 
has  set  in,  but  even  for  some  time  after  it  is  apparently  complete;  for 
certain  indications  of  latent  chronic  mischief  will  probably  remain,  such 
as  loss  of  memory,  irritability,  headache,  inability  to  concentrate  the 


500  SYSTEM  OF  MEDICINE 

thoughts,  intolerance  of  heat,  or  of  the  slightest  exposure  to  the  sun  or 
even  of  the  temperature  of  an  overheated  room.  Not  until  these  have 
completely  disappeared,  can  a  return  to  India  or  any  other  hot  climate 
be  permitted  with  any  propriety  or  prospect  of  future  health.  I  repeat 
that  frequently,  indeed,  a  patient  can  never  return  to  a  hot  climate  at  all. 

It  seems  hardly  necessary  to  say  that  cases  of  this  kind  should  be 
removed  from  a  hot  climate  to  a  colder  one  as  soon  as  travelling  can 
safely  be  permitted,  and  that  the  sufferers  should  be  carefully  watched 
on  their  way  home.  Neglect  of  this  precaution  has  resulted  in  self- 
destruction  during  the  mental  aberration  that  sometimes  follows. 

The  sequelae  of  sunstroke  occasionally  assume  a  serious  character, 
and  are  the  cause  of  permanent  disability  to  the  patient  and  a  source 
of  much  anxiety  to  his  friends.  The  slighter  forms  of  meningitis  and 
of  cerebral  mischief  not  unfrequently  pass  away  after  protracted  resi- 
dence in  a  temperate  climate,  but  they  are  also  not  unfrequently  per- 
manent, and  endanger  or  shorten  life,  causing  such  physical  or  mental 
disability  as  epilepsy,  partial  paralysis,  mania,  chronic  dementia,  im- 
paired memory,  and  inability  for  mental  concentration  —  sad  examples 
of  the  evil  effects  of  a  tropical  or  hot  climate. 

Treatment  will  depend  upon  the  nature  and  extent  of  such  mis- 
chief. These  vary  so  much  as  to  render  it  impossible  to  give  more 
definite  directions  here,  and  the  reader  is  referred  to  the  special  chap- 
ters of  this  System  on  Cerebro-spinal  and  Mental  Diseases. 

I  am  indebted  to  Brigade-Surgeon  Lieutenant-Colonel  Hooper,  Civil 
Surgeon  of  Lucknow,  for  the  following  cases  of  insolation,  which  illus- 
trate the  hyperpyrexial  symptoms,  and  the  treatment  by  the  application 
of  cold,  quinine,  and  other  remedies. 

In  all  these  cases  but  one  recovery  seems  to  have  followed ;  but  the 
subsequent  history  of  some  of  them,  could  it  be  ascertained,  would  prob- 
ably show  that  such  sequelae  as  have  been  described  in  the  text  ensued. 

No.  1.  —  Case  of  Insolation ;  Death  on  Third  Day 

A  private  soldier,  European,  eet.  22,  was  admitted  into  the  hos- 
pital, Lucknow,  on  4th  June  1892 ;  unconscious,  breathing  stertorous, 
temp.  106°,  pupils  contracted,  reflexes  abolished.  Treated  with  douch- 
ing, sponging  with  iced  water,  enemata,  sinapisms,  and  injections  of 
strychnine.  Temp,  fell  to  97-8°  F.,  but  consciousness  was  not  recovered. 
Pulse  feeble,  respirations  very  shallow  and  quick,  limbs  very  rigid. 
Pulse  gradually  failed,  respiration  quick  and  shallow,  conjunctivae  in- 
jected, cornea  ulcerated ;  temp,  went  up  again,  and  had  reached  105°  E. 
on  the  morning  of  the  6th.     He  died  on  morning  of  7th. 

Post-mortem.  —  Sinuses  of  dura  mater  distended.  No  excess  of  fluid 
in  arachnoid. 

Brain  congested,  with  marked  puncta  cruenta.  Ventricles  filled 
with  serum. 


INSOLATION  OR  SUNSTROKE  501 

Lungs  crepitant,  and  not  much  congested. 
Liver,  spleen,  and  kidneys  all  greatly  congested. 

No.  2.  —  Case  of  Insolation  ;  Recovery 

Private  soldier,  European,  aet.  34,  admitted  into  hospital,  Lucknow, 
on  22nd  June  1892.  Feeling  sick  and  dizzy  all  day.  In  the  evening 
temp,  rose  to  109°.  Cold  douche  applied  and  turpentine  enemata  given. 
Temp,  fell  to  99-8°  F. ;  continued  a  little  raised  for  a  few  days.  Thirty 
grains  of  quinine  given  daily.     Discharged  on  10th  July. 

No.  3.  —  Case  of  Insolation  ;  Recovery 

A  private  soldier,  European,  eet.  22,  was  brought  into  hospital.  Luck- 
now,  on  19th  May  1894.  He  was  unconscious,  skin  very  dry  and  hot, 
temp.  110°  F.  in  the  axilla,  eyes  fixed  and  staring,  conjunctivae  congested 
and  insensitive,  pupils  dilated,  breathing  stertorous,  and  pulse  almost 
imperceptible.  He  was  put  into  a  cold  bath  for  about  ten  minutes,  then 
into  a  wet  pack ;  ice  v/as  applied  to  the  head  and  back  of  the  neck,  and 
he  was  fanned.  Cold  water  was  injected  into  the  rectum,  and  a  large 
quantity  of  fasces  came  away.  Brandy  and  ether  were  injected  sub- 
cutaneously,  and  a  small  enema  of  brandy  and  water  was  given,  but  the 
latter  was  soon  rejected.  After  a  time  the  temperature  came  down  to 
102°,  and  the  breathing  became  easier.  Convulsions  were  painful  and 
frequent ;  chloroform  was  used,  and  dry  cupping  along  the  spine.  The 
pulse  became  stronger  after  about  six  hours,  the  pupils  slightly  sensitive 
to  touch,  and  congestion  of  conjunctivae  diminished;  but  convulsions 
still  occurred  if  he  were  touched  or  a  hand  passed  in  front  of  him.  Two 
injections  of  morjDhia,  ^  gr.  in  each,  were  administered.  The  patient 
did  not  recover  consciousness  for  over  twenty-four  hours,  and  then  only 
when  roused.  There  was  emphysema  of  the  connective  tissue  of  the  left 
side  of  the  face  and  neck,  extending  as  far  as  the  clavicle  and  over  the 
deltoid  muscle,  and  also  under  the  axilla.  The  voice  was  thick  ;  the  eyes 
were  very  sensitive  to  light,  and  the  patient  was  kept  for  some  time  in  a 
darkened  room.  Cold  water  continued  to  be  applied  to  the  head,  and 
iodide  and  bromide  of  potassium  administered.  On  the  fourth  day  after 
admission  the  temperature  became  normal ;  it  rose  slightly  subsequently, 
but  recovery  was  uninterrupted,  and  the  patient  was  discharged  on  20th 
June.     He  was  sent  to  a  hill  depot  on  10th  July. 

No.  4.  —  Ca.se  of  Sim'ple  Insolation;  Subsequent  Cerebral  Symptoms ; 

Recovery 

An  officer,  aet.  34,  was  admitted  into  hospital  on  27th  March  1894 
with  severe  pain  in  the  head,  from  which  he  had  been  suffering  for  some 
days.  On  17th  March,  after  riding  in  the  sun  all  day,  he  was  seized 
with  pain  in  back  and  aching  in  limbs.  He  went  out  shooting  the  next 
day,  and  j)ain  in  the  head  with  fever  came  on  the  same  evening. 


502  SYSTEM  OF  MEDICINE 

On  admission ;  temp.,  abdomen,  liver,  and  spleen  were  normal.  On 
the  evening  of  28t]i,  while  in  bed,  he  had  a  prolonged  attack  of  syncope, 
nansea,  cold  sweats,  weak  and  frequent  pulse,  pallor,  vertigo,  hurried 
respiration.  This  passed  off  on  the  administration  of  brandy.  The  pain 
in  the  head  ceased,  but  dizziness  and  sickness  came  on  when  he  tried  to 
raise  it.  Potas.  iodide  and  sp.  ammon.  aromat.  administered.  On  1st 
and  4th  April  temp,  rose  to  101°  and  100°  as  result  of  attempt  to  sit  up 
in  bed;  vertigo  also  increased,  with  buzzing  in  ears.  The  iodide  of 
potassium  was  discontinued,  10  grs.  of  quinine  administered  daily,  \  gr. 
of  calomel  morning  and  evening.  After  this  date  the  improvement 
continued,  the  vertigo  diminished,  but  was  induced  by  any  sudden  head 
movement.  Was  discharged  on  25th  April  for  three  months'  leave.  For 
many  months  afterwards  vertigo  came  on  with  any  sudden  movement  of 
the  head,  and  headache  was  induced  by  the  slightest  exposure  to  the  sun. 

BIBLIOGRAPHY 

1.  Dr.  Parkes.  Practical  Hyqiene,  by  De  Chaumont,  6th  ed.  1883.  — 2.  Dr.  Mac- 
lean, C.  B.  Diseases  of  Tropical  Climates.  London,  1886,  p.  ]4r>.  —  3.  Sir  W.  Aitken. 
The  Science  and  Practice  of  Medicine,  7th  ed.  1880.  —  4.  Sir  T.  Longmore,  C.  B.  Indian 
Annals  of  Medical  Science,  No.  12,  July  185!t. — 5.  Dr.  Barclay  and  Sir  T.  Crawford. 
Madras  Qnarterli/  Journal,  Oct.  1860. — 6.  Dr.  Marcus  Hill.  Indian  Annals  of 
Medical  Science,  No.  5,  Oct.  1855. — 7.  Dr.  Austen  Flint  of  New  York.  Practice 
of  Medicine.  Phil.  1886.  — 8.  Dr.  H.  C.  Wood  of  Philadelphia.  Sunstroke,  1872.— 
9.  Bassier.    Dissertation  sur  la  Calenture  (quoted  by  Maclean). 


PART  II.  — THE   INFECTIONS^ 

CONTENTS 

THE  GENERAL  PATHOLOGY  OF   INFECTION 

(ffl)  Bacterial  Forms.     (&)  Immunity,     (c)  Serum  Therapeutics. 

The  Infective  Diseases. 


I.  Diseases  of  more  or  less  established 
Bacteriology. 

(a)  Local  or  General  Diseases  due  to 
Pyococci. 

(1)  Septicemia  and  PyfBinia. 

(2)  Erysipelas. 

(3)  Infective  Endocarditis. 

(4)  Puerperal  Septic  Disease. 

(5)  Carbuncle  and  Boils. 
(Gonorrhoea  not  included  in  this  System.) 

(6)  Infective  Fevers. 

(6)  Epidemic  Pneumonia. 

(7)  Cerebro-spinal  Meningitis. 

(8)  Influenza. 

(9)  Diphtheria. 

(10)  Tetanus. 

(11)  Enteric  Fever. 

(12)  Cholera. 

(13)  Oriental  Plague. 

(14)  Relapsing  Fever. 

(c)  Infective  Diseases  of  Chronic  Course. 

(15)  Tuberculosis. 
(Ifi)  Leprosy. 

(17)  Actinomycosis. 

n.  Diseases    of   uncertain   Bacteriology. 

(a)  Not  Endemic. 

(IH)  Measles. 
(I'.t)  Rubeola. 

(20)  Scarlet  Fever 

(21)  Varicella. 


(22)  Variola. 

(23)  Mumps. 

(2i)  Whooping-Cough. 

(25)  Syphilis. 

(Mixed  Infections.) 

(5)  Topical  or  Endemic. 

(Fevers  of  India.) 

(26)  Typhus. 

(27)  Dengue. 

(28)  Yellow  Fever. 

(29)  Amoebic  Dysentery. 

(30)  Beriberi. 

(31)  Maltese  Fever. 

(32)  Epidemic  Dropsy. 
(-33)  Negro  Lethargy. 

(34)  Delhi  Boil. 

(35)  Verrugas. 

(36)  Framboesia. 


in. 


Infective    Diseases   communicable 
from  Animals  to  Man. 


(a)  Of  certain  Bacteriology. 

(37)  Glanders. 

(38)  Anthrax. 

(&.)  Of  uncertain  Bacteriology. 

(39)  Vaccinia. 

(40)  Foot  and  Mouth  Disease. 

(41)  Rabies. 

IV.  Diseases  Due  to  Protozoa. 

(42)  Malaria. 

(43)  Blackwater  Fever. 


1  The  Infectious  Diseases  will  be  d(3scribed  in  the  al)ove  order,  which  was  drawn  up 
for  me  by  Dr.  Kantliack,  and  kindly  revised  in  parts  by  Dr.  Manson,  {The  term 
Bacteriology  includes  the  study  of  all  morbiferous  micro-organisms.)  — Ed. 


504  SYSTEM   OF  MEDICINE 

THE  GENEEAL  PATHOLOGY  OE  INFECTION 

I.    Bacterial  Forms 

Bacteriology  deals  with  the  lowest  forms  of  vegetable  organisms,  and 
so  far  as  it  concerns  itself  with  the  biological  phenomena  of  these  lowly 
beini;s  it  is  a  part  of  botany.  But  since  bacteria  are  found  in  many  dis- 
ease! processes,  bacteriology  necessarily  also  forms  a  part  of  pathology, 
that  is  to  say  of  medicine.  Our  knowledge  of  disease  cannot  then  be 
complete  without  a  fair  prasp  of  the  part  played  by  the  micro-organisms. 
Many  symptoms  and  obscure  changes  are  thus  readily  explained ;  the 
treatment  of  maladies,  and  the  rules,  of  prevention  —  the  highest  form 
of  therapeutics  —  are  often  laid  down  or  indicated  by  the  bacteriological 
pathologist.  Because  so  much  new  light  has  been  thrown  on  diagnosis 
and  prognosis  in  disease,  because  some  of  our  recent  therapeutic  triumphs 
have  been  achieved  by  bacteriology,  a  System  of  Medicine  would  fail  to 
be  complete  if  it  did  not  offer  some  information  on  the  elements  of  this 
the  youngest  branch  of  pathology.  While  undertaking  this  share  of  the 
work,  I  feel  not  only  the  great  responsibility,  but  also  the  difficulties 
which  accompany  it,  and  further  realise  that  the  physician  cannot  often 
be  a  bacteriological  specialist ;  he  desires,  however,  to  learn  the  bearing 
of  bacteriology  on  the  clinical  phenomena  of  disease  and  its  application 
to  practice.  In  the  lines  that  follow,  therefore,  I  shall  endeavour  to 
give  a  general  view  of  the  facts  and  opinions  which  the  study  of  bac- 
teria has  either  disclosed  or  indicated,  in  so  far  as  they  directly  concern 
the  clinical  physician ;  whether  for  the  purposes  of  diagnosis  and  prog- 
nosis, or  for  those  of  treatment  and  prevention. 

Obviously  we  must  begin  with  a  short  account  of  the  general  morphol- 
ogy and  biology  of  bacteria,  that  is,  with  so  much  of  it  as  is  necessary 
to  demonstrate  the  influence  of  bacterial  life  and  activity  in  disease. 

Morphology  of  Micro-Organisms.  —  The  vegetable  micro-organ- 
isms, so  far  as  we  have  to  deal  with  them,  have  been  classified  by  Nageli 
under  three  headings,  namely,  I.  Hyphomycetes  or  Moulds,  II.  Blasto- 
mycetes  or  Sprouting  Fungi,  III.  Schizomycetes  or  Cleft  Fungi.  Others 
have  singled  out  the  schizomycetes  as  mycetes  or  microbes,  but,  rightly 
or  wrongly,  these  terms  are  commonly  applied  to  all  the  three  groups  of 
micro-organisms  in  a  generic  sense ;  and  when  no  harm  is  done  thereby 
it  is  well  to  bow  to  custom. 

I.  Moulds  or  Hyphomycetes.  —  These  organisms  are  characterised 
by  a  mycelium  or  interlacing  network  of  filaments  which  constitutes  the 
fungus  itself.  From  this  mycelial  network  there  extend  other  filaments 
(hyphee)  which  bear  the  fruit-bearing  organs  and  spores.  The  forma- 
tion of  these  spores  varies  in  the  different  forms,  for  (a)  in  some  cases 
the  terminal  cell  of  the  hypha  undergoes  transverse  division  (conidia), 
or  (Z>)  in  others  it  enlarges,  forming  a  receptacle  enclosing  the  spores 


THE    GENERAL  PATHOLOGY  OF  LNFECTION  505 

(sporangium  or  ascus),  or  (c)  two  hyphae  fuse  and  at  the  point  of  union 
the  spores  develop  (oospora).  Fuller  descriptions  will  be  found  in 
works  on  Botany. 

The  following  moulds  are  the  more  important  among  those  found  either 
in  disease  or  in  ordinary  human  surroundings :  — 1.  Penicillium  glaucum 
(not  pathogenetic).  2.  Oidium  lactis,  found  almost  invariably  in  sour  milk 
(not  pathogenetic,  though  formerly  supposed  to  be  the  cause  of  thrush). 
3.  Trichophyton  tonsurans,  found  in  ringworm.  4.  Achorion  Schonlein, 
found  in  favus.  5.  Microsporon  furfur,  found  in  pityriasis  versicolor. 
6.  Monilia  Candida,  said  to  be  the  cause  of  thrush.  7.  Mucor:  various 
forms  of  this  widely-distributed  genus  have  occasionally  been  obtained 
from  man,  especially  from  the  external  auditory  meatus.  8.  Aspergillus : 
two  varieties.  The  A.  niger  and  A.  fumigatus  have  occasionally  been 
found  in  man,  for  example,  in  so-called  pneumomycosis,  in  purulent 
conditions  of  the  middle  ear  and  of  the  antrum  maxillare.  9.  Actino- 
myces, pathogenetic  for  man  and  cattle.  Its  exact  botanical  position  is 
not  yet  settled  ;  some  classify  it  with  cladothrix,  others  with  strepto- 
thrix.  [This  fungus  will  be  fully  considered  in  the  article  on  "  Actinomy- 
cosis."] 10.  Streptothrix:  various  forms  of  pathogenetic  streptotriches 
have  been  described.    These  organisms  resemble  the  actinomyces  closely. 

We  are  still  comparatively  ignorant  of  the  physiological  properties  of 
these  mould-fungi.  Many  of  them  certainly  exert  a  fermentative  action: 
thus  Penicillium  glaucum  is  able  to  convert  cane-sugar  into  other  sugars ; 
some  aspergilli  contain  a  diastatic  ferment  which  converts  starch  into 
dextrose  and  maltose ;  some  species  of  mucor  are  able  to  act  as  true 
alcoholic  ferments,  and  Monilia  Candida  will  even  ferment  cane-sugar 
as  such  without  previously  inverting  it.  The  various  lesions  produced 
by  some  of  the  above-mentioned  fungi  will  be  described  under  their 
proper  headings. 

II.  Blastomycetes  or  Sprouting-Fungi,  —  These  organisms  are  fairly 
large  round  or  ovoid  cells  which,  generally  speaking,  multiply  by  budding. 
As  a  rule  they  appear  as  separate  cells  unconnected  by  any  mycelium, 
though  among  the  budding-fungi  there  are  some  which  under  certain 
conditions  will  form  a  mycelium.  Again,  although  they  mostly  multiply 
by  means  of  budding,  there  are  some  which  possess  the  property  of 
forming  spores  in  the  substance  of  the  cell  (endogenous  spore-formation). 

Three  groups  may  be  distinguished: — 1.  Saccharomyces:  budding- 
fungi  ;  mostly  without  a  mycelium ;  the  cells  are  sometimes  nucleated, 
occasionally  form  endogenous  spores,  and  generally  are  capable  of  induc- 
ing alcoholic  fermentation.  2.  Torula:  miiltiply  by  budding,  form  a  my- 
celium only  exceptionally,  never  form  spores  ;  some  have  a  pronounced 
fermentative  activity.  3.  Mycoderma:  variously  shaped  cells,  containing 
refractive  particles ;  they  form  a  film  on  the  surface  of  the  fluid  on  which 
they  grow,  and  possess  either  no  fermentative  activity,  or  but  little. 

The  pathohjgical  importance  of  these  forms  is  not  great,  though 
pathogenetic  torul*  have  recently  been  described.  However,  as  they 
are  so  widely  distributed  that  some  varieties  are  constantly  found  in 


5o6  SYSTEM  OF  MEDICINE 

the  human  excretions,  a  slight  acquaintance  with   them  is  desirable. 
Some  writers  consider  the  thrush  fungus  to  be  a  variety  of  mycoderma. 

III.  Schizomycetes  or  Fission-Fungi.  —  Most  pathogenetic  organisms, 
or  at  any  rate  those  which  are  best  known  to  us,  belong  to  this  group  of 
minute,  unicellular  vegetable  organisms.  They  owe  their  generic  name 
to  the  fact  that  they  divide  or  multiply  by  fission.  The  schizomycetes, 
so  far  as  the  pathologist  knows  them,  are  small,  minute  cells,  visible 
only  when  examined  under  the  highest  powers  of  the  microscope  (oil- 
immersions)  with  the  best  possible  illumination  (Abbe's  substage-con- 
denser) ;  they  are  devoid  of  a  nucleus,  at  any  rate  a  true  nucleus  has  not 
been  demonstrated.  When  dead  and  dried  they  have  an  affinity  for 
basic  or  nuclear  dyes,  such  as  methylene  blue,  gentian  and  methyl  violet, 
and  f  uchsine.  Living  bacteria  refuse  to  take  up  the  dye  in  a  satisfactory 
manner;  but  when  allowed  to  dry  on  a  cover-glass  and  fixed  by  heat, 
they  are  stained  readily,  unless  they  have  been  fixed  in  a  state  of  degen- 
eration or  involution.  They  refuse  acid  dyes,  such  as  eosin,  acid  fuchsin 
or  picric  acid.  Although  they  may  all  be  stained  with  basic  anilin  dyes, 
they  vary  greatly  in  the  readiness  with  which  they  imbibe  the  stain. 
Thus  tubercle  bacilli  are  stained  with  difficulty,  and  only  with  the  assist- 
ance of  mordants  ;  leprosy  and  glanders  bacilli  likewise  require  time 
and  patience,  if  not  skill.  On  the  other  hand  sarcinae  and  pyococci  are 
easily  overstained.  It  is  impossible  to  lay  down  general  rules  as  to  the 
time  of  exposure  to  the  dye,  or  as  to  the  particular  dye,  required  for  the 
various  organisms.     Experience  is  the  only  guide. 

The  schizomycetes  in  ordinary  medical  language  are  called  bacteria; 
in  fact  these  two  names  have  become  almost  synonymous.  From  the 
botanist's  point  of  view  this  is  undoubtedly  incorrect ;  the  convenient 
confusion  of  terms  is,  however,  sanctioned  by  usage,  and  we  may  safely 
accept  "  bacteria"  as  the  generic  term  interchangeable  with  schizomycetes. 
Bacteria  are  generally  classified  according  to  their  morphological  distinc- 
tions —  that  is,  their  shapes  and  forms  —  as  1.  Cocci ;  2.  Bacilli ;  and  3. 
Spirilla.  This  classification  is  not  a  natural  one ;  but  so  long  as  we  are 
unacquainted  with  the  exact  relation  of  these  forms  to  each  other,  it 
is  less  perplexing  to  use  a  provisional  classification  which  is  both 
practicable  and  easy. 

We  shall  now  consider  these  three  subdivisions  in  detail:  —  1.  The 
Coed  or  Micrococd  are  minute  spheroidal  or  oval  cells,  and,  when  growing 
in  artificial  media  or  io  the  animal  body,  they  always  remain  cocci ;  their 
spheroidal  form  is  constant.  The  cocci  are  again  subdivided  according  to 
their  arrangement  or  grouping.  Thus  we  may  have  (a)  paired  cocci,  that  is, 
cocci  arranged  in  twos,  the  so-called  Z)()9Zococci.  These  are  often  surrounded 
by  a  distinct  capsule,  which  may  be  stained  by  appropriate  methods.  As 
examples  may  be  mentioned  the  capsular  pneumococci  and  the  non-cap- 
sular  gonococci.  (5)  The  cocci  may  be  arranged  in  chains,  when  they 
are  called  Streptococd.  These  chains  may  be  either  short  or  long.  The 
shortest  streptococci  consist  of  two  component  members.  Thus  we  find 
that  the  pneumococcus,  which  in  the  animal  body  is  generally  an  encap- 


THE    GENERAL  PATHOLOGY  OF  INFECTION  507 

suled  diplococcus,  occasionally  appears  as  an  encapsuled  streptococcus 
of  four  or  five  or  six  component  elements ;  and  on  artificial  cultivation, 
especially  in  liquid  media,  it  frequently  develops  as  an  ordinary  non- 
capsular  streptococcus.  The  encapsuled  diplococcus  is  therefore  the 
most  primitive  and  simplest  form  of  streptococcus,  (c)  The  Tetracocci 
are  grouped  in  fovirs,  often  enclosed  in  a  capsule,  though  on  artificial 
cultivation  the  capsule  is  frequently  lost,  (d)  The  Sarcince  appear  in 
packets  of  eight  or  more  cocci,  (e)  If  the  cocci  are  arranged  in  irregular 
clusters,  or  in  heaps  of  no  particular  shape  and  devoid  of  symmetry,  we 
name  them  Staphylococci.  Tetracocci  and  sarcinae  on  artificial  cultiva- 
tion not  infrequently  appear  as  staphylococci ;  and  sarcinae  again  under 
such  conditions  often  appear  as  non-capsular  tetracocci  or  as  diplococci ; 
so  that  the  tetracocci  or  sarcinse,  or  the  non-capsular  diplococci,  may  be 
regarded  as  the  simplest  forms  of  staphylococci.  We  see  then  that 
there  is  no  constancy  of  arrangement  here,  though  the  constancy  of 
individual  form  is  always  preserved ;  that  is,  diplococci  may  develop 
on  the  one  hand  into  streptococci,  on  the  other  hand  into  staphylococci ; 
tetracocci  readily  transform  themselves  into  staphylococci,  but  in  every 
case,  streptococci  remain  always  streptococci  and  never  become  staphy- 
lococci ;  and  conversely  staphylococci  are  never  changed  into  streptococci. 
The  staphylococci  clusters  are  often  held  together  by  a  tough  mucous 
material ;  such  clusters  are  termed  zoogloea. 

2.  The  Bacilli  are  rod-like  structures,  that  is,  they  have  a  long 
diameter  often  considerably  longer  than  the  transverse.  These  rod-like 
organisms  may  be  very  short  and  plumb,  or  they  may  be  long,  thin  and 
graceful ;  they  may  have  pointed  or  blunted  ends;  they  may  be  arranged 
in  pairs,  in  short  and  long  chains,  or  in  filaments.  When  fusiform  or 
spindle-shaped  in  appearance  the}'-  are  often  called  Clostridia. 

Dr.  Klein  and  others  have  shown  that  some  bacilli  —  for  example, 
the  tubercle  or  diphtheria  bacilli  —  have  a  tendency  to  form  true 
mycelial  threads,  which  would  suggest  that  these  organisms  possess  a 
fungus  ancestry ;  others,  like  the  anthrax  bacillus,  assume  a  yeast-like 
appearance  on  artificial  cultivation.  On  the  other  hand,  the  actinomyces 
when  grown  in  the  laboratory  generally  passes  through  a  bacillary 
phase  before  it  obtains  its  fully  developed  mycelial  structure.  These 
facts  are  of  great  importance,  because  they  remind  us  of  our  imperfect 
knowledge  of  bacterial  morphology.  This  variability  of  form,  termed 
polymorphism  or  pleomorphism,  will  be  discussed  later. 

3.  The  Spirilla  include  all  the  curved  or  spiral  forms.  At  one  time 
a  distinction  was  made  between  the  spirilla  and  the  vibrios,  which  are 
slightly  twisted  bacteria,  or  curved  bacilli.  The  latter  were  also  called 
comma  bacilli,  as  for  example  the  organisms  of  Asiatic  cholera.  Now 
we  know  that  the  vibrios  and  comma  bacilli  easily  grow  into  true  spirilla, 
and  that  we  are  here  dealing  with  a  good  example  of  pleomorphism. 
We  shall  therefore  speak  of  '<  spirilla,"  and  more  properly  call  the 
comma  bacillus  or  vibrio  of  cholera  the  spirijlum  of  Asiatic  cholera. 
It  appears  that  under  certain  conditions  the  vibrios  or  spirilla  may  lose 


5o8  SYSTEM   OF  MEDICINE 


their  curved  appearance,  and  become  transformed  into  straight  bacillary 
structures. 

The  cell  substance  of  these  various  bacteria  is  generally  colourless, 
refractive  and  homogeneous ;  but  occasionally  it  is  granular  or  vacuo- 
lated. Many  bacteria  are  enclosed  by  a  distinct  cell  membrane ;  it  is 
doubtful,  however,  whether  they  all  possess  an  enclosing  sheath. 

We  must  now  consider  a  few  special  morphological  features  of  the 
bacteria,  features  either  recognised  as  specific  characters,  or  of  biologi- 
cal importance.  These  are  —  1.  Spore-formation;  2.  Flagella  or  cilia ; 
3.  Involution  forms  ;  4.  Pleomorphism  and  variability. 

1.  Spores,  —  Most  micro-organisms  multiply  by  binary  fission ;  many, 
however,  are  capable  also  of  a  higher  or  more  specialised  form  of  pro- 
liferation ;  namely,  by  means  of  spores. 

Spore-formation  has  been  observed  hitherto  in  bacilli  only ;  micro- 
cocci never  possess  true  spores.  When  fully  developed,  the  spores 
appear  as  well-defined,  sharply-contoured,  highly-refractive  bodies, 
round  or  oval  in  shape.  They  are  either  central  or  terminal ;  that  is, 
the  spore  may  occupy  the  middle  or  one  or  other  extremity  of  the  bacil- 
lus. In  the  latter  case  the  spore-bearing  organisms  have  the  shape  of  a 
drumstick :  the  tetanus  bacillus  and  some  water  and  intestinal  bacilli  are 
the  best  examples  of  this  type.  "Wlien  the  spores  are  centrally  situated 
the  bacillus  itself  may  become  swollen  and  spindle-shaped  (Clostridium), 
as  in  the  case  of  the  Bacillus  acidi  butyrici;  or  the  spore  may  develop 
without  producing  any  morphological  change  in  the  bacillus.  Occasion- 
ally before  or  during  the  spore-formation  the  bacilli  grow  out  into  long 
threads  or  filaments,  in  which  a  beaded  series  of  spores  appears,  as  in 
the  case  of  the  Bacillus  anthracis ;  or  the  bacilli  themselves  increase  in 
length,  as  in  the  case  of  the  tetanus  bacillus.  Spores  which  are  devel- 
oped in  the  substance  of  the  bacillus,  whether  central  or  terminal,  are 
described  as  endogenous  spores  or  endospores.  Each  bacillus  contains 
only  one  spore,  which  is  eventually  freed  by  leaving  its  parent,  or  by 
the  death  of  the  latter.  Under  favourable  conditions  these  spores  germi- 
nate and  are  again  developed  into  bacilli.  They  are  highly  resistant  to 
external  influences,  —  such  as  drying,  heating,  disinfecting,  etc., — more 
or  less  serious  disturbances  which  destroy  the  bacilli  themselves,  being 
easily  withstood  by  their  spores.  These  resisting  powers,  however, 
vary  greatly ;  some  spores,  like  those  of  the  tetanus  bacillus,  remain 
unaffected  after  being  heated  for  an  hour  at  80°  C. 

Spores  are  formed  nnder  certain  conditions  only;  there  must  always 
be  the  optimum  of  air,  warmth  and  nourishment — conditions  which  vary, 
of  course,  for  each  organism.  Thus  the  anthrax  bacillus  requires  a  suf- 
ficient amount  of  air  (or  oxygen)  and  of  warmth,  and  it  refuses  to  form 
spores  in  the  animal  body,  or  at  a  temperature  of  42°-45°  C,  or  if  certain 
substances,  such  as  carbolic  acid  or  alcohol,  be  added  to  the  broth  in 
which  it  is  grown.  By  continued  cultivation  in  carbolised  broth,  or  at 
42°  C,  this  bacillus  may  permanently  lose  its  property  of  forming  spores, 
and  become  "  asporogenous '' ;  although  the  morphological  apiDcarances 


THE    GENERAL  PATHOLOGY  OF  INFECTION  509 

are  not  otherwise  modified.  Although  strongly  resistant  to  most  external 
influences,  the  spores  of  many  bacilli  —  for  example,  of  bacillus  anthra- 
cis  —  are  killed  by  a  comparatively  short  exposure  to  direct  sunlight 
in  the  presence  of  air. 

In  studying  the  aetiology  of  infective  diseases  it  is  important  to 
investigate  the  power  of  spore-formation  possessed  by  any  particular 
bacillus,  for  this  is  to  some  extent  a  measure  of  the  resistance  on  the 
part  of  the  infective  organism,  and  therefore  of  the  risk  of  infection  or 
contagion.  Asporogenous  organisms,  speaking  generally,  die  sooner,  or 
are  more  easily  destroyed  by  antiseptics  and  disinfectants,  and  their  dis- 
tribution is  often  more  narrowly  limited.    To  this  point  we  shall  return. 

Besides  endogenous  spores,  another  form  of  spore,  —  the  so-called 
arthrospore  —  has  been  described,  especially  by  De  Bary  and  Hiippe; 
their  existence  is  however,  doubtful.  Arthrospores  are  supposed  to 
be  members  of  a  chain  or  group  of  micro-organisms  which  acquire  a 
greater  vitality  or  power  of  resistance,  and  thus  become  the  starting- 
point  of  new  life.  They  may  be  characterised  by  increased  size  and 
refraction.  It  is  said  that  streptococci  may  persist,  or  may  be  perpetu- 
ated by  arthrogenous  spore-formation.  Certainly  on  examining  chains 
of  such  cocci  we  often  find  larger  and  more  striking  individuals  —  two 
or  three  times  as  large  as  other  members  of  the  chain  —  but  it  is  doubt- 
ful whether  these  peculiar  forms  are  really  spores.  They  stain  readily 
with  ordinary  aniline  dyes,  while  endospores  stain  with  difficulty,  and 
only  by  means  of  special  and  elaborate  methods :  moreover,  they  seem 
to  be  no  more  resistant  to  external  influences  than  the  ordinary  cocci. 
The  whole  subject  of  arthrospores  is  still  in  obscurity. 

2.  Flagella  or  Cilia.  —  It  has  been  known  for  a  long  time  that  many 
micro-organisms  possess  the  power  of  spontaneous  movement.  When 
examined  under  the  microscope  in  a  drop  of  fluid  —  in  a  hanging  drop  — 
they  are  seen  to  move  across  the  field,  sometimes  floating  away  quietly 
and  slowly,  sometimes  darting  across  quickly,  sometimes  propelling 
themselves  with  a  screw-like  action.  Bacilli  and  spirilla  or  vibrios 
especially  are  motile,  though  some  micrococci  also  share  this  property. 
Lofiier  has  shown  by  special  and  difficult  staining  methods  (which  since 
have  been  made  much  easier),  that  such  organisms  generally  possess 
flagella  or  cilia  by  means  of  which  they  propel  themselves.  Some  bacilli 
have  only  one  or  two  such  flagella ;  others  —  as,  for  example,  the  typhoid 
bacillus  —  are  completely  surrounded  by  them:  some,  again,  have  a 
single  flagellum  at  one  or  other  end,  or  at  both  ends ;  others  a  bundle 
of  terminal  flagella.  The  vibrios,  as  a  rule,  have  one,  two,  or  three  cilia 
at  one  extremity.  The  rapidity  of  movement  seems,  as  a  rule  but  by  no 
means  always,  to  vary  with  the  number  of  flagella.  The  ciliary  proc- 
esses also  vary  considerably  in  length,  thickness  and  shape,  and  appear  to 
sjjring  from  a  sheath  around  the  bacterial  cell;  as  a  rule  they  are  very 
much  longer  than  the  organisms  bearing  them,  and  are  spirally  twisted. 
It  appears  that  some  organisms,  although  incapable  of  spontaneous  move- 
ment, nevertheless  possess  cilia,  for  example  the  bacillus  anthracis.     It 


5IO  SYSTEM   OF  MEDICINE 

would  seem  that  for  a  given  species  of  bacillus  or  vibrio  the  number  of 
flagella  is  constant  or  varies  within  narrow  limits,  so  that  these  have 
become  important  morphological  factors,  and  are  often  of  great  use  in 
distinguishing  between  allied  or  similar  forms.  Thus  the  bacterium 
coli  commune  closely  resembles  the  typhoid  bacillus,  but  it  possesses 
few  flagella,  varying  from  one  to  six,  or  ten,  y\^hile  the  Eberth-Gatfky 
bacillus  is  completely  surrounded  by  them.  At  the  same  time,  it  must 
be  remembered  that  the  flagella  are  extremely  brittle,  and  are  often 
missing  in  greater  or  less  numbers. 

3.  Involution  Forms.  —  Under  certain  conditions  micro-organisms, 
especially  the  bacilli  or  the  vibrios,  become  altered  in  shape,  losing  their 
ordinary  form,  or  becoming  even  quite  unrecognisable,  it  may  be  through 
age,  exhaustion  of  the  nutrient  medium,  or  other  harmful  influences. 
Thus  the  vibrio  of  Asiatic  cholera,  when  kept  for  some  time,  may  be- 
come bacillary  or  coccoid  in  shape;  bacilli,  again,  may  become  beaded 
or  varicose,  shorter  or  longer.  On  transferring  such  aberrant  forms  to  a 
fresh  soil,  or  on  placing  them  under  more  favourable  conditions,  unless 
they  have  degenerated  or  have  aged  past  all  recovery,  they  assume  their 
original  shape  and  structure.  Abnormal  or  unusual  forms,  in  healthy, 
young,  and  vigorous  growths,  must  not  be  confounded  with  involution 
forms.  Thus,  diphtheria  bacilli,  grown  on  the  surface  of  blood  serum  or 
agar-agar,  often  become  elongated,  clubbed,  or  branched ;  tubercle  bacilli 
also  show  a  tendency  to  elongation  and  branching  or  clubbing ;  anthrax 
bacilli  may  grow  as  yeast  forms.  Here  we  have  either  a  pleomorphism 
(or  polymorphism),  or  a  reversion  to  an  ancestral  type  which  is  best 
seen  in  young  colonies ;  but  involution  invariably  implies  degeneration. 

4.  Pleoniorpliism  and  Variability  of  Form.  —  Koch  originally  upheld 
the  doctrine  of  the  constancy  of  form,  ''die  Konstanz  der  Form." 
Broadly  speaking  this  is  true  enough;  most  pathogenetic  organisms  ad- 
here to  one  type  or  form ;  but  many  micro-organisms  show  a  great  ten- 
dency towards  variation.  Thus  vibrios  often  become  spirilla ;  the  ray 
fungus  passes  through  a  coccoid  and  bacillary  stage;  the  diphtheria 
bacillus  may  either  be  long,  short,  straight,  or  clubbed.  True,  a  strepto- 
coccus will  never  become  a  staphylococcus  or  a  bacillus ;  but,  as  a  strep- 
tococcus, it  will  vary,  growing  occasionally  in  short  chains,  occasionally 
in  long  chains  ;  sometimes  in  the  shape  of  fine  small  dots,  at  other  times 
as  larger  and  plumper  cocci.  This  diversity  of  shape  among  organisms 
of  the  same  species  is  called  pleomorphism  or  polymorphism,  which 
terms  simply  imply  individual  clifferences.  Thus  if  we  were  to  cultivate 
diphtheria  bacilli  from  a  single  bacillus  sown  in  broth,  we  should  find 
the  descendants  very  variable  in  shape ;  some  are  small,  others  larger, 
some  straight,  others  clubbed  or  branched:  or  starting  from  a  single 
vibrio,  we  should  find  that  some  of  its  descendants  are  spirillar,  others 
S-shaped,  bnt  most  of  them  true  vibrios.  Pleomorphism  must  be  care- 
fully distinguished  from  variability :  the  former  is  a  character  belonging 
to  a  species,  and  is  transmitted  from  generation  to  generation  ;  variation 
of  individuals  depends  on  environment,  some  species,  under  the  influence 


THE    GENERAL  PATHOLOGY  OF  INFECTION  511 

of  adaptation,  being  more  easily  changed  than  otliers,  whether  tempo- 
rarily or  permanently,  so  that  new  varieties  or  even  new  species  may 
be  produced.  Upon  what  pleomorphism  depends  we  do  not  at  present 
understand :  in  some  cases,  apparently  —  as  in  those  of  the  diphtheria 
and  tubercle  bacilli  —  it  is  assumed  by  Klein  and  others  to  be  based  on 
the  ancestral  history  of  the  organism.  We  must  carefully  distinguish, 
hovi^ever,  between  a  true  pleomorphism  and  an  accidental  contamination 
of  a  culture  with  extraneous  organisms  —  a  confusion  of  two  very 
different  things  which,  especially  in  the  earlier  days  of  bacteriology, 
led  to  many  errors. 

Variation  may  lead  to  change  of  form,  or  to  change  of  function; 
the  latter  we  shall  consider  subsequently.  Degeneration  and  involution 
are  no  more  variation  than  are  disease  and  old  age  in  animals.  In  most 
cases  change  of  environments  —  that  is,  generally  change  of  soil  or 
temperature  —  produces  merely  temporary  variations.  Thus  typhoid 
bacilli  in  ordinary  broth  will  appear  in  one  form,  in  carbolised  beef- 
broth  in  a  widely  different  one:  so  long  as  they  are  grown  in  these 
media  they  will  retain  these  respective  forms ;  but  if  transferred  from 
carbolised  to  ordinary  broth  there  is  an  almost  immediate  return  to  the 
ordinary  shape.  Similarly  the  Bacillus  pyocyaneus  in  different  media 
may  be  cultivated  as  a  small  bacillus,  as  a  long  rod,  as  a  filament,  and 
even  as  a  comma  form ;  but  a  return  to  the  ordinary  media  is  always 
followed  by  a  return  to  the  recognised  form.  Similarly  variations  in 
mobility  and  in  arrangements  and  numbers  of  flagella  may  be  tempo- 
rarily produced  by  change  of  environments. 

It  seems  extremely  difficult  to  produce  permanent  varieties  of  form, 
but  it  is  possible:  thus  the  bacillus  prodigiosus  may  be  changed  from 
the  small  bacillary  into  a  permanent  long  bacillary  form;  and  the 
anthrax  bacillus  may  be  converted  into  an  asporogenous  species.  An 
extremely  good  summary  of  the  variability  of  bacteria,  by  Professor 
Adami,  is  to  be  found  in  the  Medical  Clironide  for  September  1892. 

We  are  comparatively  ignorant  of  natural  variations,  and  the  greatest 
confusion  exists  between  varieties  and  species.  This  is  well  seen  in  the 
case  of  the  choleraic  vibrios :  numerous  forms  of  these  have  been 
obtained  from  cholera  stools,  which  by  some  writers  are  regarded  as 
varieties,  by  others  as  species  —  the  former  are  probably  influenced  by 
their  opinion  that  cholera  is  caused  by  one  specific  organism  only,  the 
latter  recognise  in  them  different  and  distinct  forms  of  the  comma-shaped 
organism.  Now  in  the  case  of  these  various  choleraic  vibrios,  we  find  that 
continuous  growth  in  identical  media  leads  to  no  assimilation  of  charac- 
ters ;  they  become  modified  under  such  conditions,  but  when  the  limit 
of  modification,  due  to  adaptation,  has  been  reached,  the  acquired  charac- 
ters remain  stable,  and  continued  exposure  to  like  conditions  does  not 
give  rise  to  any  general  assimilation  of  characters  in  the  similarly 
cultivated  organisms.  This  being  so,  it  would  seem  that  we  are  dealing 
with  species  rather  than  with  varieties.  The  qiiestion  is,  however,  beset 
with  so  many  difficulties  that  we  must  for  the  present  be  content  with 


512  SYSTEM   OF  MEDICINE 

an  arbitrary  standard  based,  perhaps,  on  preconceived  ideas.  As  Dr.  D. 
D.  Cunningham  says,  "  If  tlie  vibrio  of  Finkler-Prior  is  a  different  species 
from  Kocli's  comma  bacillus,  its  distinctive  characters  must  be  of  specific 
value ;  if  this  be  so,  then,  as  many  so-called  choleraic  vibrios  differ  among 
each  other  no  more,  or  even  less,  than  do  Finkler-Prior's  and  Koch's 
vibrios,  we  must  consider  the  various  choleraic  vibrios  as  so  many 
species."  Consistency  must  be  preserved  in  all  matters  of  doubt,  and, 
whatever  our  hypotheses,  we  cannot  without  more  evidence  regard  like 
differences  as  specific  in  one  case  and  non-specific  in  another. 

II.    Biological  Requirements 

All  bacteria,  being  protoplasmic  cells,  require  food  for  further  de- 
velopment and  propagation,  which  must  consist  both  of  nitrogenous 
and  non-nitrogenous  substances.  To  study  the  vital  phenomena  of 
bacteria,  however  incompletely  or  unsatisfactorily,  we  must  cultivate  or 
grow  them.  In  the  laboratory  Ave  can  only  place  them  in  conditions 
which  approximate,  often  very  slightly  indeed,  to  those  pertaining  to 
them  in  nature.  In  most  cases  the  artificial  cultivation  of  bacteria  in 
test-tubes  and  incubators  has  no  pretence  to  resemble  natural  growth ; 
it  is  merely  an  experimental  device  by  which  we  seek  to  unravel  the 
mysteries  of  microbic  life.  We  vary  the  soil  as  much  as  we  can,  we 
alter  the  surroundings,  we  imitate  what  we  suppose  to  be  the  natural 
state;  but  as  we  can  never  reproduce  this  exactly,  our  conclusions  can 
only  be  regarded  as  approximations  to  the  truth.  In  bacteriology  con- 
clusions are  too  readily  drawn  on  incomplete  evidence,  yet  in  this  study 
especially  rigorous  and  unimpeachable  evidence  is  required. 

There  is  no  uniform  or  general  nutrient  medium  suitable  for  every 
form  of  microbic  life  either  in  the  laboratory  or  in  nature.  Some 
organisms  thrive  best  in  highly  albuminous  media ;  others  on  or  in  sub- 
stances poor  in  albumin :  some  grow  better  on  a  solid  stratum,  others  in 
a  liquid  medium.  No  general  rules  can  be  laid  down;  for  practical 
laboratory  purposes  we  find  that  soluble  and  diffusible  albumins  and 
proteids  are  the  best  nitrogenous,  and  sugar  or  glycerine  the  best  non- 
nitrogenous  media.  Some  bacteria  refuse  to  grow  on  any  mixture  we 
may  compound  or  concoct ;  they  refuse  even  blood  serum  and  the  living 
animal  body  —  as  for  instance  the  leprosy  bacilli ;  others  will  only  grow 
in  the  living  tissues ;  others  again  on  dead  matter  only.  A  suitable 
artificial  nutrient  medium  for  bacteria  must  contain  a  preponderance  of 
water,  certain  quantities  of  carbonaceous  and  nitrogenous  organic  sub- 
stances, and  in  addition  potassium  salts  and  phosphoric  acid  compounds. 
As  already  mentioned,  nitrogen  is  best  supplied  by  means  of  albuminous 
substances,  notably  peptones ;  though  urea  and  ammonium  salts  are 
useful  substitutes.  Some  organisms  are  capable  of  obtaining  their 
nitrogen  from  nitrates,  which  they  gradually  reduce  to  nitrites  and 
eventually  to  ammonia.  The  best  sources  of  carbon  we  find  in  the 
various  forms  of  sugar,  in  mannite  and  in  glycerine. 


THE    GENERAL  PATHOLOGY  OF  INFECTION  513 


We  cannot  discuss  these  matters  fully  in  a  work  on  medicine ;  fur- 
ther information  must  be  sought  in  special  treatises,  or  better  still,  it 
must  bo  gained  by  patient  laboratory  observation. 

Of  importance  in  the  selection  of  artificial  media  are  (a)  the  concen- 
tration, (i»)  the  reaction,  (c)  the  temperature,  (c?)  the  presence  or  absence 
of  free  oxygen,  (e)  the  light,  and  (/)  the  atmospheric  pressure. 

(a)  Concentration.  —  Some  organisms  are  capable  of  thriving  in 
extremely  dilute  albuminous  solutions ;  the  vibrio  of  Asiatic  cholera, 
for  instance,  can  be  separated  best  by  means  of  cultivation  in  weak 
peptone  solutions. 

(6)  The  reaction  of  our  artificial  media  is  generally  neutral  or  faintly 
alkaline.  Most  organisms  are  sensitive  to  an  excess  of  alkali  or  to  an 
excess  of  acid,  but  some  develop  best  in  decidedly  acid  media. 

(c)  Th.e  temperature  most  favourable  to  growth  in  a  test-tube  varies, 
within  certain  limits,  with  the  particular  species.  As  a  general  rule 
it  may  be  stated  that  all  pathogenetic  organisms  found  in  morbid  lesions 
of  warm-blooded  animals  prefer  38-5°  C,  that  is  blood  heat:  conversely 
those  which  under  natural  conditions  produce  disease  in  fish  and  other 
cold-blooded  animals  are  frequently  capable  of  growth  onl^^  at  lower 
temperatures.  There  are  also,  however,  many  non-pathogenetic  bacteria 
which  refuse  to  grow  above  20"  or  22°  C,  especially  many  water  and  air 
organisms;  and  again,  as  Dr.  Macfadyen  has  recently  shown,  there  is  a 
class  of  microbes  which  refuse  to  grow  at  any  temperature  below  50°  C. ; 
such  organisms  are  called  "thermophile."  Microbic  life  is  impossible 
at  very  low  or  at  very  high  degrees  of  temperature.  Numerous  organ- 
isms, however,  have  been  found  in  the  snow  crystals  of  freezing  cham- 
bers, and  in  ice  and  snow.  Experience  alone  can  tell  us  the  optimum 
temperature  for  a  given  kind  of  micro-organism. 

(d)  Most  micro-organisms  require  free  oxygen  for  their  growth  and 
development ;  but  there  are  some  which  cannot  thrive  in  an  atmosphere 
containing  oxygen.  The  latter  are  called  anaerobes,  the  former  aerobes. 
Amongst  the  anaerobes  we  find  some  which,  though  preferably  anaerobic, 
can  yet  exist  in  an  atmosphere  containing  oxygen ;  these  are  the  facultor 
five  aerobes :  and  again  there  are  some  aerobes  which  possess  the  faculty 
of  growing  in  an  atmosphere  deprived  of  oxygen ;  these  are  the  faculta- 
tive anaerobes.     We  have  thus  the  following  groups  :  — 

Aerobic  germs :  —  (i.)  Obligatory  aerobes,  which  must  be  supplied 
with  oxygen,  (ii.)  Facultative  anaerobes,  which  preferably  grow  under 
aerobic  conditions,  but  may  also  exist  as  anaerobes. 

Anaerobic  germs :  —  (i.)  Obligatory  anaerobes,  which  can  grow  only 
in  an  atmosphere  free  from  oxygen,  (ii.)  Facultative  aerobes  or  organ- 
isms which  preferably  are  anaerobic,  but  which  may  grow  also  under 
aerobic  conditions. 

Among  obligatory  anaerobic  germs  we  find  the  bacillus  of  malignant 
oedema,  readily  obtained  from  garden  earth;  the  bacillus  of  tetanus, 
another  inhabitant  of  the  soil,  and  the  bacillus  of  quarter-evil.  These 
bacilli  can  yjroduce  their  poisons  or '' toxins "  only  in  media  wherein 

VOL.    I  2    Ii 


514  SYSTEM   OF  MEDICINE 

they  are  sheltered  from  free  oxygen.  The  best  known  facultative  anae- 
robes are  the  pyococci,  the  bacillus  anthracis,  the  bacillus  of  typhoid 
fever,  the  bacterium  coli  commune,  and  the  microbes  of  pneumonia  and 
of  Asiatic  cholera.  The  commonest  obligatory  aerobe  is  the  hay  bacillus 
or  the  bacillus  subtilis.  It  is,  however,  impossible  to  draw  a  hard  and 
fast  line  between  the  facultative  anaerobes  and  the  facultative  aerobes. 
The  following  are  the  various  methods  in  common  use  to  obtain  the 
suitable  conditions  for  anaerobiosis :  — 

1.  The  oxygen  may  be  removed  by  means  of  a  solution  of  pyrogallic 
acid  in  caustic  potash  (Buchner's  method).  This  is  the  best  and  easiest 
way  of  obtaining  an  atmosphere  free  from  oxygen. 

2.  The  organisms  may  be  grown  in  vacuo  ■  by  means  of  exhausting 
the  tubes  or  flasks  containing  the  inoculated  nutrient  medium. 

3.  The  atmosphere  may  be  replaced  by  an  indifferent  gas,  preferably 
by  hydrogen. 

Whatever  method  be  used,  reducing  substances  may  be  added,  at  the 
same  time,  to  the  media  in  which  the  organisms  are  grown ;  such  sub- 
stances are  glucose,  formate  and  sulphindigotate  of  sodium. 

Many  pathogenetic  organisms,  though  in  the  laboratory  generally 
cultivated  under  aerobic  conditions,  in  the  animal  body  must  grow 
as  more  or  less  strictly  obligatory  anaerobes.  Thus  in  deep  or  closed 
abscesses  oxygen  is  either  absent  or  present  only  in  minute  traces. 
There  can  hardly  be  any  doubt  that  the  chemical  activity  of  the  patho- 
genetic bacteria  must  vary  under  such  opposed  conditions  as  aerobiosis 
and  anaerobiosis.  In  the  absence  of  oxygen  facultative  anaerobes  will 
often  display  a  most  extraordinary  fermentative  action.  We  are  still 
far  too  ignorant  of  the  minute  changes,  chemical  or  physical,  in  the 
tissues  to  speculate  with  any  degree  of  promise ;  but  this  much  is  certain 
that,  even  if  we  choose  media  most  closely  resembling  the  tissue  sub- 
stances, we  cannot  reason  directly  from  changes  in  the  test-tube  to 
changes  in  the  animal  body,  because  the  conditions  of  atmosphere  and 
oxygen  among  others,  are  or  may  be  extremely  different. 

(e)  Recent  researches  have  shown  that  many  bacteria  are  injured  by 
sunlight ;  and  speaking  generally,  it  is  best  to  cultivate  organisms  in  the 
dark.  Prof.  Marshall  Ward,  who  has  paid  especial  attention  to  this 
subject,  has  shown  that  the  blue  and  violet  rays  of  the  spectrum  are 
especially  destructive  to  certain  forms.  Thus  anthrax  spores,  which  are 
extremely  resistant  to  external  influences,  typhoid  bacilli,  and  choleraic 
spirilla  soon  die  when  exposed  to  the  rays  of  the  sun ;  tubercle  bacilli 
are  either  attenuated  in  their  virulence  or  destroyed ;  and  chromogenetic 
organisms  lose  their  power  of  producing  pigment,  and  in  some  instances 
are  converted  into  colourless  varieties.  It  has  been  shown  that  these 
effects  are  not  due  to  the  heat  rays ;  they  appear  to  be  the  result  of 
oxidation;  for  in  a  vacuum,  or  in  the  depth  of  the  nutrient  medium, 
insolation  is  less  effective  or  even  powerless.  Some  observers  think  that 
ozone,  formed  by  the  action  of  the  solar  rays,  acts  as  a  strong  germicide; 
others  suggest  that  hydrogen  peroxide  is  the  destructive  agent. 


THE    GENERAL  PATHOLOGY  OF  LNFECTLON  515 

It  is  asserted  by  some  observers  that  the  quality  of  the  nutrient 
medium  is  not  altered  by  the  light;  that  the  action  is  a  direct  one, 
affecting  the  organisms  in  the  medium :  others,  however,  maintain  that 
insolation  may  have  a  deleterious  or  unfavourable  effect  on  the  soil. 
Even  diffuse  sunlight  has  an  inhibitory  or  noxious  effect  on  the  growth 
of  certain  forms  of  micro-organisms.  It  must  not  be  imagined,  how- 
ever, that  all  organisms  are  injured  alike  by  the  solar  rays ;  some  grow 
well  or  even  more  vigorously  in  sunlight.  It  has  been  found  that  the 
solar  rays  are  capable  of  destroying  or  rather  of  decolorising  solutions 
of  some  of  the  bacterial  pigments,  for  example,  the  green  or  blue  pig- 
ment of  the  bacillus  pyocyaneus  dissolved  in  chloroform,  or  the  red 
pigment  of  the  bacillus  prodigiosus  extracted  by  ether  or  water.  And 
here  also  it  will  be  seen  that  the  blue  rays  are  more  active  than  the  red. 
That  sunlight  destroys  or  diminishes  the  power  or  virulence  of  bacte- 
rial poisons  is  likewise  well  known. 

(/)  The  influence  of  atmospheric  pressure  on  bacterial  life  has  not 
yet  been  thoroughly  worked  out ;  ordinary  atmospheric  variations  seem 
to  be  indifferent.  We  know,  however,  that  beyond  certain  depths,  or 
above  certain  altitudes,  micro-organisms  cannot  be  detected  with  our 
ordinary  means.  Regnard  has  shown  that  putrefactive  organisms  are 
inhibited  in  their  growth  and  activity  by  pressures  varying  from  600  to 
700  atmospheres.  Albuminous  substances  which  readily  putrefy  were 
kept  for  weeks  in  a  sound  condition  under  such  pressures,  even  when 
such  organisms  were  knoAvn  to  be  present.  It  is  of  course  possible 
that,  as  there  are  thermophile  bacteria  which  thrive  at  amazingly  high 
temperatures,  there  are  also  organisms  which  resist  such  pressure  as  is 
found  in  the  lowest  depths  of  the  sea. 

Summary.  —  Most  of  the  known  micro-organisms  can  be  cultivated  on 
artificial  media ;  but,  as  already  stated,  there  are  many  which  refuse  to 
grow  on  such  soils,  for  example,  the  bacillus  of  leprosy,  the  spirillum  of 
relapsing  fever,  and  many  spirillar  forms  which  are  found  in  the  tissues 
and  in  animal  secretions  or  excretions.  We  must  always  remember  that 
the  artificial  media  used  in  the  laboratory  for  the  cultivation  of  micro- 
organisms are  '•'  artificial,"  and  that  the  phenomena  observed  under  these 
conditions  are  evidently  not  the  natural  ones.  Scientific  work,  however, 
could  hardly  be  possible,  unless  media  could  be  made  up  for  artificial  cul- 
tivation. Those  that  are  commonly  in  use  may  be  divided  into  (1)  liquid 
media,  and  (2)  solid  media.  The  former  include  broth,  milk,  urine,  blood 
serum,  vegetable  infusions ;  the  latter  potatoes,  meat,  gelatine,  agar-agar, 
or  coagulated  blood  serum.  It  would  be  beyond  the  scope  of  this  article 
to  enter  into  a  fuller  discussion  or  description  of  these  various  media  and 
their  selective  advantages  ;  it  will  be  sufficient  to  say  that  there  is  no  uni- 
versal medium,  fluid  or  solid,  for  all  organisms  :  some,  for  instance,  grow 
"well  on  agar-agar,  and  with  difficulty  on  gelatine ;  others  better  in  liquid 
than  on  or  in  solid  media.  Many  bacteria  suffer  in  an  acid  reaction,  others 
prefer  acidity.  Then  there  are  some  which  grow  best  on  serum  or  media 
containing  serum,   as,  for  instance,  the  gonococcus.     Such   organisms 


5i6  SYSTEM   OF  MEDICINE 

may  often  be  gradually  accustomed  to  an  existence  and  active  life  on  or 
in  the  ordinary  media  of  the  laboratory.  Thus  it  has  not  taken  many 
years  to  "  force  "  the  bacillus  of  tuberculosis  to  grow  on  such  ordinary 
substances  as  glycerine  agar-agar ;  yet  when  Koch  first  separated  this 
bacillus,  it  was  with  serum  only  that  he  could  succeed.  Again  it  is  a 
common  experience,  on  first  separating  an  organism  from  the  living 
animal,  to  lind  that  it  grows  slowly  or  with  ditticulty  on  agar-agar ;  but 
if  frequently  transferred  from  one  tube  of  agar-agar  to  another,  it  will 
soon  become  adapted  to  this  soil. 

Classification  of  Micro-Organisms.  — These  observations,  made  in  the 
laboratory  and  at  the  bedside,  in  respect  to  the  question  of  soil  have 
led  us  to  make  the  following  classification  — 

1.  The  parasitic  micro-organisms,  which  are  capable  of  developing 
and  thriving  in  living  animal  tissues. 

2.  The  saprophytic  micro-organisms,  which  can  live  outside  living 
animal  tissues,  that  is,  on  dead  or  dying  tissues,  or  on  mineral  and  in- 
organic substances,  or  on  vegetable  matter. 

The  parasites  are  again  subdivided  into  (a)  obligatory  parasites,  and 
(6)  facultative  saprophytes.  The  former  are  restricted  exclusively  to 
living  animal  tissues,  while  the  latter,  after  leaving  them,  can  continue 
to  exist  outside  the  living  animal  body  also  —  although,  perhaps,  they 
only  attain  full  vigour  and  development  when  they  find  their  resting- 
place  in  the  living  tissues.  Similarly  the  saprophytes  also  are  classi- 
fied as  (a)  obligatory  saprophytes,  and  (b)  the  facultative  parasites. 
After  what  has  been  said  the  meaning  of  these  names  is  obvious.  Now 
organisms  which  can  be  grown  in  or  on  the  usual  laboratory  media  are 
not,  strictly  speaking,  obligatory  parasites,  for  they  possess  the  faculty 
of  living  on  dead  matter  outside  the  animal  body.  Later  we  shall  see 
that  a  full  grasp  of  this  classification  is  of  the  utmost  importance  in  the 
setiology,  prevention,  and  hygienic  treatment  of  infective  diseases. 
However,  we  must  realise  that  we  know  very  little  of  the  natural  life  and 
habitat  of  most  pathogenetic  organisms ;  and  that  often  when  we  argue 
that  certain  infective  organisms  cannot  find,  or  can  but  rarely  find,  suita- 
ble conditions  for  growth  outside  the  animal  body,  we  may  be  arguing 
from  ignorance.  More  than  one  organism,  once  thought  to  be  a  true  par- 
asite, has  gradually  been  degraded  to  the  less  dignified  position  of  a  fac- 
ultative saprophyte  or  facultative  parasite.  The  tubercle  bacillus,  for 
instance,  has  been  shown  to  grow  well  on  ordinary  potatoes,  on  bread, 
boiled  turnips  and  macaroni  under  aerobic  as  well  as  anaerobic  condi- 
tions, at  the  ordinary  room  temperature  and  at  blood  heat ;  it  is  certainly 
therefore  a  facultative  saprophyte.     To  this  question  we  shall  return. 

It  must  be  remembered  that  organisms  found  in  the  animal  body  are, 
firstly,  not  necessarily  parasitic ;  and,  secondly,  not  necessarily  harmful. 
It  is  true,  so  far  as  we  know,  that  the  normal  blood  and  tissues  do  not  con- 
tain micro-organisms ;  but  micro-organisms  are  invariably  found  on  the 
mucous  and  cutaneous  surfaces  and  near  their  various  outlets.     They  are 


THE    GENERAL  PATHOLOGY  OF  LNFECTION  517 

also  found  in  many  secretions  and  excretions,  for  example,  the  saliva  and 
faeces,  which  are  readily  contaminated  with  bacteria.  Now  it  is  obvious 
that  such  organisms  are  generally  either  saprophytes  or  at  most  faculta- 
tive parasites.  Again,  many  of  these  organisms  may  be  of  distinct  and 
special  benefit  to  the  host.  It  is  well  known  that  plants  thrive  badly 
when  grown  in  sterile  earth  and  nourished  with  sterile  food.  Similar 
experiments  have  not  yet  been  made  on  the  higher  animals ;  but  it  is 
probable  that  an  animal  kept  and  nourished  under  strictly  aseptic  con- 
ditions would  thrive  as  badly  as  would  a  plant.  Many  of  the  organisms 
found  in  the  human  body  —  especially  those  on  the  mucous  surfaces  of  the 
alimentary  tract  —  may  have  become  necessary  to  our  metabolic  activity. 
Microbes  which  are  tolerated  and  harboured  by  the  body,  which  grow 
and  thrive  with  it,  and  seem  even  to  contribute  to  its  welfare,  are  not 
parasites,  but  are  said  to  live  with  it  in  symbiosis;  they  are  ''  commensal." 

III.   Products  of  Bacterial  Activity 

The  bacteria,  while  growing  in  the  tissues,  or  when  cultivated  in  an 
artificial  medium  such  as  broth,  remove  and  use  up  certain  substances 
for  their  own  nutrition;  but  they  also,  by  means  of  their  protoplasmic 
activity,  manufacture  others  which  either  pass  into  the  broth  and  are 
there  held  in  solution,  or  produce  secondary  changes  in  the  broth  by 
fermentation  or  other  chemical  interaction.  It  is  obvious  then  that  the 
liquid  or  medium  in  which  bacteria  are  growing  may  become  altered 
(a)  by  the  assimilation  of  nutritive  material  by  the  organisms ;  (6)  by 
the  products  of  secretion  elaborated  and  given  out  by  the  bacterial  cell ; 
and  (c)  by  subsequent  secondary  changes  induced  by  these  products. 

The  sum  total  of  these  chemical  and  physiological  changes  constitutes 
all  that  is  included  under  the  term  ''  bacterial  products."  These  products 
are  not  necessarily  toxic  when  tested  on  the  ordinary  laboratory  animals. 
It  will  be  found  that  any  one  pathogenetic  organism  manufactures  a 
series  of  substances,  of  which  some  are  harmless,  others  poisonous;  even 
these  latter  indeed  are  not  equally  poisonous,  but  differ  in  kind  and  in 
degree  of  activity.  No  doubt  the  specific  symptoms  and  phenomena  of 
most  infective  diseases  are  due  to  specific  poisonous  agents  ;  but  we  must 
be  careful  not  to  lose  sight  of  the  complex  nature  of  bacterial  chemical 
changes  which  in  the  body  lead  to  a  series  of  secondary  symptoms,  no  less 
important  perhaps  than  the  more  striking  specific  ones.  Unfortunately 
the  language  of  the  bacteriological  chemist  is  at  present  far  from  exact. 
The  processes  of  bacterial  activity  are  extremely  complex,  and  until  we 
know  more  of  them,  we  are  compelled  to  use  such  general  terms  as 
"bacterial  products,"  "toxins,"  and  "virus."  For  instance,  when  diph- 
theria bacilli  are  grown  in  a  flask  of  broth,  the  liquid  is  said  to  contain 
the  bacterial  products;  but  many  of  the  substances  held  in  solution 
by  the  liquid  may  not  have  been  primarily  produced  by  the  bacteria, 
but  by  a  secondary  fermentative  action.  Bacteriological  chemistry  is  a 
young  branch  of  science,  and  as  yet  even  more  backward  than  physio- 


5i8  SYSTEM  OF  MEDICINE 

logical  chemistry ;  we  shall  therefore  restrict  ourselves  here  to  a  few  of 
the  more  familiar  points  of  theoretical  and  practical  importance. 

The  assimilated  substances  are  employed  (a)  for  the  purpose  of 
building  up  the  bacterial  cell ;  and  (h)  for  the  purpose  of  manufacturing 
certain  substances  which  are  afterwards  discharged  from  the  bacterial 
cell  by  a  process  of  secretion  or  excretion.  For  us  the  substances 
eliminated  by  the  bacterial  cells  and  the  secondary  products  elaborated 
by  these  substances  from  the  culture  medium  are  of  the  greatest  im- 
portance. We  shall  first  take  a  general  survey  of  the  chemical  bodies 
obtained  from  bacterial  cultures,  that  is,  not  from  any  one  culture  in 
particular,  but  from  a  large  variety  of  cultures  taken  collectively :  — 
the  scope  of  bacterial  chemistry. 

1.  Oases  are  formed  or  given  off  by  many  organisms,  for  example,  the 
anaerobic  bacteria,  the  many  varieties  of  bacillus  coli  communis,  and 
numerous  putrefactive  organisms.  Among  these  gases  are  CO2,  H,  CH4, 
H2S  and  NH3.  CO2  no  doubt  is  given  out  by  all  organisms.  Some, 
however,  possess  the  power  of  forming  gas  to  such  an  amount  that, 
when  grown  suitably  in  solid  media,  large  gas  bubbles  will  appear  in  the 
substance  of  the  gelatine  and  the  agar-agar;  and  when  placed  in  the 
animal  body,  gas  will  be  formed  sometimes  also  in  the  tissues,  to  such  an 
extent  as  to  produce  an  emphysematous  condition  (some  forms  of  septic 
gangrene,  malignant  oedema,  ''  schaumleber,"  symptomatic  anthrax). 

2.  Fatty  and  oxy-  acids  and  their  amido-compounds  are  commonly 
found  in  bacterial  cultures ;  for  example,  acetic,  propionic,  butyric,  and 
lactic  acids  and  their  compounds ;  also  leucin  and  other  amides. 

3.  Of  importance  also  are  the  bodies  belonging  to  the  aromatic 
series,  such  as  tyrosin,  phenol,  cresol,  which  are  oftenest  found  in  fer- 
menting and  putrefying  mixtures. 

4.  Many  organisms  are  capable  of  forming  indol,  a  substance  well 
known  to  the  physiologist,  which  is  formed  almost  certainly  by  bacterial 
action  from  proteids  by  a  process  of  decomposition  during  their  stay  in 
the  intestine.  It  is  manufactured  by  many  putrefactive  organisms,  by 
the  bacterium  coli,  and  numerous  choleraic  vibrios. 

5.  Some  organisms  are  chromogenetic,  that  is,  they  secrete  or  manufact- 
ure pigments.  The  latter  may  occasionally  be  contained  in  the  substance 
of  the  organism  (intracellular),  more  commonly  in  the  medium  outside 
(extracellular)  ;  sometimes  they  impart  a  general  diffuse  colour  to  their 
surroundings,  a  colour  varying  in  intensity  Avith  the  medium  in  or  on 
which  the  bacteria  flourish.  The  range  of  colours  is  very  wide.  Thus 
red  colouring  matter  is  formed  by  the  bacillus  prodigiosus ;  green  or  blue 
by  the  bacillus  pyocyaneus  and  the  bacillus  fluorescens;  yellow  by 
many  sarcinse,  bacilli,  and  staphylococci ;  violet  by  the  B.  violaceus 
and  the  B.  ianthinus.  The  pigment  formation  depends  (a)  on  the 
nature  and  consistence  of  the  medium,  being  most  marked  as  a 
rule  on  a  solid  one ;  (b)  on  the  presence  of  air  and  oxygen  (thus  the 
bacillus  prodigiosus  does  not  form  pigment  in  the  depth  of  a  gelatine 
tube) ;  (c)  on  the  temperature  (some  organisms  like  the  bacillus  prodigio- 


THE    GEI^ERAL  PATHOLOGY  OF  INFECTION  519 

sus  refuse  to  form  their  colouring  matter  in  the  warm  incubator) ;  (d) 
on  the  activity  of  the  light  to  which  the  organisms  are  exposed  (sunlight 
often  prevents  colour  formation,  and  may  cause  the  pigment  to  disappear 
after  it  has  once  appeared). 

6.  Lastly,  there  are  the/ermente  and  enzymes,  the  ptomaines,  the  tox- 
albamins,  and  the  products  of  fermeatatiori.  These  substances  to  the  pa- 
thologist are  of  the  greatest  importance,  and  they  are  taken  together 
here  on  account  of  their  close  relation,  chemical  or  historical,  one  to 
another ;  also  because  these  bodies  stand  out  prominently  among  the 
other  bacterial  products,  often  as  physiologically  or  pathologically  spe- 
cific substances  which  are  found  only  with  certain  organisms.  The  bacte- 
rial products,  as  I  should  have  said  before,  are  either  general  or  indiiferent, 
that  is,  such  as  are  common  to  all  or,  at  any  rate,  to  a  large  number  of 
micro-organisms ;  or  specific,  that  is,  such  as  belong  to  a  few  only. 

Fermentation  is  a  process  by  which  complex  substances  are  split  up 
into  simpler  ones.  It  may  be  (a)  purely  chemical,  initiated  and  effected 
by  the  products  of  secreting  cells ;  or  (6)  vital,  governed  by  the  vital 
phenomena  of  the  cellular  organisms.  In  the  latter  case  we  are  dealing 
with  the  manifestation  of  life  by  the  cells  ;  on  their  death  fermentation 
ceases.  The  cellular  organisms  are  the  true  ferments  as  distinguished 
from  the  enzymes  or  chemical  ferments.  The  former  are  destroyed  by 
disinfectants,  notably  chloroform  or  thymol,  substances  which  do  not 
affect  the  activity  of  the  enzymes.  Many  of  the  vegetable  organisms 
secrete  or  form  enzymes,  while  they  themselves  act  as  ferments.  The 
yeast  cells,  for  instance,  manufacture  an  enzyme,  invertin,  which  converts 
cane  sugar  into  dextrose  and  laevulose ;  but  they  themselves  act  as  an 
alcoholic  ferment  which  changes  the  dextrose  into  alcohol.  Although 
most  enzymes  are  discharged  outwards,  that  is,  are  secreted,  and  act  ex- 
tracellularly,  some  of  them  effect  their  fermentative  action  intracellularly, 
that  is,  iu  the  substance  of  the  bacterial  cell.  The  micrococcus  (bacillus) 
urese  is  the  best  known  example  of  an  organism,  capable  of  forming  an 
enzyme,  acting  intracellularly.  Erom  the  dead  bodies  of  these  organisms 
a  substance  can  be  separated  which  will  change  urea  into  ammonium  car- 
bonate. It  is  important  thus  to  distinguish  between  ferments  and  enzymes. 

Among  the  enzymes  the  following  have  been  separated  or  isolated :  — 

(1)  Diastatic  enzymes,  which  convert  starches  into  glucose  or  dextrose, 
have  been  found  in  lactic  acid  bacilli,  and  in  certain  intestinal  germs. 

(2)  Invertin,  an  enzyme  capable  of  changing  cane  sugar  into  dextrose, 
is  found  in  intestinal  bacteria,  in  yeast  cultures,  and  in  lactic  acid 
bacilli.  (3)  Many  organisms  are  capable  of  peptonising  proteids,  that 
is,  of  converting  them  into  albumoses  or  peptones.  The  liquefaction  of 
gelatine,  a  property  of  a  large  number  of  bacteria,  seems  to  be  due 
to  peptonisation.  (4)  The  presence  of  bacteria  in  milk  often  produces 
coagulation  or  curdling.  The  bacillus  coli  communis  is  one  of  the  most 
active  organisms  in  this  direction.  There  are  other  enzymes,  as  for 
instance  those  capable  of  dissolving  cellulose  and  of  splitting  up  urea, 
but  they  are  of  less  importance. 


520  SYSTEM  OF  MEDICINE 


Some  of  these  enzymes  have  been  prepared  from  bacterial  cultures 
in  a  more  or  less  pure  state.  Such  enzymes,  forming  peptones,  dextrose, 
and  other  substances  which  remain  in  solution,  must  greatly  alter  the 
composition  of  the  media  in  which  the  bacteria  are  growing.  Peptones 
and  albumoses  are  the  commonest  substances  found  in  such  albuminous 
media,  as  alkali-albumin  and  serum,  and  undoubtedly  they  owe  their 
origin  to  fermentative  processes ;  of  these  we  shall  speak  later.  Besides 
manufacturing  these  specialised  enzymes,  many  of  the  pathogenetic 
organisms  may  act  as  living  ferments,  and  by  complex  changes  produce 
specific  substances  in  the  media  in  which  they  grow,  in  other  words,  they 
may  produce  fermentation. 

We  see,  then,  that  in  any  bacterial  culture,  as  in  the  case  of  the 
yeast  cells,  two  kinds  of  fermentation  may  go  on  at  the  same  time,  (a) 
that  produced  by  chemical  substances — the  secretion  of  bacteria  in  this 
particular  case  —  a  process  comparable  to  peptic  fermentation;  (IS)  that 
carried  on  by  living  organisms.  Of  this  vital  fermentation  in  disease  at 
present  we  know  but  little.  The  best  known  forms  of  vital  fermenta^ 
tion  do  not  play  a  part  —  or  but  a  small  part  —  in  disease ;  they  are  (a) 
alcoholic  (yeast)  ;  (6)  lactic  (bacillus  acidi  lactici)  ;  (c)  butyric  (bacillus 
butyricus) ;  and  {d)  acetic  fermentation.  Fermentative  processes  are 
obviously  capable  of  altering  the  chemical  composition  of  a  nutrient 
medium  in  a  striking  manner. 

Neither  the  ferments  nor  the  enzymes  are  used  up  in  the  processes 
which  they  initiate ;  on  the  contrary,  up  to  a  certain  point,  the  ferment 
cells  multiply  in  the  nutritive  solution.  The  amount  of  enzymes  present 
must  of  course  depend  on  the  number  of  organisms.  A  nominal  quantity 
of  ferment  cells  suffices  to  produce  extensive  fermentative  changes ;  this, 
however,  is  also  true  of  many  enzymes,  as,  for  instance,  of  some  milk- 
curdling  enzymes ;  roughly,  however,  the  effect  produced  by  the  enzymes 
varies  directly  as  the  quantity  used. 

As  fermentation,  like  putrefaction,  is  a  hydrolytic  process,  both 
enzymes  and  ferments  require  water  to  liberate  their  power ;  boiling 
destroys  them,  so  does  cooling ;  and  the  retention  of  the  prodiicts  of 
their  activity  eventually  inhibits  and  impairs  fermentation.  Although 
the  enzymes  are  capable  of  acting  under  anaerobic  conditions,  the  fer- 
ment cells  cannot  permanently  do  without  oxygen ;  yet  a  temporary  re- 
duction of  the  oxygen-supply  will  often  raise  their  fermentative  activity. 

Of  the  true  chemical  nature  of  the  eAzymes  we  are  ignorant.  They 
are  probably  proteins,  soluble  in  water  but  not  diffusible,  and  precipitated 
by  ammonium  sulphate  and  alcohol.  In  aqueous  solution  they  lose  their 
fermentative  properties  when  heated  to  60°-80°  C,  though  when  dry  they 
will  resist  temperatures  of  100°-150°  C.  In  glycerine  solution  they 
retain  their  power  almost  indefinitely.  As  a  rule  they  are  easily  carried 
down  mechanically  from  their  solution  by  various  methods  of  indifferent 
precipitation,  as  by  calcium  phosphate,  cholestearin,  etc.  It  is  important 
to  keep  in  mind  this  readiness  of  the  enzymes  to  come  down  on  precipi- 
tation ;  because  it  is  quite  possible  that  some  of  the  many  discrepancies 


THE    GENERAL  PATHOLOGY   OF  INFECTION  521 

which  make  the  subject  of  bacterial  chemistry  so  perplexing  are  due  to 
imperfect  knowledge  of  the  difficulty  of  successfully  separating  the  (so- 
called)  enzymes.  To  this  matter  we  shall  come  back  m  a  final  review 
of  the  present  position. 

The  ptomaines  are  certain  basic  compounds  formed  by  the  action  of 
bacteria  on  dead  albuminous  substances  ;  they  include  highly  toxic  sub- 
stances which  have  been  compared  to  alkaloids,  and  have  been  called 
animal  alkaloids.  As  a  matter  of  fact,  however,  they  differ  consider- 
ably from  the  vegetable  alkaloids,  being  amines  (mostly  di-amines) ;  and 
they  are  formed  most  commonly  in  the  early  stages  of  putrefactive  proc- 
esses. Brieger  has  separated  ptomaines  from  cultures  of  the  typhoid 
bacillus,  the  cholera  vibrio,  and  the  bacillus  of  tetanus ;  and  Leber  ob- 
tained phlogosin  from  the  staphylococcus  aureus  and  the  streptococcus 
pyogenes.  These  bodies,  with  a  longer  series  separated  from  various 
decomposing  tissues,  are  highly  toxic ;  it  was  therefore  assumed  at  one 
time  that  the  characteristic  symptoms  of  many  infective  diseases  are 
produced  by  these  ptomaines,  and  the  symptoms  of  many  food  intoxi- 
cations and  of  certain  intestinal  infections  are  still  attributed  to  an 
absorption  of  these  substances  from  the  intestinal  tract.  Dr.  Cunning- 
ham, for  instance,  regards,  and  possibly  with  justice,  Asiatic  cholera  as 
an  intoxication  by  ptomaines  formed  by  the  bacteria  of  that  disease. 

Without  entering  deeply  into  this  question,  we  may  take  it  as  cer- 
tain that  there  are  many  pathogenetic  bacteria  which  manufacture  no 
ptomaines;  or,  at  any  rate,  whose  ptomaines  when  administered  to  an 
animal  produce  none  of  the  specific  symptoms  associated  with  the  dis- 
ease ;  lastly,  the  amount  of  ptomaines  separable  from  large  and  copious 
bacterial  cultures  is  so  very  small  that  in  many  cases  a  doubt  of  the 
specific  importance  of  these  substances  is  justifiable.  Moreover,  many 
of  Brieger's  specific  ptomaines  have  not  stood  the  test  of  time  —  for 
example,  his  tetanin,  spasmotoxin,  and  tetanotoxin,  on  which,  indeed, 
he  himself  has  turned  his  back.  Sidney  Martin  found  an  alkaloidal 
basic  body  in  anthrax  cultures,  and  in  the  tissues  of  animals  dead  of 
anthrax;  but  it  was  always  accompanied  by  other  toxic  substances.  In 
most  cases  chemical  analysis  has  failed,  with  new  methods  in  competent 
hands,  to  detect  specific  ptomaines.  ISTo  doubt  many  of  the  ptomaines, 
where  found,  produce  injurious  effects ;  but  before  we  can  concede  much 
importance  to  them  we  must  be  satisfied  that  they  are  capable  of  repro- 
ducing the  characteristic  symptoms.  Anyhow,  it  seems  that  at  present 
the  ptomaine  theory  has  lost  ground,  and  in  many  quarters  has  been 
given  up  —  it  was  merely  a  phase.  Undoubtedly  ptomaines  exist,  often 
appear  during  early  decomposition  and  putrefaction  [see  article  on 
"Ptomaine  Poisoning"],  and  are  found  in  certain  cases  of  food-poison- 
ing and  in  some  forms  of  disease;  but  it  is  erroneous  to  put  down  all 
bacterial  toxins  as  ptomaines.  Two  further  matters  may  be  mentioned 
in  this  elementary  sketch,  namely,  tliat  not  all  })tomaines  are  poisonous,' 

'  Briefer  in  his  classification  applies  the  term  "  toxins  "  to  the  poisonous  ptomaines, 
the  term  "ptomaines  "  to  those  which  are  not  poisonous  —  a  useless  method  of  classifying 


522  SYSTEM   OF  MEDICINE 

and  also  that  some  ptomaines  are  extremely  resistant  to  liigh  degrees 
•of  temperature. 

With  the  discoveries  of  toxic  albumoses  in  bacterial  cultures,  by 
Mr.  Hankin  and  Dr.  Sidney  Martin,  the  ptomaines  were  more  or  less  lost 
sight  of,  and  fresh  paths  of  research  were  opened  up.  Weir  Mitchell 
and  Reichert  had  already  shown  that  the  toxic  principles  of  snake  venom 
are  albuminous  substances  ;  they  supposed  them  to  be  mostly  toxic  pep- 
tones. Later  it  was  demonstrated  that  they  are  not  peptones  but  albu- 
moses. Others  followed  up  these  researches,  and  of  great  importance 
were  Sidney  Martin's  investigations  on  abrin,  which  he  also  proved  to 
be  a  toxic  albumose.  Indeed  it  soon  appeared  that  a  fairly  large  num- 
ber of  highly,  and  even  intensely  poisonous  substances,  whether  derived 
from  the  animal  by  glandular  activity,  or  from  seeds  of  plants,  or  from 
bacterial  cultures,  owe  their  toxic  properties  to  albumoses.  Hence  these 
peptone-like  substances  came  to  be  regarded  as  the  specific  poisons  of 
pathogenetic  bacteria,  and  this  the  more  as  they  were  obtained  from  a 
series  of  organisms.  When  Roux  and  Yersin  had  precipitated  the  active 
principle  from  diphtheria  cultures,  which  they  called  an  enzyme ;  and 
when  Brieger  and  Frankel,  working  with  different  methods,  had  come  to 
the  conclusion  that  the  diphtheria  toxin  is  an  albuminous  body,  or  a 
"  toxalbumin,"  Sidney  Martin  showed  that  from  diphtheria  cultures  in 
alkali-albumin  toxic  albumoses  can  be  obtained  which,  injected  into  a 
guinea-pig  or  rabbit,  produce  all  the  classical  lesions  of  the  disease.  But, 
before  Martin's  researches,  chemists  had  already  suspected  that  the  diph- 
theritic toxalbumins  of  Brieger  and  Frankel  were  really  albumoses.  Al- 
bumoses have  also  been  found  in  cholera  and  pneumococcus  cultures,  and 
in  Koch's  tuberculin.  Gradually,  however,  it  became  evident  that  many 
of  the  bacterial  toxins  do  not  react  as  albumoses,  but  that  some  answer  to 
peptone  tests,  others  behave  more  like  globulins,  and  so  forth.  It  seemed, 
then,  that  from  bacterial  cultures  various  kinds  of  poisonous  albumins 
or  proteids  or  albuminoid  bodies  may  be  separated,  and  hence  the  gen- 
eral term  toxalhmmns  was  applied  by  Brieger  and  Frankel  to  all  of  them. 

It  is  quite  true  that  from  several  bacterial  cultures  (B.  anthracis  and 
B.  diphtheriae)  toxic  albumoses  can  be  separated,  if  the  organisms  be 
grown  on  an  alkaline  serum  free  from  peptone ;  and  these  albumoses, 
when  injected  into  the  animal  body,  will  produce  the  lesions  character- 
istic of  anthrax  and  diphtheria:  but  it  is  equally  true  that  specific 
albumoses  are  not  to  be  obtained  from  all  pathogenetic  bacteria.  If, 
however,  we  use  the  more  general  name  toxalbumin  in  the  sense  defined 
above,  it  may  be  said  that  specific  toxalbumins  have  been  found  in 
anthrax,  diphtheria,  pneumonia,  in  almost  all  infective  diseases,  and  in 
most  cultures  of  pathogenetic  bacteria.  Toxalbumin,  however,  is  an 
inaccurate  name,  since  it  would  include  practically  only  the  true 
albumins  and  the  globulins,  and  would  exclude  the  proteins  (nucleo- 
albumins)  and  the  albuminoid  substances. 

ISTowthe  albumoses  and  peptones  which  constitute  so  important  a  series 
among  the  bacterial  products  may  be  derived  by  hydrolytic  processes  from 


THE    GENERAL  PATHOLOGY  OF  INFECTION  523 

any  one  of  those  albuminous  or  albuminoid  substances  including  the 
nucleo-albumins ;  and,  strictly  speaking,  they  are  not  covered  by  the 
name  albumin.  It  is  better,  therefore,  to  follow  Neumeister,  and  to 
speak  of  toxic  proteins,  which  designation  includes  the  albumins,  the 
proteids,  and  the  albuminoid  bodies.  Taking  this  wider  view,  we  shall 
meet  with  fewer  difficulties  than  if  we  restrict  ourselves  to  the  terms 
toxalbumins  or  to  albumoses.  In  the  case  of  snake  venom,  for  instance, 
we  find  that  their  composition  is  anything  but  uniform;  some  contain 
toxic  globulins,  others  albumoses,  primary  and  secondary,  others  perhaps 
peptones  [vide  art.  on  "Snake  Poisoning  "].  In  abrin,  again,  there  are 
both  an  albumin  and  a  globulin ;  toxic  proteins  exist  also  in  ricin  and 
other  similar  substances ;  and  we  have  seen  that  the  nature  of  the  bac- 
terial products  may  vary  considerably. 

Many  of  these  proteins  may  be  precipitated  in  an  amorphous  form 
from  the  culture  medium  in  which  the  bacteria  grow;  when  in  solution 
they  are  generally  readily  destroyed  by  heat  (snake  poison,  however,  less 
readily),  and  are  rendered  atoxic  by  the  action  of  the  digestive  secretions. 
In  a  dry  state,  like  enzymes,  they  resist  heat  better;  and  they  often 
resemble  the  enzymes  in  this  also,  that  they  set  up  their  toxic  effects 
when  injected  in  extremely  minute  doses;  so  that  they  would  seem  to 
act  not  directly  on  the  tissues,  but,  after  the  manner  of  enzymes,  to 
produce  a  kind  of  toxic  fermentation. 

Summary.  — -  We  have  seen  that  by  Brieger's  researches  the  atten- 
tion of  the  scientific  world  was  directed  towards  the  poisonous  ptomaines, 
but  we  soon  learnt  that  the  part  which  these  play  in  infective  diseases 
can  only  be  one  of  secondary  importance ;  next  we  were  taught  to  look 
for  the  secret  of  these  diseases  in  toxic  albumins,  albumoses,  or,  in  short, 
in  toxic  proteins,  that  is,  in  substances  reacting  like  proteins  (albumins, 
globulins,  albumoses,  etc.),  which  cannot  be  chemically  distinguished 
from  ordinary  known  proteins,  but  are  endowed  with  toxic  properties. 
Duclaux  and  others,  however,  have  raised  a  protest  against  this  view, 
and  have  always  assumed  that  the  toxo-proteins  in  reality  are  mixtures 
of  albuminous,  proteid,  or  albuminoid  bodies  with  the  true  toxins,  the 
latter  being  carried  down  mechanically  during  precipitation;  and  recent 
researches  have  shown  that,  if  for  the  purpose  of  cultivation  a  non- 
albuminous  solution  be  employed,  the  result  is  not  an  albumose  or  a 
globulin  or  a  toxalbumin,  but  an  indefinite  body,  perhaps  albuminoid  in 
nature,  and  allied  to  the  enzymes  and  ferments.  Brieger  and  Cohn  have 
demonstrated  that  it  is  possible  to  purify  the  toxin  of  tetanus  (which, 
when  obtained  from  broth,  appears  to  be  a  toxalbumin)  in  such  a  manner 
as  to  rid  it  more  or  less  completely  from  all  the  albuminous  and  albu- 
minoid substances  clinging  to  it;  and  Sidney  Martin,  although  his 
researches  are  as  yet  unpublished,  has  confirmed  this  in  a  most  striking 
manner.  He  has  shown  the  presence  of  albumoses  in  tetanus  cultures, 
which,  however,  are  simply  pyrogenetic  in  their  action;  the  true  toxin 
which  is  obtainffd  after  tlio  removal  of  the  toxalbumins  is  not  an  albu- 
min, nor  a  proteid,  nor  of  course  a  ptomaine. 


524  SYSTEM   OF  MEDICINE 

We  see  then  how  obscure  the  whole  subject  still  is,  and  that  the 
name  given  to  a  bacterial  toxin  apparently  varies  within  certain  limits 
with  the  culture  medium  used.  The  albumoses  are  supposed  to  be  formed 
by  a  process  of  fermentation,  the  bacterial  cell  secreting  an  enzyme  which, 
acting  on  the  albumin  in  the  culture  medium,  splits  it  up  into  albumoses ; 
as  the  peptic  cells  in  the  gastric  mucous  membrane  secrete  the  pepsin 
which,  acting  on  the  proteids  in  the  stomach,  converts  them  first  into 
albumoses.  However  tempting  this  opinion  may  be  on  account  of  its  sim- 
plicity, in  the  light  of  more  recent  researches  it  can  hardly  be  regarded 
as  conclusive.  Most  investigators,  Avhile  preparing  the  toxins  from  bac- 
terial cultures,  use  media  which  already  contain  peptones  or  albumoses ; 
we  do  not  wonder  then  that,  on  precipitation  with  alcohol  or  ammonium 
sulphate,  they  obtain  toxic  albumoses,  or  in  short  toxalbumins.  True, 
Sidney  Martin  used  a  medium  free  from  albumoses  and  peptones,  but 
containing  alkali  albumin ;  and  on  growing  anthrax  and  diphtheria  bacilli 
in  such  a  solution  he  eventually  obtained  toxic  albumoses :  it  would  seem 
then  that  these  bacilli  either  act  as  ferments,  or  secrete  enzymes,  which 
change  the  alkali  albumin  into  toxic  albumoses.  So  far  as  diphtheria  is  con- 
cerned, he  inclines  to  the  view  that  its  bacillus  secretes  an  enzyme ;  for  out 
of  the  diphtheritic  membranes  a  proteid  substance  may  be  extracted  which 
does  not  give  albumose  or  peptone  reactions,  and  yet  produces  the  same 
effect  on  the  animal  as  the  albumoses,  though  administered  in  much  smaller 
doses.  Martin  therefore  argues  that  the  bacilli  set  free  an  enzyme  which, 
by  hydrolysis,  converts  the  albumin  into  albumoses,  which  latter,  acting  as 
poisons,  produce  the  true  diphtheritic  lesions  in  the  animal.  He  finds 
also  that  they  form  identical  substances  (albumoses)  from  the  proteids  of 
the  human  body.  "  It  may  be,"  he  says,  "  that  the  chemical  substances 
which  are  especially  poisonous  are  produced  by  means  of  an  unorganised 
ferment  (that  is,  an  enzyme)  secreted  by  the  bacillus,  and  in  diphtheria 
there  is  evidence  to  show  that  this  enzyme  plays  a  direct  and  important 
pathological  part.  In  this  disease,  in  which  the  bacillus  is  limited  to  the 
superficial  parts  of  the  membrane,  and  does  not  diffuse  itself  throughout 
the  body,  something  is  secreted  by  the  bacillus  and  then  absorbed  into 
the  system,  in  the  tissues  of  which  are  afterwards  found  certain  digested 
products  (that  is,  albumoses)."  This  secretion  of  the  bacillus  may  be 
looked  upon  as  an  enzyme ;  so  that  Martin's  conclusion  is  that  the  bacillus 
diphtherise  liberates  an  enzyme  which  digests  the  proteids  of  the  body  or 
of  the  culture  medium,  forming  toxic  albumoses,  and  that  the  latter 
produce  the  characteristic  morbid  changes.  The  toxic  diphtheria  prod- 
ucts in  the  body  do  not  all  come  directly  from  the  membrane,  the 
albumoses  do  not  merely  accumulate  in  the  tissues ;  it  is  more  probable 
that  the  enzyme,  absorbed  from  the  membrane,  by  digesting  the  tissue 
proteids  forms  toxic  albumoses.  Martin  gives  a  useful  table,  which 
is  here  reproduced  in  slightly  altered  form,  to  contrast  the  chemical 
pathology  of  anthrax  and  diphtheria  with  the  physiological  processes 
of  peptic  and  tryptic  fermentation :  — 


THE    GENERAL  PATHOLOGY  OF  INFECTLON 


525 


Digestion  Process. 

Origin  of  Enzyme. 

Ezyme. 

Products  of 
Fermentation. 

Peptic. 

Peptic  cells. 

Pepsin. 

Albumoses. 
Peptones. 

Tryptic. 

Pancreatic  cells. 

Trypsin. 

Globulin-like 
body.    Peptone. 

Anthrax. 

B.  anthracis. 

Albumosrs. 
Peptone. 

Diphtheria. 

B.  diphtherise. 

Enzyme  of  Roux 
and  Yersin,  and 
of  Martin,  found 
in  membrane. 

Albumoses. 

Martin  does  not  fall  into  the  error  of  applying  this  scheme  to  all 
infective  organisms  alike ;  he  shows  that  the  albumoses  which  may  be 
separated  in  the  case  of  tetanus,  though  not  innocuous,  do  not  possess 
the  specific  characters  of  the  tetanic  poison ;  and,  as  above  mentioned, 
the  toxin  of  tetanus  is  not  an  albuminous  or  proteid  substance.  Yet,  so 
far  as  diphtheria  and  anthrax  are  concerned,  his  views  undoubtedly  are 
that  the  pathogenetic  bacteria  are  capable  of  digesting  proteids  in  such  a 
manner  as  to  produce  the  agents  which  set  up  the  symptoms  in  these 
infective  disorders.  This  conception  of  the  problem  is  very  tempting, 
but  it  is  also  beset  with  difficulties.  Thus  the  proteolytic  action  of  the 
so-called  diphtheria  enzyme  has  never  yet  been  demonstrated ;  this  so- 
called  enzyme  may  be  the  true  toxin  which  is  diffused  throughout  the 
body  at  the  same  time  as  albumoses  are  formed,  and  on  precipitation 
the  two  substances  may  be  carried  down  together  {vide  art.  ''  Diphthe- 
ria "] .    In  tetanus,  certainly,  the  albumoses  are  of  secondary  importance. 

But  the  greatest  difficulty  is  presented  by  the  researches  of  Uschinsky 
and  Buchner.  The  latter  excluded  albuminous  substances  from  their  cult- 
ure media  by  using  solutions  containing  asparagin  and  mineral  salts ; 
and  on  growing  tetanus  and  diphtheria  bacilli  in  such  solutions,  they 
obtained  the  active  and  specific  toxins  of  tetanus  and  diphtheria  as  bodies 
clearly  allied  to  the  albuminoid  substances,  but  not  classifiable  or  defin- 
able except  by  their  reactions.  They  are  therefore  disinclined  to  accept 
the  view  that  the  bacterial  poisons  are  formed  by  a  fermentative  action 
from  the  albuminous  substances  of  the  body  or  culture  media :  they  re- 
gard them  as  direct  products  of  the  bacterial  cells,  that  is,  as  direct  deriv- 
atives from  the  cell  plasma,  which,  as  such,  must  necessarily  share  the 
specific  properties  of  the  bacterial  cell  whence  they  came.  As  yet  it  has 
been  impossible  to  separate  these  substances  from  albuminous  solutions 
in  a  pure  state,  because  all  the  reagents  which  precipitate  them  will  also 
carry  down  simultaneously  the  albuminous  and  proteid  bodies  contained 
in  those  solutions.     Buchner  does  not  picture  to  himself  the  action  of 


526  SYSTEM   OF  MEDICINE 

these  toxins  as  a  fermentative  one,  chiefly  perhaps  because  within  certain 
limits  the  rapidity  and  the  intensity  of  the  effect  produced  vary  with  the 
dose  administered.  Yet  it  is  a  striking  fact,  of  which  we  can  readily 
obtain  evidence,  that  many  of  the  bacterial  and  animal  toxalbumins  pro- 
duce fatal  lesions  in  minute  doses ;  and,  what  is  still  more  wonderful, 
that  a  so-called  minimal  lethal  dose  will  often  be  followed  by  no  mani- 
fest signs  or  changes  for  some  days,  and  then  after  a  period  of  latency 
symptoms  of  astonishing  acuteness  may  suddenly  appear;  and,  lastly, 
that  ''  sublethal "  doses  frequently  lead  to  slow  wasting,  exhaustion, 
prostration  and  death.  It  would  be  usele^  with  our  present  knowledge 
to  speculate  on  the  meaning  of  these  phenomena,  to  which  there  is  no 
analogy  in  ordinary  toxicology.  We  cannot  as  yet  answer  the  following 
questions  —  whether  the  toxins  are  themselves  the  poison,  or  whether 
they  are  poison-producing  enzymes ;  or  again  on  what  the  prolonged  slow 
action  of  the  toxins  under  special  conditions  depends.  In  the  case  of 
enzymes,  such  as  pepsin  and  invertin,  we  must  carefully  distinguish  be- 
tween their  fermentative  and  their  toxic  actions.  When  injected  into 
the  animal  body  they  produce  rise  of  temperature,  general  disturbances 
and  death,  acting  not  by  means  of  fermentation,  but  as  direct  poisons. 

To  come  back  to  the  chemical  nature  of  the  toxins ;  we  have  seen  that 
during  the  fermentative  changes  produced  by  the  bacteria,  besides  the 
direct  products  of  fermentation,  there  are  other  substances  also  which 
we  may  regard  as  the  secreta  or  excreta;  that  is,  as  the  metabolic  or 
waste  products  of  the  bacteria.  In  most  cases  it  is  difficult  to  say  with 
certainty  what  they  are.  This,  however,  is  important :  "  If  an  organism 
growing  in  various  media  always  produces  certain  definite  substances, 
then  we  are  forced  to  consider  these  to  be  the  genuine  metabolic  prod- 
ucts." Now  we  find,  for  instance,  that  if  the  cholera  vibrio  be  culti- 
vated on  different  media,  we  can  extract  a  series  of  substances  different 
in  their  chemical  reactions,  but  all  identically  toxic.  ISTaturally  the  fer- 
mentation processes  must  vary  with  the  nutrient  medium  employed,  and 
their  reactions  can  only  be  complete  with  certain  special  media ;  but, 
nevertheless,  the  metabolic  products  appear  to  remain  physiologically 
and  pathologically  constant :  so  we  may  conclude  with  Wesbrook  that 
the  choleraic  toxin  is  the  constant,  associated  either  with  the  proteins  of 
the  nutrient  medium  or  with  the  products  of  fermentation.  This  seems 
more  reasonable  than  to  assume  that  the  vibrio  may  form  different 
chemical  toxins  with  constant  physiological  or  pathological  properties. 

This  vibrio  forms  an  interesting  illustration  of  the  continual  change  of 
our  opinions.  Brieger  described  no  less  than  six  ptomaines,  all  toxic,  but 
none  specifically  so ;  Scholl,  growing  the  vibrio  in  eggs,  obtained  a  toxo- 
peptone ;  Gamaleia  extracted  poisonous  substances  from  the  bodies  of  the 
dead  bacteria,  which  he  classified  as  nucleins  and  nucleo-albumins ;  Voges 
also  sought  for  the  cholera  toxin  in  the  bacterial  cell,  and  regarded  it  as 
an  enzyme,  since  when  obtained  from  suitable  media  it  reacts  neither 
as  an  albumin  nor  albumose  nor  peptone.  Duclaux,  as  previously  stated, 
consistently  refused  to  regard  the  bacterial  products  as  true  proteins,  but 


THE    GENERAL   PATHOLOGY   OF  INFECTION  527 

argued  that  they  are  special  bodies  of  unknown  nature,  mechanically 
carried  down  during  precipitation,  or  perhaps  forming  compounds  with 
the  proteins.  This  view  of  Duclaux  has  much  in  its  favour ;  the  chemi- 
cal evidence,  however,  is  still  wanting:  fresh  observations  are  needed. 
In  the  meantime  we  may  sum  up  that  among  the  specific  toxins  there 
have  been  found  (a)  ptomaines,  (ft)  toxic  proteins,  toxalbumins,  (c)  nucleo- 
albumins  and  albuminoid  substances,  id)  ferment-like  bodies  (enzymes) 
secreted  by  the  bacterial  cell ;  and  knowing  as  little  as  we  do,  it  is  safest 
to  apply  to  the  bacterial  poisons  the  general  term  toxin. 

Matters  have  not  been  made  easier  by  Dr.  Klein's  division  of  these 
poisons  into  (a)  intracellular  and  (&)  extracellular  poisons.  Klein 
has  shown  that  the  protoplasm  of  the  bacterial  cells  is  often  highly 
poisonous ;  and  argues,  therefore,  that  many  bacteria  contain  poisonous 
substances  in  their  protoplasm  (intracellular  poisons).  These,  as  a  rule, 
he  says,  produce  none  of  the  specific  symptoms ;  but  when  injected 
into  the  animal  cause  inflammation,  suppuration,  and  often  death. 
They  must  be  distinguished  from  the  "extracellular"  poisons  formed 
by  a  fermentative  or  other  action  on  the  culture  medium,  the  extra- 
cellular poisons  being  the  true  specific  toxins.  Thus,  to  give  an 
example,  the  diphtheria  bacillus,  acting  on  the  surrounding  albuminous 
medium  or  animal  tissue,  forms  its  toxic  albumoses,  that  is,  "the  extra- 
cellular specific  poisons,"  which  cause  the  classical  symptoms  of  the 
disease;  while  within  itself  the  diphtheria  bacillus  contains  the  "intra- 
cellular non-specific  poison."  Chemical  analyses  of  the  bacterial  proto- 
plasm were  made  before  Klein  by  ISTencki,  who  obtained  from  putrefactive 
and  other  organisms  albuminous  or  albuminoid  bodies  which  he  called 
mycoproteins.  These  resemble  the  true  albumins,  but  are  nevertheless 
essentially  different  in  their  reactions.  These  mycoproteins  i;ndoubtedly 
correspond  to  Klein's  intracellular  poisons. 

Buchner  approaches  Klein  very  closely  in  some  of  his  views.  He  also 
distinguishes  between  "  bacterio-proteins  "  (not  to  be  confounded  with 
Nencki's  mycoproteins)  (that  is,  mycoproteins  or  intracellular  poisons) 
and  the  specific  amorphous  toxins,  which,  however,  he  also  associates 
closely  with  the  cell  protoplasm.  The  former  are  common  to  many  bac- 
teria, are  more  resistant  to  heat,  and  when  injected  into  the  animal  body 
produce  inflammation,  suppuration,  and  fever.  According  to  Buchner, 
then,  both  the  bacterio-proteins  and  the  specific  toxins  are  intracellular 
poisons;  and  this  seems,  for  the  present  at  least,  the  soundest  view  to 
accept,  because  if,  for  argument's  sake,  we  were  to  accept  Klein's  view,  we 
should  find  that  the  virulence  of  his  so-called  intracellular  poisons  varies, 
as  a  rule,  di  rectly  with  that  of  his  extracellular  poisons.  A  gain,  immunity 
from  the  intracellular  poisons  generally,  if  not  always,  implies  also  im- 
munity from  the  extracellular  poisons.  It  would  take  us  too  far,  nor  is  it 
necessary  at  present,  to  discuss  these  views  more  fully ;  I  must  content 
myself  with  this  short  mention  of  them.  I  may,  however,  allude  to  recent 
researches  on  yeast  fermentation,  which  show  that  as  the  yeast  cells  them- 
selves always  contain  alcohol,  it  is  quite  possible  that  the  formation  of 


523  SYSTEM  OF  MEDICINE 


alcohol  is  an  intracellular  process ;  the  alcohol,  which  is  the  analogue  of  the 
toxin,  being  secreted  or  excreted  by  the  cells  into  the  surrounding  medium. 

Fuller  accounts  of  the  various  toxins  Vill  be  found  in  special  articles. 
Here  we  can  admit  only  a  general  summary  of  a  subject  full  of  specula- 
tions, and  open  to  many  fallacies  due  to  personal  bias  and  to  the  present 
defects  in  our  knowledge  of  physiological  chemistry.  The  chief  lesson 
to  be  derived  from  the  study  of  bacterial  toxicology  is  this,  that  the 
characteristic  symptoms  of  any  infection  are  due  to  toxins ;  therefore 
in.  our  study  of  microbic  disease  our  aim  must  be  to  establish  the 
specificity  of  the  bacterial  products.  Thus  while  dealing  with  a  disease, 
such  as  tetanus,  which  is  readily  recognised  by  strikingly  characteristic 
symptoms,  we  must  show,  not  merely  that  these  symptoms  are  produced 
by  injecting  the  bacilli  of  tetanus,  but  that  the  toxins  (or  sterilised  cult- 
ures containing  the  metabolic  products  in  solution)  will  produce  the 
same  symptoms;  in  other  words,  that  the  toxins  and  microbes  are  alike 
specific.  This  has  already  been  done  for  tetanus,  diphtheria,  and  anthrax. 
We  find,  then,  that  the  pathogenetic  bacteria  produce  poisons,  whatever 
their  chemical  nature  may  be,  which,  on  obtaining  entrance  into  the 
animal  body,  will  cause  the  appearance  of  the  specific  symptoms  of  the 
disease  under  consideration. 

We  have  seen  that  the  various  substances,  toxic  and  atoxic,  produced 
by  bacterial  life,  are  manifold;  and  that  any  one  organism  may,  and 
probably  does,  form  a  number  of  them,  partly  by  secretion  or  excretion, 
and  partly  by  fermentation.  Thus  we  may  explain  the  complexity  of 
the  symptoms  of  infective  diseases,  the  specific  symptoms  being  caused 
by  the  specific  poisons,  and  the  concomitant  symptoms  by  the  other 
substances  formed  by  bacteria  and  bacterial  fermentation.  We  must 
alwaj^s  remember  that  as  the  chemical  processes  and  their  products  are 
far  from  simple,  their  effects  must  likewise  be  complex. 

The  fermentative  action,  real  or  apparent,  of  the  pathogenetic 
bacteria  and  their  products  is  then  perhaps  their  most  striking  and 
important  property  —  at  least  in"  all  general  infective  lesions;  the 
organisms  themselves  acting  partly  as  ferments,  partly  as  zymoge- 
netic  cells.  The  toxins  often  resemble  enzymes  so  closely  that  the 
general  opinion  inclines  to  place  all  these  bodies  in  one  and  the  same 
chemical  group,  not  as  identical  but  as  allied  bodies.  Hence,  wherever 
in  nature  we  find  fermentation,  real  or  apparent,  the  presence  of  living 
micro-organisms  must  be  suspected;  though  of  course  we  must  not 
forget  that  certain  zymotic  or  fermentative  processes  appear  to  be  in- 
dependent of  bacteria,  as,  for  instance,  intoxication  with  snake  poison. 
Organisms  capable  of  initiating  and  completing  fermentation  have  been 
called  zymogeiietk ;  and  since  many  morbid  processes  are  analogous,  if 
not  akin,  to  fermentative  processes,  and  are,  moreover,  produced  by 
organisms,  the  term  zymotic  has  been  applied  to  them,  —  a  term,  how- 
ever, to  be  avoided  rather  than  recommended. 

Though  we  cannot  enumerate  and  discuss  all  the  various  complex 


THE    GENERAL  PATHOLOGY  OF  INFECTION  529 

chemical  and  physical  changes  which  micro-organisms  in  general  are 
capable  of  producing  in  their  surroundings,  allusion  must  be  made  to  a 
few  other  important,  or  at  least  highly  interesting  phenomena  of  bac- 
terial activity,  such  as  the  processes  of  nitrification,  putrefaction,  and 
production  of  light. 

(a)  Nitrilication  takes  place  especially  in  the  soil  and  in  water,  and 
is  one  of  the  most  important  and  essential  processes  for  organic,  and 
especially  for  vegetable  life.  In  the  soil,  where  it  has  been  more  care- 
fully studied  by  Winogradski,  Frankland,  and  Warington,  two  separate 
changes  are  said  to  take  place,  (a)  Some  organisms  decompose  am- 
monia into  water  and  nitrous  acid ;  {(S)  others,  though  powerless  over 
ammonia,  oxidise  nitrites  to  nitrates,  and  in  that  way  supply  the  nitrog- 
enous food  to  chlorophyllous  plants. 

Conversely  many  bacteria  possess  the  power  of  reducing  nitrates  to 
nitrites  ;  others  are  capable  even  of  absorbing  free  nitrogen.  All  these 
organisms  are  of  the  utmost  importance  in  the  vegetable  economy,  as 
they  assist  the  growing  plant  and  the  germinating  seed  to  obtain  the 
necessary  supply  of  food.  These  organisms  collectively  complete  the 
processes  of  putrefaction  by  converting  the  ammonia  first  into  nitrous 
acid,  and  the  nitrous  compounds  further  into  nitrates,  in  the  presence 
of  basic  substances.  The  nitrates  are  then  again  reduced  to  nitrites 
and  ammonia,  and  so  on.  The  cholera-vibrios  possess  the  faculty  of 
forming  nitrites,  while  many  bacteria  found  in  faeces  are  capable  of 
still  further  reducing  the  nitrites  to  ammonia.  There  is  reason  to 
believe  that  bacteria  are  as  important  to  animal  life  as  they  are  to  plant 
life ;  experiments  on  lower  animal  forms  prove  this,  and  the  laws  of 
adaptation  would  lead  us  to  expect  it. 

(6)  Putrefaction  may  be  roughly  considered  as  a  form  of  fermenta- 
tion of  albuminous  and  albuminoid  matter.  The  whole  chemical  process 
of  putrefaction  is  too  complex  to  be  considered  here  ;  a  few  words  must 
suffice.  It  seems  that  the  first  change  is  peptonisation,  effected  in  part 
by  the  peptonising  enzymes  possessed  by  most  organisms  of  decomposi- 
tion. The  peptonised  substances  are  then  further  changed  and  split  up ; 
amido-derivatives  (especially  amido-acids),  aromatic  bodies,  and  sulpho- 
acids  are  next  formed,  and  these  are  further  split  up,  indol  being  among 
the  final  products.  The  list  of  substances  which  may  appear  during 
putrefaction  is  very  extensive ;  it  contains  among  the  gases  CO2,  H, 
H2S,  and  CH4;  among  the  fatty  acids  acetic,  butyric,  and  valerianic 
acids,  besides  various  amido-compounds  —  amines,  indol,  skatol ;  bodies 
of  the  aromatic  series ;  various  ptomaines ;  basic  compounds,  etc.,  the 
chemical  combinations  varying  qualitatively  and  quantitatively  with 
the  particular  bacterial  species  concerned,  and  with  the  decomposing 
medium.  Tlie  result  of  putrefaction  in  all  cases  is  the  decomposition 
of  highly  complex  substances  into  others  of  simpler  and  more  assimi- 
lable structure.  It  is  especially  under  anaerobic  conditions  that  the 
odour  of  jjutrefaction  is  observed. 

The  list  of  putrefactive  organisms  includes  various  forms  of  proteus 

vol..  I  2  m 


530  SYSTEM   OF  MEDICINE 

(vulgaris,  mirabilis,  Zenkeri),  for  which  formerly  the  name  bacterium 
termo  had  to  do  duty,  and  also  a  large  number  of  other  aerobic  and 
anaerobic  bacteria,  many  of  which  are  still  without  proper  names. 

(c)  The  pliospliorescence  observed  on  the  surface  of  sea-water,  or  on 
decomposing  meat  or  fish,  is  due  to  photogenetic  bacteria,  of  which  there 
are  many  varieties.  This  curious  and  beautiful  effect  depends  on  active 
oxidation,  and  the  phosphorescence  disappears  in  the  presence  of  CO2. 

Our  observations  on  bacterial  products  must  be  concluded  here,  for 
in  a  general  introduction  it  would  be  out  of  place  to  enter  into  matters 
which  are  either  doubtful  or  of  importance  rather  to  the  specialist  than 
to  the  physician.  The  latter  will  find  no  dilficulty  in  appreciating 
the  excellent  warning  of  Professor  Welch,  who  says  that  "  in  fixing  our 
attention  upon  the  poisonous  chemical  products  of  bacteria  we  must  not 
lose  sight  of  the  fact  that  these  are  results  of  vital  activities.  In  the 
case  of  most  infective  diseases  we  can  no  more  dissociate  the  actvial 
presence,  multiplication,  and  specific  vital  activities  of  the  bacteria 
within  the  body  from  the  disease  than  we  can  substitute  any  chemical 
substances  for  the  actual  presence  and  growth  of  the  yeast  fungi  in  the 
production  of  alcohol  from  sugar.  AVe  cannot  resolve  bacteriology  into 
toxicology." 

Variability  of  Virulence.  —  As  the  shape  and  forms  of  bacteria  may 
vary  or  may  be  altered  by  changes  in  their  surroundings,  so  likewise 
may  their  physiological,  chemical,  or  vital  activity  be  greatly  modified 
—  often  to  such  an  extent  that  in  many  cases  we  seem  to  come  very 
near  new  species.  Thus,  as  said  above,  many  chromogenetic  organisms 
lose  their  power  of  forming  pigment  under  special  conditions ;  among 
these  conditions  are  absence  of  oxygen,  increased  temperature,  insola- 
tion, and  change  in  the  chemical  reaction  of  the  nutrient  medium.  In 
some  cases  by  such  interferences  we  may  obtain  varieties  which,  if  they 
do  not  remain  permanently  colourless,  at  any  rate  have  become  incapa- 
ble of  pigment  production  for  many  generations,  or  —  to  express  it 
differently  —  show  no  reversion  to  the  chromogenetic  type  for  a  long 
time.  Similarly  modifications  may  be  brought  about  in  the  fermenta- 
tive activity  of  bacteria  by  change  of  soil  or  by  continued  growth  on 
ordinary  laboratory  media.  Thus  organisms  which  at  first  liquefy 
gelatine  may  lose  this  power  permanently ;  conversely  organisms  which 
at  first  were  incapable  of  liquefying  gelatine  gradually  and  permanently 
acquire  this  quality.  Lauder  Brunton  and  Macfadyen  mention  a  curi- 
ous instance  of  adaptation,  if  such  it  may  be  called,  while  discussing 
the  observation  that  bacteria  which  form  a  peptonising  enzyme  on 
proteid  soil  can  produce  a  diastatic  enzyme  on  carbohydrate  soil. 

Loss  of  virulence  —  that  is,  impaired  toxin  formation  or  impaired 
metabolic  activity  —  is  not  only  the  most  important  change,  but  also 
that  most  frequently  observed.  Thus  the  pneumococcus,  if  continuously 
grown  on  ordinary  media,  very  soon  ceases  to  be  virulent,  and  this  loss 
of  virulence  is  permanent :  similarly  the  diphtheria  bacillus  on  agar-agar 


THE    GENERAL  PATHOLOGY   OF  INFECTLON  531 

soou  becomes  less  virulent.  This  loss  of  virulence  is  called  attenuation, 
and  it  may  be  brought  about  in  many  ways  besides  prolonged  cultivation 
in  or  on  artificial  media,  as  by  heat,  evaporation,  drying,  chemical  dilu- 
tion, or  the  addition  of  chemical  substances  to  the  culture  media :  these 
methods,  however,  require  no  further  consideration.  Attenuation  may 
be  temporary  or  permanent,  as  in  the  case  of  anthrax,  where  the  loss 
of  virulence  is,  moreover,  accompanied  by  loss  of  spore-formation.  It 
is  often  found  also  that  an  organism  obtained  from  a  bacterial  lesion  of 
severe  or  malignant  type  soon  loses  its  virulence,  or  is  from  the  outset 
less  virulent  than  an  organism  separated  from  a  less  severe  case  of  the 
same  lesion.  The  streptococci  are  in  this  respect,  perhaps,  the  most  vari- 
able of  all  germs,  and  therefore  the  most  annoying  to  the  active  worker. 
This  variability  in  virulence  cannot  be  satisfactorily  explained  at  present; 
but  it  must  necessarily  lead  us  to  be  cautious  in  our  attempts  to  interpret 
vital  phenomena  by  means  of  test-tube  reactions  only. 

The  virulence  of  many  organisms  may  also  be  permanently  or  tem- 
porarily increased,  either  by  changing  the  composition  of  the  nutrient 
media  in  or  on  which  they  grow,  or  by  passing  the  organisms  through  a 
series  of  animals  (a  process  which  is  called  "passage  "),  especially  if  the 
animals  be  relatively  insusceptible.  In  some  cases,  however,  continued 
passage  will  lead  to  permanent  attenuation ;  an  important  observation  in 
so  far  as  it  helps  to  throw  light  on  the  natural  decline  of  many  epidemics, 
which  may  cease  by  virtue  of  a  gradual  attenuation  brought  about  by 
continuous  transmission  from  man  to  man. 

It  would  take  us  too  far  to  discuss  the  question  of  natural  races  or 
varieties ;  indeed,  our  observations  and  premises  are  not  exact  enough 
to  give  us  much  confidence  in  so  doing.  Most  writers  assume  the  ex- 
istence of  natural  non-virulent  varieties  in  the  cases  of  the  organisms 
of  cholera,  typhoid,  diphtheria,  pneumonia,  and  traumatic  infections. 
These,  under  special  conditions  —  unknown  to  us — may  acquire  viru- 
lence either- before  or  on  gaining  access  to  the  body,  and  will  then  be 
capable  of  producing  the  lesion  proper  to  each.  This  is  possible,  if  not 
probable  :  it  is  safer,  however,  to  suspend  our  judgment  for  the  present. 


IV.   Bacterial  Activity  in  Disease 

Having  considered  the  products  of  bacterial  activity  in  general,  we 
can  now  approach  the  all-important  question  of  the  relation  of  micro- 
organisms to  disease.  No  one  doubts  any  longer  that  a  number  of 
diseased  processes  are  due  to  bacteria,  and  the  epithet  pathogenetic  is 
applied  to  all  organisms  capable  of  producing  a  morbid  lesion  in  the 
animal  body. 

The  term  pathogenetic  is,  however,  a  relative  one,  because  —  (1)  An 
organism  quite  harmless  to  one  animal  may  be  capable  of  causing  disease 
in  another ;  (2)  an  organism  wliich,  under  ordinary  conditions,  is  harm- 
less, under  special  conditions  may  give  rise  to  serious  lesions ;  (3)  many 


532  SYSTEM  OF  MEDICINE 

organisms,  generally  regarded  as  harmless  saprophytes,  under  special 
circumstances  of  experiment  may  prove  injurious. 

Thus  Dr.  Klein  has  shown  that  the  bacillus  prodigiosus,  which  by 
all  bacteriologists  is  considered  not  to  be  pathogenetic,  when  injected 
into  the  peritoneal  cavity  of  a  guinea-pig  may  cause  a  fatal  peritonitis : 
Buchner,  again,  has  shown  that  the  dead  bodies  of  bacteria,  subcuta- 
neously  injected  into  animals,  Avill  produce  suppuration.  We  must  bear 
such  observations  clearly  in  mind ;  and  we  must  further  remember  that 
often  an  organism,  unable  by  itself  to  initiate  any  morbid  change,  may, 
with  the  assistance  of  another  organism,  or  in  conjunction  with  it,  cause 
most  serious  mischief :  conversely,  the  pathogenetic  power  of  some  or- 
ganisms may  be  counteracted  by  the  presence  of  another  organism. 

The  lesion  produced  by  so-called  pathogenetic  organisms  may  be  (a) 
local  or  general ;  (6)  specific  or  non-specific.  If  it  be  local  the  organisms 
remain  in  situ,  multiplying  there  rapidly  or  slowly,  and  forming  their 
toxins,  or  setting  up  fermentative  processes.  The  poisons,  secreted  by 
the  organisms  or  formed  by  the  action,  fermentative  or  otherwise,  of  the 
organisins  on  the  tissues,  are  absorbed,  and  lead  to  special  symptoms  and 
constitutional  disturbances ;  or  they  may  react  locally  on  the  tissues, 
causing  necrosis  or  destruction.  The  constitutional  symptoms  produced 
in  such  a  case  may  be  as  serious  as,  or  more  serious  than,  those  of  a 
general  infection.     A  few  examples  will  illustrate  these  points. 

In  diphtheria  and  tetanus  we  have  examples  of  local  infections  by 
pathogenetic  organisms,  accompanied  by  severe  general  disturbances. 
The  bacilli  of  diphtheria  generally,  and  those  of  tetanus  always,  remain 
at  the  seat  of  infection,  multiplying  quickly  in  the  case  of  diphtheria, 
and  slowly  and  to  a  limited  extent  in  the  case  of  tetanus.  Both  manu- 
facture deadly  toxins,  which,  as  they  are  absorbed  or  enter  the  circula- 
tion, produce  the  serious  symptoms  of  the  respective  diseases.  In  an 
ordinary  suppuration  we  have,  again,  an  instance  of  a  local  lesion  pro- 
duced by  pyogenetic  organisms.  Here,  however,  the  general  intoxica- 
tion is  usually  less  severe;  but  the  local  changes  may  be  extremely 
severe,  and  end  in  ulceration  or  necrosis. 

If  the  bacterial  lesion  be  a  general  one,  the  organisms  will  be  found 
everywhere  in  the  blood,  tissues,  and  lymph  channels  ;  that  is,  a  ''  septi- 
caemia "  occurs,  using  that  word  in  its  stricter  pathological  sense,  and 
not  giving  it  a  clinical  meaning.  In  these  cases  the  poisons  and  toxins 
are  manufactured  in  the  blood  itself,  and  the  intoxication  may  there- 
fore be  very  serious.  At  the  same  time  the  mechanical  presence  of 
bacteria  in  the  vessels,  leading  to  vascular  obstruction  or  embolism, 
may  act  deleteriously.  A  lesion  ^vhich  is  usually  a  local  process,  for 
some  reason  or  another  may  become  general.  Thus  suppuration  may  at 
any  time  be  followed  by  a  general  septicaemia,  the  pyogenetic  cocci  cir- 
culating in  the  vessels ;  similarly,  a  pneumonia  may  be  followed  by 
infective  endocarditis,  and  this  again  by  a  general  septicaemia.  Tuber- 
culosis also  may  suddenly  become  general,  often  after  operative  interfer- 
ence.    We  find  that  the  less  susceptible  an  individual  to  any  particular 


THE    GENERAL  PATHOLOGY   OF  INFECTION  533 

microbic  lesion,  or  the  greater  the  toxic  power  of  an  organism,  the  less 
are  the  chances  of  a  general  diffusion.  Man,  for  instance,  being  com- 
paratively resistant  to  anthrax,  when  infected  with  this  bacillus  will 
suffer,  as  a  rule,  from  malignant  pustule  only.  These  matters  are  also  of 
some  importance  inasmuch  as  they  concern  both  prognosis  and  diagnosis. 
If,  for  instance,  in  the  case  of  pneumonia,  diplococci  are  found  in  the 
blood,  the  prognosis  is  very  grave  ;  similarly  if,  in  the  course  of  tubercular 
disease,  tubercle  bacilli  appear  in  the  circulation,  or  if,  after  a  wound 
infection,  pyogenetic  cocci  appear  in  the  blood,  death  almost  always  fol- 
lows. So  far  as  diagnosis  is  concerned,  the  presence  of  microbes  in  the 
blood  in  diphtheria,  endocarditis,  typhoid  fever,  or  other  diseases,  always 
implies  general  septic  complications. 

A  far  more  difficult  question  is  that  of  specificity  of  disease. 
There  are  certain  pathological  lesions,  characteristic  in  their  appear- 
ance and  nature,  the  symptoms  of  which  stand  out  so  distinctly,  that 
they  may  be  recognised  at  once.  If  these  depend  on  the  presence  and 
action  of  a  particular  organism,  an  organism  invariably  associated  with 
them,  they  are  called  "  specific  "  ;  and  they  are  said  to  be  due  to  specific 
pathogenetic  organisms.  Thus  tetanus  is  a  specific  disease,  accompanied 
by  unmistakable  signs  and  symptoms,  and  it  is  invariably  caused  by  one 
and  the  same  organism,  the  bacillus  of  tetanus.  Without  this  bacillus 
there  can  be  no  tetanus  ;  and  it  is  only  the  ignorant  who,  using  a  loose 
terminology,  still  speak  of  "  idiopathic  "  tetanus.  Similarly  tuberculosis, 
actinomycosis,  leprosy,  glanders,  anthrax,  typhoid  fever,  gonorrhoea,  and 
diphtheria  are  specific  diseases.  These  lesions  are  severally  due  to  one 
particular  organism,  which  is  essential.  Although  many,  if  not  the  greater 
number,  of  bacterial  diseases  are  specific  in  this  sense,  it  is  erroneous  to 
assume,  on  the  other  hand,  that  all  of  them  are  specific.  Undoubtedly 
the  same  morbid  lesion  may  be  produced  by  several  different  micro-organ- 
isms. Thus,  ulcerative  or  infective  endocarditis  is  a  distinct  disease, 
characterised  by  certain  pathological  and  anatomical  changes,  and  often 
therefore  regarded  as  specific ;  yet  it  may  be  produced  by  a  number  of 
organisms,  among  which  we  may  mention  the  various  pyogenetic  staphy- 
lococci and  the  streptococci  of  suppuration,  erysipelas  and  pneumonia. 
\yide  art.  "Infective  Endocarditis."]  Strictly  speaking,  then,  there  is 
no  specific  organism  of  infective  endocarditis  ;  any  one  of  a  number  of 
cocci  may  produce  a  disease,  bacteriologically  different  from,  but  anatomi- 
cally, pathologically  and  clinically  identical  with  that  produced  by  another 
member  of  the  same  group  of  organisms.  Similarly  suppuration  may  be 
produced  by  any  one  of  a  large  number  of  bacteria ;  and  in  the  malady 
clinically  recognised  as  erysipelas,  instead  of  the  streptococcus  of  erysipe- 
las, other  organisms  may  often  be  found.  Septicaemia  and  pyaemia,  again, 
may  be  produced  by  more  than  one  kind  of  bacterium,  and  the  same 
applies  to  pneumonia.  We  see  then  that  the  saine  pathological  process 
may  lie  brought  about  by  various  organisms ;  in  other  words,  we  may  have 
clinical  or  pathological  identity  without  bacteriological  identity.  This  ob- 
servation applies  especially  to  those  more  general  pathological  conditions. 


534 


SYSTEM  OF  MEDICINE 


such  as  simple  inflammation,  cellulitis,  suppuration,  septicaemia ;  the  more 
specialised  the  process  the  more  likely  are  we  to  find  a  specific  organism. 
These  are  matters  of  the  utmost  importance,  because  they  explain  the  oppo- 
sition, frequently  rather  imaginary  than  actual,  which  often  exists  between 
the  physician  and  the  pathologist.  A  particular  name  is  associated  with  a 
set  of  phenomena  which  constitute  a  certain  disease,  and  this  name  has 
been  applied  to  the  disease  before  anything  was  known  of  its  pathol- 
ogy, or  anything  suspected  of  its  bacteriology.  Subsequently  it  is 
found  impossible  to  adapt  the  pathological  and  bacteriological  facts  to 
the  narrower  or  wider  signification  of  the  clinical  name.  The  bacteri- 
ologist finds  that  a  clinical  process  or  set  of  phenomena  may  be  produced 
by  more  than  one  kind  of  micro-organism ;  clinically  the  results  may 
be  indistinguishable,  though  bacteriologically  diverse. 

Again  a  specific  organism,  when  it  finds  access  into  the  animal  body, 
will  always  produce  the  same  lesion;  for  example,  the  tetanus  bacillus  will 
invariably  produce  tetanus.  But  we  find  that  the  bacteria  which  are  said 
to  cause  some  of  the  so-called  specific  diseases  are  by  no  means  specific 
in  their  action.  Thus  the  pneumococcus  is  said  to  be  the  specific  organism 
of  pneumonia,  yet  we  find  that  in  some  cases  it  will  produce  a  fibrinous 
inflammation,  in  others  oedema,  in  yet  others  suppuration,  ulcerative 
endocarditis,  cellulitis,  or  septicaemia.  Similarly  the  pyogenetic  organ- 
isms vary  considerably  in  their  action.  We  must,  therefore,  be  ex- 
tremely cautious  in  the  employment  of  the  term  "  specific,"  and  must 
adhere  to  strict  definitions.  Eecent  experiences  of  cholera  have  taught 
us  that  the  specificity  of  Koch's  comma  bacillus  was  a  dream,  and  that 
a  large  number  of  different  vibrios  are  found  in  this  disease. 

The  interaction  of  various  organisms  is  another  matter  of  serious 
importance  which  has  attracted  attention  during  recent  years.  In 
many  infective  processes  we  always  find  two  or  more  organisms  in 
symbiosis ;  that  is,  we  have  concurrent  infections  by  several  organisms. 
Thus  in  pneumonia  we  invariably  find  pyococci  and  the  bacillus  coli  com- 
munis in  the  company  of  the  pneumococcus.  And  it  has  frequently  been 
shown  experimentally  that  a  non-pathogenetic  organism  (that  is,  an  organ- 
ism which  does  not  possess  the  power  of  producing  specific  or  non-specific 
morbid  changes  when  placed  in  the  tissues)  is  of  ten  rendered  deadly  when 
another,  perhaps  equally  non-pathogenetic  organism  is  introduced  at  the 
same  time  :  we  also  know  that  the  virulence  of  many  pathogenetic  or- 
ganisms is  often  increased  or  decreased  by  the  concurrent  inoculation  of 
another  organism,  which  again  may  be  non-pathogenetic.  This  shows 
how  erroneous  a  popular  impression  may  be,  and  how  relative  a  term 
"  specificity  "  really  is.  This  interaction  of  micro-organisms  has  not  as 
yet  been  sufficiently  studied,  and  here  this  brief  allusion  must  sufiice ;  I 
shall  revert  to  this  matter  presently.  It  is  certain  that  if  in  certain 
lesions  the  same  collection  of  organisms  is  constantly  found,  we  may  be 
led  astray  if  we  fix  on  one  of  them  as  specific,  and  neglect  the  others  as 
contaminations.  A  study  of  the  correlation  and  interaction  between 
the  various  organisms  frequently  or  almost  invariably  found  together,  may 


THE    GENERAL   PATHOLOGY   OF  INFECTION  535 

in  future  explain  many  clinical  facts  and  observations  which  as  yet  bac- 
teriology has  not  explained. 

A  pathogenetic  specific  germ  must  fulfil  the  following  conditions : 
(a)  it  must  be  a  parasite  or  a  facultative  parasite ;  (6)  it  must  be  found 
invariably  in  the  tissues  of  an  animal  dead  from  or  affected  with  the 
disease  in  question ;  (c)  it  must  never  under  any  circumstances  occur  in 
other  diseases,  nor  within  the  normal  tissues ;  (d)  the  organism  trans- 
mitted from  the  diseased  or  dead  animal  to  an  unaffected  susceptible 
animal  must  reproduce  the  lesion,  and  in  this  second  diseased  animal 
the  original  organism  must  be  found ;  (e)  if  the  organism  can  be  culti- 
vated outside  the  animal  body,  then  an  artificial  cultivation  inoculated 
experimentally  into  a  susceptible  animal  must  again  produce  the  disease, 
and  this  animal  must  again  contain  the  organism  in  its  tissues  or  blood ; 
(/)  these  processes  must  occur  in  invariable  succession  under  identical 
conditions ;  {(j)  the  toxins  and  poisonous  substances  obtained  from  the 
artificial  cultivations  must  agree  chemically  and  physiologically  with 
those  obtained  from  the  diseased  animal. 

Unless  all  these  conditions  are  fulfilled  the  evidence  of  the  speci- 
ficity of  a  given  organism  is  incomplete.  In  laboratory  experiments 
considerable  research  is  often  required  to  establish  all  these  points,  be- 
cause even  the  mode  of  inoculation  frequently  alters  results ;  moreover 
it  is  not  always  easy  to  find  a  suitable  susceptible  animal,  or  to  find  the 
method  of  artificial  cultivation  most  adapted  for  poison  formation ;  the 
need  of  some  concurrent  inoculation  may  also  have  to  be  considered. 
Another  difficulty  arises  when,  in  the  absence  of  experiments  on  man, 
it  is  impossible  identically  to  reproduce  the  disease  in  another  species. 
This,  however,  cannot  always  be  regarded  as  an  insuperable  objection, 
if  it  be  remembered  that  the  same  organism  or  the  same  toxin  may, 
under  various  circumstances,  produce  different  naked  eye  lesions,  that 
is  to  say,  different  phenomena  of  a  like  morbid  process. 

It  will  be  well  here  to  give  a  list  of  the  various  infective  diseases  in 
man,  at  the  same  time  stating  how  far  their  bacterial  pathogenesis  has 
been  proven :  — 

1.  All  the  conditions  just  enumerated  have  been  fulfilled  for  anthrax, 
diphtheria,  and  tetanus,  chiefly  through  the  brilliant  work  of  Dr.  Sidney 
Martin,  who  was  the  first  of  pathologists  to  establish  the  toxic  specificity 
in  addition  to  the  bacterial  specificity  previously  demonstrated. 

2.  The  bacterial  specificity  has  been  satisfactorily  settled  for  the 
following  diseases :  glanders,  tuberculosis,  actinomycosis,  gonorrhoe,a,  and 
malignant  ORdema.  Specific  organisms  have  been  separated  and  the 
disease  has  been  artificially  reproduced  in  animals.  All  the  conditions 
excepting  the  chemical  agreement  of  the  disease  and  the  organism,  have 
been  fulfilled. 

V>.  The  next  group  includes  those  diseases  with  each  one  of  which  a 
certain  organism  is  always  associated,  an  organism  which  can  be  culti- 
vated, and  which  is  restricted  to  its  own  disease ;  the  successful  animal 


536  SYSTEM    OF  MEDICINE 

experiment,  however,  is  wanting.     In  this  group  we  have  typlioid  fever, 
influenza,  mycetoma  or  Madura  disease. 

4.  The  proof  is  still  incomplete  in  the  case  of  leprosy  and  relapsing 
fever,  —  diseases  which  are  characterised  by  the  invariable  presence  of 
easily  recognisable  organisms,  which  are  not  associated  with  any  other 
normal  or  morbid  processes.  These  organisms,  however,  have  not  yet 
been  grown  outside  the  human  body ;  but  so  far  as  relapsing  fever  is 
concerned,  artiiicial  inoculation  of  human  blood  into  monkeys  has  been 
successful :  in  leprosy,  on  the  other  hand,  experimental  infection  from 
man  to  animal,  or  from  man  to  man,  has  not  been  achieved.  Arning's 
well-known  experiment  brought,  apparently,  the  desired  proof  that  lep- 
rosy may  be  successfully  inoculated  from  the  diseased  to  the  healthy 
individual ;  it  has,  however,  no  scientific  value,  since  it  was  performed 
on  a  native  of  an  area  where  leprosy  is  endemic,  and  whose  relations 
had  leprosy ;  so  that  before  the  experimental  inoculation  was  performed 
he  must  have  been  freely  exposed  to  the  risks  of  infection.  For  such  an 
experiment  to  have  any  value  whatever  it  must  be  performed  on  an  in- 
dividual clear  of  taint,  living  in  a  country  where  leprosy  does  not  occur. 
On  the  other  hand,  a  large  number  of  inoculations  with  leprous  material 
have  been  practised  on  man  in  Europe  without  a  single  success. 

Although  in  the  last  three  groups  of  bacterial  diseases  the  chain  of 
evidence  is  not  quite  complete,  yet  the  constant  and  exclusive  associa- 
tion of  characteristic  organisms  with  morbid  processes  equally  charac- 
teristic, compels  us  to  believe  in  their  specifically  infective  nature. 

5.  There  are  a  larger  number  of  infective  lesions  which  are  not  specific 
in  the  seiise  defined  above,  — lesions,  that  is,  which  may  be  produced  by 
more  than  one  species  of  micro-organism,  or  by  several  members  (varieties) 
of  a  definite  group  of  organisms.  The  various  organisms  in  each  of  these 
cases  are  pathogenetic  and  do  produce,  but  do  not  always  reproduce, 
disease  in  the  animal  on  inoculation.  Clinically  there  is  often  no  differ- 
ence between  the  disease  caused  by  one  organism  and  that  caused  by 
another.  In  this  group  are  the  various  forms  of  inflammatory  and  suppu- 
rative lesions  :  pneumonia,  osteomyelitis;  septicmmia,  injcamia,  endocarditis, 
meningitis,  erysipelas,  angina  Ludovici,  bronchopnenmonia,  indeed,  the  vari- 
ous forms  of  infective  inflammatory,  suppurative,  or  septic  lesions  which 
at  present  we  are  unable  clinically  to  distinguish  by  their  bacterial  flora. 

6.  Cholera  is  an  infective  lesion,  produced  by  a  number  of  vibrios 
which  differ  widely  from  one  another;  sometimes  several  kinds  are 
found  in  the  same  individual ;  at  other  times  only  one  kind,  in  rare 
cases  none  at  all.  The  animal  experiment,  so  far  as  the  reproduction 
of  a  true  choleric  lesion  is  concerned,  has  hitherto  failed.  In  this  group 
we  may  include  also  various  other  clinical  forms  of  diarrhoea,  which  are 
imdoubtedly  due  to  infection,  but  the  bacterial  aetiology  of  which  is  as 
uncertain  as  that  of  cholera. 

7.  Lastly,  there  are  a  number  of  infective  diseases,  contagious  it 
may  be  in  the  highest  degree,  in  which  no  organisms  have  been  separated, 
but  which  we  presume  to  be  due  to  bacteria.     These  are  syphilis,  rabies, 


THE    GENERAL  PATHOLOGY  OF  INFECTION  537 

yellow  fever,  dengue,  typhus  fever,  mumps,  wlioopiTig-cough,  small-pox, 
measles,  scarlet  fever,  and  other  so-called  exanthemata.  Whether  future 
research  will  prove  them  to  be  bacterial  lesions  it  is  hazardous  to  say  ; 
for  the  present  they  will  be  inchided  under  that  heading,  since  the 
assumption  of  their  bacterial  origin  constitutes  a  good  enough  working 
hypothesis,  and  one  which  at  the  same  time  can  do  no  possible  harm. 

As  there  is  variation  in  the  morphology  and  chemical  activity  of 
bacteria,  so  there  is  also  considerable  inconstancy  in  their  activity  in  bac- 
terial disease.  This  hardly  requires  any  further  elucidation  if  we  admit 
that  the  same  micro-organism  may  vary  in  virulence,  that  it  may  produce 
highly  toxic  substances  under  certain  conditions  and  bodies  practically 
atoxic  under  others,  that  it  may  be  readily  attenuated,  and  conversely 
that  its  virulence  and  infective  powers  may  be  greatly  increased.  Change 
of  chemical  activity  naturally  implies  change  of  activity  in  disease. 
Moreover,  I  have  already  pointed  out  that  the  same  micro-organisms 
may  be  the  cause  of  various  morbid  and  pathological  lesions.  What 
this  pathogenetic  variability  depends  upon  in  all  cases  it  is  impossible 
to  assert ;  sometimes,  no  doubt,  on  the  resistance  and  insusceptibility 
of  the  individual,  often  on  changes  in  the  micro-organisms  themselves, 
which  we  may  guess  at,  but  cannot  define.  Tuberculosis  may  appear 
in  many  forms,  which  clinically  and  pathologically  are  quite  distinct ; 
again  the  pyogenetic  streptococcus  may  produce  the  most  dissimilar 
lesions,  and  no  less  perplexing  are  the  multiform  activities  of  the 
pneumococcus.  We  shall  deal  later  with  personal  insusceptibility.  It 
is  generally  true  that  the  better  protected  the  individual  the  more  likely 
is  a  bacterial  infection  in  him  to  be  followed  by  local  reactive  changes ; 
and  with  regard  to  changes  in  the  virulence  of  pathogenetic  organisms, 
we  find  similarly  that  attenuated  bacteria  are  capable  of  producing  local 
changes  only,  while  virulent  ones  are  apt  to  be  followed  by  severe  general 
infection  and  disturbance.  Enough  has  already  been  incidentally  said 
on  these  matters  in  the  previous  pages,  so  that  this  short  recapitulation 
must  be  considered  sufhcient.  It  is  important  to  remember  that  amongst 
pathogenetic  organisms  in  general,  there  is  as  little  constancj^  of  patho- 
logical potency  as  of  morphological  characters  or  chemical  activity. 

V.  Infection  and  Contagion 

A.  Infection.  —  The  term  infection  has  frequently  been  used  in  the 
previous  pages ;  now  we  shall  fully  consider  its  meaning.  The  use  of 
the  word  is  gradually  becoming  narrowed  down  to  the  signification 
which  modern  pathology  and  bacteriology  have  attached  to  it.  A  full 
discussion  of  older  definitions  is  unnecessary ;  the  time  has  come  for 
uniformity  of  terminology.  The  connotation  of  a  scientific  term  is 
liaV^le  to  alteration,  and  it  should  be  sufficiently  plastic  to  adapt  itself  to 
new  requirements.  Ii)fection  as  a  clinical  or  pathological  term  dates 
from  the  days  before  the  microbe  was  dreamt  of  as  an  important  setio- 


538  SYSTEM   OF  MEDICINE 

logical  factor  of  disease.  Now  tliat  tlie  veil  lias  been  lifted  from  the 
mysteries  of  bacterial  disease,  if  we  Avish  to  keep  the  term,  we  must  adapt 
it  to  modern  ideas.  Our  ideas  of  infection  and  of  intoxication  are  be- 
coming more  definite  as  bacteriological  research  advances.  Formerly 
pathologists  understood  by  infective  diseases  those  which  are  set  up  by 
certain  poisons,  or  poisonous  substances  (whether  organised  —  that  is 
living  —  or  non-organised)  either  entering  the  body  from  without,  or 
manufactured  in  and  by  the  tissues  of  diseased  individuals.  They  dis- 
tinguished between  a  contagium  and  a  miasma,  the  former  being  an 
endogenous  virus  developed  in  the  diseased  individual,  while  the  latter 
was  assumed  to  arise  exogenously,  that  is,  outside  the  diseased  organism. 
According  to  this  view  contagious  diseases  can  be  transmitted  only  from 
man  to  man,  or  from  animal  to  man,  or  conversely ;  while  miasmatic 
diseases  may  be  acquired  by  persons  without  coming  into  contact  with 
individuals  similarly  affected.  This  distinction  led  to  many  difficulties. 
Anthrax,  for  instance,  is  always  transmitted  to  man  from  an  animal 
suffering  from  anthrax,  yet  it  appears  in  animals  without  previous  con- 
tact with  similarly  diseased  animals  ;  that  is,  the  disease  is  contagious, 
in  the  older  sense  of  the  term,  for  man  and  miasmatic  for  animals. 

With  the  advance  of  bacteriology  the  microbic  nature  of  almost  all 
infective  diseases  has  been  recognised,  and  we  have  gradually  been  com- 
pelled to  modify  our  definitions.  At  the  present  time  we  include  under  in- 
fective diseases  only  those  icJiich  are  caused  bj/  living  pathogenetic  germs  which 
enter  the  tissues  from  without,  and  are  capable  of  multiplying  in  the  same.  A 
disease  caused  by  substances  not  capable  of  reproduction,  as,  for  example, 
gaseous  or  other  chemical  non-organised  bodies,  is  an  intoxicative  process. 

Though  for  practical  as  well  as  theoretical  reasons  we  must  distinguish 
between  infective  and  intoxicative  processes,  we  must  remember  that  the 
chief  lesions  and  symptoms  following  an  infection  are  caused  by  the  toxic 
products  of  the  infection-carriers.  This  statement  is  true  for  almost  all, 
if  not  for  all  infective  diseases.  In  several  infections  we  already  have 
experimental  proof  of  its  truth  (for  example,  in  anthrax,  diphtheria, 
tetanus,  and  suppurative  infections).  We  may,  then,  pronounce  the  gen- 
eral law  that  in  any  infective  process  due  to  a  vegetable  organism  the  chief  le- 
sions are  clue,  not  to  the  mechanical  presence  of  the  micro-organisms,  but  to  the 
action  of  the  metabolic  products  of  these  organisms.  Broadly  speaking,  we 
have  an  infection  first  and  an  intoxication  afterwards  ;  the  latter,  indeed, 
it  is  which  gives  the  disease  its  specific  and  characteristic  signs.  The 
poison  is  manufactured  within  the  body,  and  has  not  been  introduced 
as  such  from  without.  The  real  difference  then  between  infection  and 
intoxication  proper  is  that  in  the  latter  a  poison  is  taken  in  as  such, 
while  in  the  former  bacteria,  introduced  from  without,  prepare  the  poison 
or  toxin  in  the  tissues.  In  intoxication  proper  the  effects  are  generally 
immediate  ;  in  an  infective  process  an  interval  must  elapse  before  a 
sufficient  dose  of  poison  has  been  producbd.  In  the  one  case  we  have 
no  inciibation  period,  in  the  other  we  must  have  an  incubation  period 
of  varying  length. 


THE    GENERAL  PATHOLOGY  OF  INFECTION  539 

Incubation.  — The  shorter  this  period  the  more  the  infective  process 

resembles  an  intoxication.  Some  poisons  produced  by  micro-organisms 
are  harmful  in  comparatively  large  doses  only,  others  will  destroy  life 
or  give  rise  to  symptoms  in  extremely  small  doses.  Anthrax  is  a  good 
instance  of  the  more  slowly  acting  poison ;  tetanus  and  diphtheria  well 
illustrate  the  class  of  more  active  toxins.  In  tetanus  we  find  that  the 
bacilli  multiply  but  slightly  at  the  seat  of  inoculation;  here,  therefore, 
the  mechanical  effect  produced  by  the  presence  of  the  bacilli  may  be 
entirely  neglected.  In  infections  such  as  anthrax,  on  the  other  hand, 
the  bacilli  multiply  rapidly  in  the  vessels  ;  so  that  in  mice,  for  instance, 
all  the  vessels  of  the  body  are,  as  it  were,  injected  with  pure  cultures  of 
anthrax  bacilli,  and  the  mechanical  effect  alone  of  the  bacilli  must  be 
of  some,  if  not  of  great  importance.  In  diphtheria,  also,  and  in  septic 
embolisms  the  organisms  may  produce  mechanical  disturbances,  directly 
or  indirectly,  which  materially  modify  the  symptoms  caused  by  the 
toxins  absorbed  by  the  blood,  lymph  and  tissues. 

To  sum  up,  then,  an  infection  leads  to  disease  or  death,  either  by  intoxi- 
cation alone,  or  by  intoxication  aided  by  mechanical  interference  caused  by 
the  presence  of  the  bacilli  themselves. 

The  effect  of  such  intoxication  may  be  general  or  local.  Examples 
of  this  we  find  in  tetanus  and  diphtheria,  or  in  rabies,  where  the  poison 
causes  general  symptoms ;  while  in  other  cases,  as  in  certain  forms  of 
suppuration,  the  process  remains  localised.  It  is,  however,  extremely 
difficult  to  draw  a  hard  and  fast  line  between  the  two,  as  a  local  process 
may  suddenly  become  general.  I  cannot  dwell  further  on  these  points  ; 
the  whole  matter  is  extremely  intricate,  and  premature  generalisation 
must  be  carefully  avoided. 

The  difference  between  infection  and  intoxication  is  well  illustrated 
by  certain  kinds  of  food-poisoning.  Firstly,  there  are  cases  where  an 
individual,  in  perfect  health,  partakes  of  some  article  of  food  and  dies  a 
few  hours  later.  The  chemist  succeeds  in  separating  an  alkaloidal  poi- 
son, and  animals  fed  with  the  tainted  food  die  rapidly.  Here  we  have 
a  true  intoxication.  In  other  instances  the  bacteriologist  separates  a 
specific  bacillus  which,  introduced  by  feeding  into  mice,  produces  in 
them  illness  and  death  after  a  definite  incubation  period,  varying  from 
twelve  to  twenty-four  hours.  At  first  sight  both  cases  seem  to  be 
examples  of  food  intoxication,  for  in  each  instance  animals  fed  on  the 
suspected  food  die.  In  the  first  case,  however,  death  was  directly  due 
to  a  chemical  poison  introduced  into  the  animal  body  as  such ;  while  in 
the  other  the  disease  did  not  set  in  until  the  second  day  after  feeding, 
that  is,  not  until  the  bacilli  introduced  had  manufactured  sufficient 
poison  to  bring  about  illness  and  death. 

Infective  diseases,  then,  are  caiised  by  organised  beings,  and  an 
incubation  period  is  characteristic  of  them. 

B.  Contagion  and  Contagiousness. — There  is  much  confusion  in 
the  use  of  the  terms  contagion,  contagium,  contact,  and  contagiousness. 


540  SySTEM  OF  MEDICINE 


By  contagion  we  understand  what  the  German  expresses  by  the  woru 
Ansteckung ;  contagium  being  the  Ansteckungsstoff ;  while  contact  is 
equivalent  to  Beriihrung,  and  contagiousness  to  Ansteckimgskraft.  "In- 
fective" and  "contagious  "  are  attributes  which,  partly  through  inaccu- 
racy of  expression,  have  been  frequently  confused,  not  only  by  laymen, 
but  unfortunately  also  by  serious  writers  who  are  not  sufficiently  care- 
ful about  their  terminology.  Infection  is  the  general  term,  and  includes 
contagion.  It  stands  to  reason  that  a  disease  or  lesion  which  is  infec- 
tive, as  above  defined,  may  be  transmitted  from  the  diseased  to  the 
healthy,  since  the  germs  which  are  responsible  for  the  mischief  are 
capable,  it  may  be,  of  unlimited  reproduction  within  the  diseased  body  ; 
but  it  does  not  necessarily  follow  that  it  is  always,  or  even  usually,  thus 
transmitted.  As  instances,  pneumonia,  typhoid  fever,  and  cholera  may 
be  mentioned ;  these  are  all  infective  diseases,  but  are  they  ordinarily 
contagious  ?  Relapsing  fever,  again,  is  never  transmitted  from  man  to 
man ;  yet  modern  research  has  shown  that  when  we  transfuse  the  blood 
of  a  person  suffering  from  it  into  the  circulation  of  a  healthy  man  or 
monkey,  we  may  reproduce  an  attack  in  the  new  host.  Under  extraor- 
dinary, and  generally  artificial,  conditions,  therefore,  even  this  disease 
may  lie  contagious.     \_Vide  art.  on  "Eelapsing  Fever.''] 

Contagion  evidentbj  may  be  either  direct  or  indirect :  that  is,  infection 
may  be  brought  about  either  by  contact  directly  from  A  to  B,  or  indi- 
rectly from  A  to  B  through  a  third  body  C.  For  want  of  a  better  term, 
"  contact  "  is  here  used  in  its  widest,  or  at  any  rate  in  an  extended 
sense,  denoting  not  mere  touch  only,  but  also  any  form  of  infection  or 
inoculation,  whether  through  the  broken  or  unbroken  cuticle,  the  res- 
piratory or  alimentary  tracts,  or  in  any  other  possible  way.  We  may 
distinguish  therefore  direct  and  indirect  contact  —  diseases  directly  and 
indirectly  contagious. 

Whether  a  disease  be  directly  or  indirectly  contagious,  or  both,  will 
depend  primarily  on  the  nature  of  the  organism  which  causes  this  disease. 
If  an  infective  lesion  be  due  to  a  strictly  obligatory  parasite,  then  it  can 
be  transmitted  only  by  direct  contact,  that  is,  by  immediate  transference 
from  living  tissue  to  living  tissue.  The  less  parasitic,  and  therefore  the 
more  saprophytic  the  infective  organisms,  the  greater  will  be  the  chances 
of  transmitting  the  lesion  by  indirect  contact;  for  in  this  case  the  organ- 
isms can  thrive  more  or  less  well  for  a  considerable  time  outside  the  ani- 
mal body.  This  is  a  matter  of  some  practical  impoi'tance,  because  a  disease 
which  is  exclusively  directly  contagious  can  be  stamped  out  by  isolation 
alone  ;  while  in  a  disease  both  directly  and  indirectly  contagious  isolation 
alone  is  of  no  avail ;  or,  to  express  the  matter  in  bacteriological  terms, 
isolation  can  only  prevent  infective  lesions  due  to  obligatory  parasites, 
and  not  lesions  due  to  facultative  saprophytes,  or  facultative  parasites. 

Arranging  the  more  important  infective  diseases  on  this  principle  we 
find  that  there  are  — 

i.  Diseases  caused  by  strictly  obligatory  parasites  which  readily  perish 
outside  the  living  animal  body ;  these  must  be  directly  contagious,  and 


THE    GENERAL  PATHOLOGY  OF  INFECTLON  541 

are  best  prevented  by  isolation,  segregation,  or  destruction  of  the  individ- 
ual ;  assisted,  of  course,  by  disiuf  ective  measures.  Examples  are  syphilis, 
rabies,  gonorrhoea.  The  organisms,  real  or  imaginary,  which  cause  these 
diseases  are  of  slight  resistance,  and  soon  die  outside  the  animal  body. 

ii.  Diseases  caused  by  obligatory  parasites  of  greater  resistance,  capable 
of  surviving,  for  a  little  time  at  least,  outside  the  animal  body,  although 
incapable  of  multiplying  under  such  conditions  ;  these,  though  generally 
or  almost  always  directly  contagious,  may  occasionally  also  be  indirectly 
contagious.  Examples  are  variola,  scarlatina,  measles,  glanders,  diph- 
theria. Isolation  and  segregation  with  disinfection  are  still  the  best 
means  of  preventing  infection. 

iii.  Diseases  caused  by  facultative  saprophytes,  or  parasitic  organisms 
capable  of  thriving  outside  the  animal  body ;  these  are  obviously  either 
directly  or  indirectly  contagious  ;  and  the  greater  the  saprophytic  faculty 
of  the  organisms,  the  greater  the  chances  of  indirect  contagion.  Segre- 
gation and  isolation  are  utterly  ineffectual  as  preventive  measures  ;  and 
absolute  disinfection  is  theoretically  the  only  means  of  prevention :  in 
practice,  however,  this  is  almost  always  impossible.  Examples  are  tuber- 
culosis, actinomycosis,  pyogenetic  infections.  It  is  quite  possible  that 
with  increased  knowledge  of  the  biological  conditions  of  jjathogenetic 
organisms  more  than  one  disease  at  present  included  in  the  previous 
groups  will  eventually  have  to  be  placed  in  this  one.  Thus,  as  evidence 
accumulates,  it  seems  more  and  more  probable  that  the  bacillus  of 
diphtheria  is  a  vigorous  facultative  saprophyte ;  and  the  same  perhaps 
may  in  future  be  said  of  the  pyogenetic  streptococci. 

iv.  Disectses  caused  by  facultative  ptarasites,  or  saprophytic  organisms 
capable  of  acting  as  parasites  ;  these  are  hardly  ever  directly  contagious, 
and  occasionally  not  even  indirectly  contagious.  Examples  are  anthrax, 
typhoid  fever,  cholera,  tetanus.  Anthrax  is  as  a  rule  directly  communi- 
cated from  the  diseased  or  dead  animal  to  man  (that  is,  directly  contagious 
to  man)  ;  the  animal,  on  the  other  hand,  generally  acquires  it,  with  its 
food,  from  fields  or  meadows  where  anthrax  spores  have  been  deposited 
from  diseased  animals  (that  is,  indirectly  contagious  to  animals)  :  certain 
localities  are  breeding-places  for  the  anthrax  bacillus,  and  here  an  animal 
must  acquire  the  disease  independently  of  direct  or  indirect  contagion. 

The  more  widely  these  organisms  are  distributed  the  less  contagious 
will  be  the  diseases  caused  by  them.  Tetanus,  for  instance,  is  hardly  ever 
directly  or  indirectly  contagious  ;  it  is  generally  acquired  independently 
of  any  previous  case.  During  an  epidemic  of  typhoid  fever  or  cholera 
the  respective  organisms  are  generally  so  extensively  diffused  through 
water  that  contagion  may  practically  be  neglected. 

Diseases  caused  by  facultative  parasites  are  frequently  endemic  in 
certain  areas ;  thus  cholera  is  constant  in  certain  districts  of  India,  in 
others  it  appears  in  epidemics.  In  the  former  case  the  organism  must 
be  pre-eminently  saprophytic,  and  find  the  suitable  conditions  for  growth 
in  the  soil  or  water.  It  stands  to  reason  that  isolation  in  such  cases 
must  be  quite  ineffectual,  and  that  preventive  measures  must  be  directed 


542  SYSTEM  OF  MEDICINE 

to  the  habitat  of  the  organisms  and  against  their  further  diffusion,  whether 
by  means  of  water-filtration,  drainage,  cultivation  of  the  soil,  or  otherwise. 

V.  Diseases  ivhich  are  infective  bat  not  contagious. — Excluding  malaria 
(which  is  due  to  plasmodial  infection,  and  is  not  a  bacterial  disease),  it 
seems  that  relapsing  fever,  due  to  a  specific  spirillum,  is  never  transmitted 
by  direct  or  indirect  contact  from  one  individual  to  another.  It  must  be 
remarked,  however,  that  our  present  knowledge  of  the  bacterial  pathology 
of  this  disease  is  very  imperfect.  These  non-contagious  blood  diseases 
(relapsing  fever  and  malaria)  are  always  endemic,  and  can  be  avoided 
only  by  change  of  abode. 

The  Natural  Mode  of  Propagation.  —  The  public  are  always  ready 
to  assume,  because  a  disease  is  due  to  organisms  capable  perhaps  of 
unlimited  growth  in  the  body,  and  can  be  transmitted  by  inoculation 
from  one  guinea-pig  or  white  mouse  to  another,  that  it  is  therefore 
always  and  under  all  conditions  propagated  directly  from  the  affected 
individual  to  the  healthy ;  which  means  that  its  diffusion  depends  exclu- 
sively on  contagion.  At  once  the  cry  is  raised  for  segregation,  separation 
and  so  forth,  instead  of  pausing  to  study  the  natural  mode  of  propa- 
gation of  an  infective  disease.  This  evidently  depends  on  many  factors 
which  may  in  part  be  deduced  from  the  above  statements :  — 

A.  The  germs  never  leave  the  animal  body,  or  they  do  so  in  a  state 
in  which  they  are  incapable  of  setting  up  a  fresh  infection.  In  this  case 
there  can  be  no  contagion ;  the  germs  must  have  an  abode  somewhere 
outside  the  human  body  (relapsing  fever  is  an  example). 

B.  The  germs  as  they  leave  the  body  retain  full  possession  of  their 
infective  powers.  If  they  retain  both  their  vitality  and  virulence,  then, 
and  then  oidy,  can  the  disease  be  transmitted  from  the  affected  to  the 
healthy ;  that  is,  it  may  be  spread  by  contact,  direct  or  indirect :  but 
whether  it  is  generally  spread  in  this  manner  depends  on  the  following 
points :  —  (a)  The  saprophytic  or  parasitic  nature  of  the  infective  organ- 
isms, which  has  been  sufficiently  discussed  above.  (fS)  Their  distribution 
and  diffusion  in  space,  or  the  readiness  with  which  they  either  multiply 
or  may  be  diffused  after  once  leaving  the  animal  body ;  if  a  germ  be  so 
widely  distributed  as  to  be  almost  ubiquitous,  then  we  may  practically 
neglect  contagion  as  a  means  of  spreading  the  disease  (v.  supra). 

It  is  well  to  state  here  that  aerial  infection  is  less  common  than  at 
one  time  it  was  supposed  to  be,  and  under  ordinary  conditions  this  mode 
of  infection  has  been  demonstrated  only  for  pyogenetic,  tubercular  and 
pneumonic  lesions;  though  it  must  be  assumed  to  exist  in  influenza, 
(malaria),  diphtheria,  and  some  of  the  exanthemata,  such  as  small-pox  and 
scarlatina.  For  the  organisms  of  typhoid  fever,  cholera,  dysentery,  and 
various  forms  of  diarrhoea  we  must  search  the  water ;  while  the  soil  is 
commonly  inhabited  by  the  bacilli  of  tetanus  and  malignant  oedema,  and 
also  of  anthrax :  pathogenetic  pyococci  are  found  likewise  in  the  soil, 
which  also  absorbs  the  infective  discharges  of  diseased  individuals,  dis- 
charges which  contain  organisms  that,  under  favourable  conditions,  may 
survive  for  months.     Dust  may  prove  a  fertile  source  of  infection  for 


THE    GENERAL  PATHOLOGY  OF  INFECTION  543 

tuberculosis,  wound  infections,  tetanus  and  pneumonia.  That  some  bac- 
terial diseases  find  their  ineans  of  diffusion  in  food  is  so  well  known  as 
to  require  no  further  comment.  I  may  mention  m,ore  especially  tuber- 
culosis, typhoid  fever,  cholera,  diphtheria  and  scarlet  fever.  For  the 
sake  of  brevity  we  must  pass  over  the  other  possible  sources  of  ectan- 
thropic  infections,  such  as  insects,  clothes,  furniture  and  the  like. 
Seeing,  then,  that  the  tubercle  bacillus  is  found  in  the  dust,  in  the  food 
(milk),  and  in  other  accessible  sources,  we  must  pause  before  putting 
every  fresh  case  of  infection  down  to  contagion,  and  before  we  recom- 
mend isolation  of  the  diseased  as  the  one  preventive  measure. 

(y)  The  power  of  the  organisms  to  form  spores  outside  the  diseased 
body  naturally  lessens  the  importance  of  direct  contagion  and  increases 
the  chances  of  indirect  contagion.  (8)  The  abundance  of  germs  leaving 
the  affected  individual  favours  indirect  contagion  by  causing  a  wider 
diffusion,  and  by  offering  more  chances  of  ectanthropic  infection.  In 
some  infective  diseases  the  organisms  are  never,  or  but  rarely,  discharged 
from  the  body,  as  for  instance  in  tetanus,  where  the  bacilli  are  found  in 
small  numbers  at  the  seat  of  inoculation ;  in  others  the  organisms  are 
discharged  in  large  numbers,  especially  in  the  diseases  which  affect  the 
excretory  passages,  or  organs  in  direct  or  easy  communication  with  such 
passages.  In  bacterial  intestinal  lesions,  —  for  example,  in  typhoid  fever 
and  cholera — thousands  of  bacilli  or  vibrios  must  pass  away  with  the 
dejecta :  similarly  in  pulmonary  infections  — for  example,  in  tuberculosis, 
pneumonia,  influenza  —  the  sputa  must  swarm  with  bacteria.  From  ex- 
tensive ulcerating  bacterial  skin  affections  —  as,  for  example,  in  nodular 
leprosy  —  myriads  of  bacilli  may  be  discharged.  (The  breath,  by  the 
way,  if  unmixed  with  saliva  or  mucus,  is  free  from  micro-organisms.) 
The  urine,  again,  may  contain  numerous  organisms  —  as  in  gonorrhoea, 
some  forms  of  puerperal  fever,  typhoid  fever  and  tuberculosis.  When 
the  bacteria  are  incapable  of  saprophytic  existence,  or  when  from  the 
nature  of  the  disease  the  discharges  can  be  more  closely  guarded,  the 
danger  of  increased  diffusion  is  so  far  limited.  Thus  the  urine  in  gon- 
orrhoea and  the  sputum  in  acute  pneumonia  are  not  dangerous  sources  of 
infection.  On  the  other  hand,  consumptives  by  their  expectorations  con- 
tribute largely  to  the  wide  diffusion  of  the  tubercle  bacillus ;  from  the 
chronic  nature  of  their  disease  they  are  less  easily  controlled,  and,  espe- 
cially in  the  poorer  classes,  they  are  reckless  with  their  expectoration. 

Tej  The  mode  and  readiness  of  infection  is  naturally  of  great  impor- 
tance, for  some  organisms  will  produce  disease  in  whatever  way,  and 
when  they  have  been  introduced  into  the  body  in  very  small  numbers. 
Others  are  virulent  when  received  in  large  numbers,  or  only  when 
taken  in  by  the  stomach,  and  harmless  when  injected  subcutaneously. 
Thus  guinea-pigs  succumb  to  the  smallest  injection  of  the  tetanus 
bacillus,  and  white  mice  are  so  susceptible  to  anthrax  that  almost  a 
single  virulent  spore  or  bacillus  is  sufficient  to  destroy  them.  Rabbits 
generally  acquire  a  fatal  septicaemia  when  injected  with  a  very  small 
number  of  virulent  pneumococci.     On  the  other  hand,  it  requires  a  large 


544  SYSTEM  OF  MEDICINE 


number  of  bacilli  pyocyanei  to  bring  about  a  fatal  septicaemia  in  rodents, 
or  a  large  number  of  pyogenetic  staphylococci  to  produce  suppuration. 
To  some  extent,  no  doubt,  these  laboratory  observations  apply  also  to 
natural  conditions,  especially  since  experiment  shows  that  the  result  pro- 
duced often  varies  as  the  quantity  of  germs  introduced.  Thus  a  small 
number  of  bacilli  pyocyanei  "will  lead  to  a  small  local  abscess  only, 
followed  probably  by  a  condition  of  acquired  immunity ;  a  larger  number 
will  lead  to  local  necrosis,  and  a  still  larger  number  to  septicaemia  and 
death.  The  same  direct  relation  between  quantity  and  effect  may  be 
observed  with  many  pathogenetic  organisms.  Koch  found  that  white 
mice  are  resistant  to  tubercle  bacilli  inoculated  subcutaneously,  but  suc- 
cumb to  subperitoneal  inoculations,  or  when  the  bacilli  are  introduced 
by  means  of  inhalation.  The  same  rule  applies  also  to  dogs  and  rats : 
when  large  quautities  of  bacilli  were  used  these  animals  failed  to  offer 
any  resistance,  whatever  the  mode  of  infection  employed.  Again, 
Blagovestchewski  has  demonstrated  that,  on  simultaneously  injecting 
the  anthrax  bacillus  and  the  bacillus  pyocyaneus  into  the  anterior 
chamber  or  subcutaneous  tissue  of  rabbits,  no  infection  but  on  the  con- 
trary inrmunity  against  anthrax  will  result ;  while  on  injecting  a  similar 
mixture  into  the  circulation  the  animal  will  die  of  a  double  infection. 
E-oger,  on  the  other  hand,  has  shown  that  rabbits,  which  are  naturally 
immune  from  quarter-evil,  will  succumb  to  this  disease,  if  the  bacilli  be 
injected  into  the  anterior  chamber.  It  is  evident,  then,  that  the  easier 
and  the  more  general  the  mode  of  the  infection,  both  as  regards  the  number 
of  germs  and  the  jyaths  of  infection,  the  greater  the  danger  of  spreading  a 
contagious  disease ;  and  before  we  estimate  the  true  risk  of  contagion, 
we  must  find  out  what  form  of  infection  is  necessary  to  produce  the 
disease,  what  quantity  of  bacteria,  and  how  readily  such  infection  can 
be  brought  about. 

(^)  The  natural  habitat  of  the  pathogenetic  organisms  greatly  affects 
the  ordinary  risk  of  contagion.  Thus  the  normal  body  on  its  cutaneous 
and  mucous  surfaces  often  contains  large  numbers  of  such  organisms 
which  may  suddenly  assume  infective  properties ;  that  is  to  say,  they 
may  produce  acute  infection.  In  such  cases  contagion  is  a  factor  which 
may  be  neglected :  a  good  example  is  pneumonia,  (rj)  The  contagious- 
ness of  an  infective  disease  further  depends  on  certain  social,  local, 
climatic  and  other  hygienic  conditions  which  cannot  be  discussed  here. 
(0)  The  susceptibility  or  predisposition  of  the  individuals  is  a  factor  of 
far-reaching  importance.  When  we  test  a  microbe  for  its  pathogenetic 
property,  we  always  choose  a  highly  susceptible  animal  —  an  animal, 
that  is,  which  will  acquire  the  disease  under  normal  physiological  con- 
ditions. When  studying  the  contagiousness  of  any  disease  in  man,  we 
should  recollect  that  the  healthy  body  offers  unequal  resistances  to  the 
various  germs  and  their  poisons.  Take,  for  instance,  diphtheria  or  ery- 
sipelas, inoculate  a  healthy  person  with  the. morbid  material,  and  diph- 
theria or  erysipelas  will  result  almost  to  a  certainty.  Do  the  same 
with  leprosy  or  tubercidosis,  and  probably  there  will  be  no  specific 
consequences. 


THE    GENERAL   PATHOLOGY  OF  INFECTION  545 

Leprosy  is  not  communicable  from  the  diseased  to  the  healthy  and 
sound.  The  experimental  evidence  on  this  point  is  so  strong  that  mere 
opinions  to  the  contrary  are  of  little  importance.  Many  attempts  have 
been  made  to  inoculate  leprosy  from  the  leper  to  the  non-leper,  but  never 
has  a  success  been  proved.  Leprosy  cannot  be  transmitted  from  the 
diseased  to  the  healthy  by  means  of  inoculation  —  in  other  words,  it  is 
not  contagious  under  normal  conditions.  To  transmit  the  disease  some- 
thing else  is  wanted  besides  the  contagium  vivum,  which  is  not  sufficient 
of  itself  to  produce  leprosy ;  this  something  else  may  be  a  special  pre- 
disposition, a  want  of  resistance. 

Contagion  and  contagiousness,  then,  cannot  be  measured  by  an  abso- 
lute standard,  a  truth  almost  persistently  forgotten.  The  scientific  and 
the  practical  aspects  of  the  question  must  be  considered  separately.  In 
a  scientific  classification  of  infective  diseases  we  justly  include  under 
contagious  affections  all  those  which  may  be  propagated  by  contagion, 
that. is  by  inoculation  or  any  form  of  infection,  irrespective  of  the  fact 
whether  they  generally,  or,  indeed,  ever  are  naturally  spread  in  this 
manner.  When  practical  sanitary  and  preventive  measures  are  contem- 
plated, the  natural  and  epidemiological  conditions  must  be  carefully 
considered. 

Summary.  —  Contagious  infective  diseases  are  spread  by  direct  or 
indirect  contact  or  —  to  put  it  in  symbolic  language  —  from  A  to  B,  so 
that  B  cannot  be  infected  without  A ;  or  from  A  to  B  through  an  ectan- 
thropic  body  X.  In  the  first  case,  to  save  B  we  must  remove  or  destroy 
A.  In  the  second  case  three  courses  are  open  to  us,  namely,  to  find  out 
whether  we  can  best  save  B  by  destroying  A  alone,  or  X  alone,  or  both 
A  and  X.  But  if  we  find  that  to  destroy  A  alone  is  of  no  avail,  and 
that  to  destroy  X  is  an  impossibility,  what  are  we  to  do  ?  Now,  it  is  a 
well-ascertained  fact  that  in  many  cases  an  individual  has  a  natural 
resistance  against  the  infective  germ,  and  that  the  latter  cannot  exert 
its  detrimental  effect  until  this  resistance  is  lost ;  and  this  may  give  us 
the  key  to  action,  which  will  be  adapted  to  restore  the  resistance,  while, 
at  the  same  time,  of  course,  X  is  kept  in  abeyance.  To  this  point  we 
shall  return. 

The  micro-organisms  responsible  for  a  number  of  our  commoner 
infective  diseases  belong  to  the  group  of  facultative  parasites,  or  faculta- 
tive saprophytes,  organisms  which  are  capable  of  multiplying  outside  the 
human  body.  These  diseases  are  seldom  directly,  and  occasionally  not 
even  indirectly,  contagious.  A  good  example  is  cholera.  The  germs  leaving 
the  human  body  are,  generally  speaking,  incapable  of  setting  up  an  im- 
mediate infection.  No  doubt  direct  contagion  does  occur,  but  it  is  a  rare 
excej)tion ;  and  sudden  outbreaks  of  cholera  are  easily  explained  by  assum- 
ing that  large  quantities  of  germs  grow  concealed  and  unsuspected  out- 
side the  human  organism,  or  that  otherwise  becoming  diffused  they  have 
obtained  access  to  a  general  source  of  infection,  for  instance  the  drinking 
water.  The  saprophytic  nature  or  phase  of  the  common  bacillus,  —  if  we 
assume  it  to  be  the  contagium  vivum  of  cholera  —  is  of  great  importance 

VOL.    I  2    N 


546  SYSTEM   OF  MEDICINE 

in  regard  to  the  contagiousness  or  non-contagiousness  of  cholera,  and  to 
the  best  mode  of  preventing  further  outbreaks  or  diffusion  of  tlie  disease. 

It  has  been  said  above  that,  if  a  germ  be  widely  distributed  in  space, 
"we  may  practically  neglect  contagion  as  a  means  of  spreading  the  disease. 
This  may  be  illustrated  by  the  familiar  instance  of  tuberculosis.  Con- 
sidering the  large  number  of  consumptives,  the  immense  numbers  of 
bacilli  in  the  sputum,  and  the  persistence  of  these  bacilli,  the  sources  of 
infection  must  be  almost  ubiquitous,  and  accordingly  the  exclusive  im- 
portance of  contagion  vanishes.  To  go  back  to  our  symbols,  we  cannot 
remove  X,  or  can  do  so  in  part  only,  because  it  is  well  known  that  the 
tubercle  bacilli  are  capable  of  leaving  the  animal  body  and  remaining 
dormant  outside  it  for  a  long  time,  in  the  full  possession  of  their  infective 
'  and  germinative  properties.  Dried  they  retain  their  virulence  for  months; 
boiling  does  not  always  destroy  them,  nor  does  putrefaction.  The  bacillus 
resists  the  digestive  action  of  the  gastro-intestinal  secretions,  and  it  is 
much  less  parasitic  than  is  generally  assumed.  Thus,  Sander  has  suc- 
ceeded in  growing  it  on  ordinary  potatoes  and  in  their  juice,  on  boiled 
macaroni,  baked  bread,  and  in  ordinary  tap  water ;  and  it  is  certain  that 
it  can  be  readily  acclimatised  to  changes  of  temperature.  Hence  it  is 
nearly  certain  that,  within  limits,  it  is  capable  of  a  saprophytic  existence, 
and  we  are  therefore  forced  to  assume  that,  in  towns  at  any  rate,  we 
are  surrounded  almost  everywhere  by  infective  tuberculous  material. 
Infection,  therefore,  is  possible  in  two  ways,  (a)  from  the  diseased 
directly,  or  (6)  from  objects  in  the  immediate  vicinity  of  the  affected 
person,  or  far  removed  both  in  time  or  space  from  him.  To  prevent 
further  infection  we  should  have  to  remove  both  the  phthisical  individ- 
uals and  the  bacilli  scattered  outside  the  human  body.  The  former 
cannot  be  done  satisfactorily,  because  phthisis  is  an  extremely  chronic 
affection,  not  always  easily  diagnosed  in  its  early  stages,  and  what  is 
diagnosed  as  incipient  phthisis  is  often  a  lesion  considerably  advanced. 
Isolation  and  segregation  would  therefore  be  folloAved  by  so  little  success 
as  to  seem'  unjustifiable.  Nor  can  we  entirely  remove  the  ectanthropic 
sources  of  infection.  We  know,  however,  that  only  those  of  our  fellow- 
creatures  will  acquire  tuberculosis  who  are  disposed  to  the  disease ;  and  the 
question  is  whether  we  can  alter  this  disposition  when  once  established,  or 
altogether  prevent  its  establishment  ?    The  answer  will  be  suj)plied  later. 

We  must  understand  that  in  reasoning  upon  laboratory  experiments 
the  precepts  of  logic  and  common-sense  are  not  to  be  altogether  forgotten. 
Laboratory  experience,  for  instance,  has  taught  us  that  tuberculosis  is 
an  infective  lesion,  due  to  a  bacillus  capable  of  multiplying  within  the 
body.  It  is  also  contagious ;  experiments  on  guinea-pigs  prove  this. 
But  Ave  must  remember  that  guinea-pigs  are  extremely  susceptible 
animals,  and  that  the  healthiest  specimen,  if  inoculated  with  the  small- 
est quantities  of  mammalian  tubercle  bacilli,  will  succumb.  In  the 
case  of  guinea-pigs  segregation,  destruction,  and  assiduous  disinfection 
of  the  cages  would  keep  the  spread  of  tuberculosis  in  abeyance. 

Mankind,  on  the  other  hand,  is  naturally  resistant  to  tuberculosis. 


THE   GENERAL  PATHOLOGY  OF  INFECTION  547 

This  disease  is  directly  or  indirectly  contagious  for  all  healthy  guinea- 
pigs  alike ;  but  in  man  it  is  contagious  only  for  those  who  have  lost 
their  resistance,  those,  that  is,  who  in  some  way  or  other  have  become 
disposed  to  the  disease.  In  a  well-regulated  laboratory  we  prevent  the 
outbreak,  or  at  any  rate  the  spread  of  phthisis  among  guinea-pigs  by  re- 
moving or  destroying  the  diseased  animals,  and  at  the  same  time  getting 
rid  of  the  bacilli  by  disinfection.  From  our  own  surroundings,  however, 
we  can  only  remove  the  sources  of  infection  in  part ;  and  so  long  as  we 
cannot  do  so  entirely,  the  destruction  or  isolation  of  the  diseased  subjects 
would  be  ineffectual. 

The  question  of  predisposition  must  now  be  studied  more  fully. 

VI.   Predisposition 

I.  Personal  predisposition  is  best  defined  as  susceptibility  to  a 
disease ;  it  may  be  either  natural  or  acquired.  A  natural  predisposition 
may  be  either  a  property  of  a  species,  which  as  such  is  transmitted  from 
parent  to  offspring  (racial  predisposition)  ;  or  it  may  be  an  accidental 
character  of  one  or  more  individuals  of  a  species  (individual  predisposi- 
tion), not  necessarily  transmitted  to  the  offspring.  Thus  guinea-pigs  are 
naturally  extremely  susceptible  to  tuberculosis;  man  to  syphilis  or  diph- 
theria. On  the  other  hand  man  or  animal  may  be  naturally  resistant 
against  an  infective  disease,  as  is  a  hen  against  tetanus.  In  the  last  case 
the  resistance  is  absolute;  that  is,  so  long  as  we  work  within  the  limits 
of  experiment,  the  normal  animal  cannot  be  infected;  in  other  cases  it 
may  be  relative  and  partial,  as,  for  example,  in  the  case  of  man's  resist- 
ance against  tuberculosis,  leprosy,  anthrax,  or  cholera.  We  must  assume 
that  in  such  cases  the  disposition  is  entirely  or  partly  absent.  The 
cause  of  this  individual  disposition  we  do  not  fully  understand. 

The  predisposition,  like  immunity,  depends  on  various  factors,  among 
which  the  most  important  are  —  (1)  intrinsic  cell  properties  ;  and  (2)  ex- 
trinsic conditions  reacting  harmfully  on  the  body  and  its  tissue  proc- 
esses. Within  certain  limits  every  organism  has  special  cellular 
mechanisms  to  Avard  off  an  infection.  Thus  the  acidity  of  the  gastric 
juice,  and  a  proper  supply  of  it,  may  prove  too  strong  for  the  cholera 
vibrio ;  the  ciliated  epithelium  and  the  sensitiveness  of  the  bronchial 
mucous  membrane  and  the  germicidal  action  of  the  mucus  may  protect 
the  respiratory  organs  against  an  invasion  by  tubercle  bacilli.  Again,  we 
know  from  Lofder's  experiments  that  the  age  and  nature  of  the  epithelial 
lining  are  conditions  of  great  importance  in  the  case  of  diphtheria :  the 
vaginal  mucous  membrane  of  young  animals  is  easily  attacked,  but  that 
of  old  animals  is  very  resistant.  Orth  and  Wyssokowitsch  have  shown 
that  traumatic  lesions  at  a  seat  of  infection  will  cause  a  local  predisposi- 
tion to  certain  infective  processes.  These  investigators  produced  a  well- 
marked  malignant  endocarditis  by  first  causing  a  slight  injury  to  the 
cardiac  valves,  and  then  injecting  a  culture  of  staphylococci :  endocar- 
ditis did  not  result  when  the  valves  were  intact.     Similarly  pyogenetic 


54S  SYS  TEA!  OF  MEDICINE 

cocci  will  readily  produce  suppuration  in  an  oedematous  rabbit,  although, 
harmless  to  rabbits  in  a  normal  state. 

The  question  of  predisposition  has  been  more  clearly  put  before  us 
during  recent  times,  and  a  short  summary  may  here  be  given  of  the  most 
important  experiments  and  observations  which  show  that  predisposition 
is  a  definite  quality  which  can  be  estimated  within  the  precincts  of  the 
laboratory,  and  is  not  a  mere  makeshift  to  explain  clinical  difficulties. 

II.  Acquired  Predisposition. — Various  means  exist  by  which  a  re- 
fractory or  resistant  animal  can  be  rendered  susceptible  —  by  which,  that 
is,  a  disposition  can  be  established  to  any  particular  infective  disease ; 
or,  to  put  the  case  differently,  we  possess  means  to  make  a  disease  which 
is  non-contagious  to  a  certain  species  of  animal  extremely  contagious  to 
certain  members  of  that  species.  We  may  reduce  the  natural  resistance 
of  an  animal  against  a  microbe  either  by  general  or  special  interferences, 
and  thus  establish  an  acquired  disposition.  The  former  are  of  more 
interest  to  us,  as  they  prove  how  much  good  can  be  effected  by  sanitary 
surroundings  in  the  prevention  of  disease,  and  we  shall  lead  off  with  them. 

General  Interferences.  —  1.  Canalis  and  Morpurgo  have  shown  that  by 
means  of  starvation  we  can  render  pigeons,  which  are  naturally  resistant 
against  anthrax,  extremely  susceptible  to  this  infection.  They  succumb, 
either  if  we  allow  them  to  starve  immediately  after  the  inoculation,  or 
starve  them  six  days  previously  and  then  inoculate  them,  at  tlie  same 
time  continuing  the  process  of  starvation.  But  if  we  feed  them  regularly 
immediately  after  inoculation,  then,  in  spite  of  having  previously  been 
starved  for  six  days,  they  will  survive.  However,  if  we  allow  them  to 
starve  longer  than  six  days  before  the  inoculation,  they  will  succumb, 
whether  we  feed  them  or  not  after  the  infection. 

Similarly  hens,  naturally  immune,  become  susceptible  to  an  anthrax 
infection  through  starvation.  White  rats,  on  the  other  hand,  do  not  lose 
their  natural  immunity  in  this  manner.  Sacchi,  by  means  of  starvation, 
succeeded  in  rendering  a  local  anthrax  infection  in  pigeons  a  general  infec- 
tion. Similar  experiments  have  also  been  made  on  artificially  immu- 
nised rabbits.  Pernice  and  Alessi  proved  that  dogs,  hens,  pigeons,  and 
frogs  can  be  rendered  susceptible  to  anthrax,  by  depriving  them  of  water. 

2.  Again,  fatigue  and  loss  of  blood  are  capable  of  removing  the 
natural  immunity  of  animals.  Thus  Charrin  and  Roger  have  shown 
that  the  normal  white  rat,  which,  as  is  well  known,  is  very  insusceptible 
to  anthrax,  becomes  susceptible  to  this  disease  in  a  marked  degree,  if  it 
is  made  to  work  a  treadmill  in  a  cage  until  it  is  thoroughly  fatigued. 
Roger  has  further  demonstrated  that  rabbits,  which  are  relatively  re- 
fractory to  quarter-evil,  lose  their  immunity  by  exhaustion  and  fatigue ; 
and  Rodet  and  others  have  established  an  acquired  disposition  by 
inducing  a  general  anaemia  by  artificial  loss  of  blood. 

3.  An  unsuitable  diet,  as  Hankin  has  shown,  may  remove  the  resistance 
of  the  body  against  anthrax.  Thus  refractory  rats,  fed  on  sour  milk 
and  bread,  lose  their  insusceptibility ;  a  pure  meat  diet  increases  it. 
Hans  Leo  administered  phloridzin  in  small  doses  with  the  food  for  some 


THE    GENERAL   PATHOLOGY   OF  INFECTION  549 

days  previous  to  inoculation,  with  the  result  that  sugar  showed  itself  in 
the  tissues  of  the  animal  under  experiment :  this  animal  now  became 
highly  susceptible  to  a  glanders  infection,  which  in  its  normal  condition 
it  was  able  to  resist.  The  same  treatment,  however,  did  not  increase  the 
susceptibility  of  rats  to  anthrax  and  tuberculosis. 

4.  Exposure  to  heat,  cold,  and  moisture  has  been  investigated  by 
Pasteur,  Petruschky,  Fermi  and  Salsano,  and  others.  Thus  on  im- 
mersing a  hen  in  water  it  loses  its  resistance  to  anthrax,  and  the 
same  occurs  on  reducing  its  temperature  by  the  administration  of 
antipyrin.  Frogs,  if  kept  at  a  temperature  of  2o°-35°  C,  will  easily 
succumb  to  anthrax.  Guinea-pigs  and  white  mice,  which  are  resist- 
ant to  avian  tuberculosis,  can  be  rendered  susceptible  by  keeping 
them  after  inoculation  in  a  warm  chamber  at  33°-35°  C.  This  will  also 
increase  the  susceptibility  of  white  mice  to  mammalian  tuberculosis. 
Cold,  on  the  other  hand,  does  not  affect  the  special  disposition  of  these 
animals. 

We  see,  then,  that  it  is  easy  by  such  general  means  as  starvation, 
fatigue,  exposure,  and  bad  diet  to  reduce  the  insusceptibility  of  certain 
animals  to  infective  diseases.  Now,  if  in  a  community  of  which  the 
normal  individuals  are  insusceptible,  a  certain  number  of  these,  through 
one  or  other  of  the  above  causes,  become  susceptible,  then  the  disease 
may  be  extremely  contagious  for  these  modified  persons,  though  non- 
contagious for  the  community  as  a  group.  This  shows  how  cautious  we 
must  be  in  pronouncing  any  infective  disease  to  be  contagious  to  a  com- 
munity. In  many  cases  it  would  evidently  be  absurd  to  clamour  for 
physical  or  social  extinction  of  the  affected  individual ;  we  must  attack 
the  problem  differently.  Knowing  by  what  processes  the  disease  has 
become  contagious  for  a  certain  community,  Avhile  preventing  a  further 
distribution  of  the  contagium  by  disinfection  and  other  appropriate 
measures,  we  must  so  improve  the  social  and  personal  hygiene  as  to 
reverse  the  direction  of  modification. 

A  consideration  of  tuberculosis  from  this  point  of  view  will  make 
my  meaning  clearer.  We  cannot  hope  to  destroy  the  contagium  vivtim, 
it  is  too  widely  distributed ;  nor  can  we  destroy  the  affected  individuals 
—  such  a  process  would  be  unavailing,  even  if  free  from  other  objec- 
tions. How,  then,  can  we  prevent  the  spread  of  the  disease  ?  If,  as 
it  seems,  the  disposition  to  it  be  due  to  any  or  all  of  the  above  causes, 
let  these  be  removed.  Now  we  know  that  a  healthy  man  is  relatively 
immune  from  tuberculosis  ;  w^e  also  know  that  bad  hygiene,  exposure, 
and  the  like,  may  render  him  susceptible  to  it;  the  rational  preventive 
measure,  therefore,  is  to  counteract  the  causes  of  this  acquired  suscepti- 
bility, while  at  the  same  time  we  order  all  consumptives  to  destroy 
their  sputum.  That  improved  personal  hygiene  and  public  sanitation, 
and  a  higher  standard  of  life  materially  diminish  the  death-rate  from 
consumption  is  already  ascertained;  the  vital  statistics  of  England 
clearly  dfimonstrate  that  sanitary  legislation  has  coincided  with  a  con- 
siderable diminution  of  the  number  of  deaths  from  phthisis. 


550  •  SYSTEM  OF  MEDICINE 

The  same  reasoning  applies  to  leprosy.  This  affection,  as  mentioned 
above,  is  comparatively,  if  not  quite,  harmless  to  healthy  men  living 
under  sound  conditions.  Bad  hygiene,  poverty,  insufficient  food,  and 
so  forth,  increase  the  liability  to  the  disease.  How  is  it  that  the  pest 
has  died  out  in  England  and  is  decreasing  in  India  ?  Certainly  not 
merely  on  account  of  segregation,  for  such  measures  have  virtually 
never  been  taken  in  Europe,  and  in  India  cannot  be  taken.  In  Norway 
the  disease  was  decreasing  before  segregation  was  enforced.  The  chief 
cause  of  the  disappearance  of  the  leprosy  from  these  parts  is  to  be 
found  in  a  general  improvement  of  social  and  personal  surroundings 
and  a  raised  standard  of  living. 

But  why  shall  we  not  order  the  compulsory  isolation  of  tubercular 
patients  ?  Because  in  tuberculosis  we  have  a  chronic,  extremely  insid- 
ious disease,  widely  distributed  over  the  world,  a  disposition  to  which  is 
comparatively  easily  acquired  or  inherited ;  the  tubercle  bacilli  already 
exist  everywhere,  and  compulsory  isolation  could  not  be  carried  out 
rigorously  enough  to  lessen  the  spread  of  the  disease.  Long  before  we 
have  recognised  the  complaint,  our  patient,  consciously  or  unconsciously, 
has  already  disseminated  his  share  of  bacilli  ready  to  be  taken  up  by  the 
nearest  individuals,  and  to  fix  upon  the  susceptible.  If  there  is  to  be 
any  isolation  at  all,  the  more  reasonable  course  would  be  to  isolate  those 
so  disposed.  In  the  Avealthier  classes  this  is  done,  directly  and  indirectly, 
with  good  results.  In  the  case  of  the  masses  the  only  thing  to  be  done 
is  to  counteract  the  general  causes  of  susceptibility,  and  to  persist  in 
disinfection  on  ordinary  common-sense  lines. 

The  above  considerations  will  also  explain  the  meaning  and  nature 
of  endeniicity,  or  the  state,  both  of  the  individuals  living  in  a  district, 
and  of  the  medium  in  which  they  live,  which  favours  a  certain  infective 
disease.  Undoubtedly  cholera  is  a  disease  for  which,  if  it  appears  spo- 
radically, a  special  individual  bent  is  required;  and  if  it  appears  in 
epidemics,  there  must  be  the  local  predisposition  in  addition.  Now  in  cer- 
tain parts  of  India,  as,  for  example.  Lower  Bengal  and  Assam,  cholera 
is  always  present  or  "  endemic."  Such  endemic  areas  are,  for  the  most 
part,  over-populated,  poor,  or  extremely  unhealthy.  May  not  these  and 
similar  factors  reduce  the  resistance  of  the  population,  and  render  the 
existence  of  the  evil  a  necessary  consequence  ?  This  matter  gains  in 
interest  as  we  remember  that  in  those  areas  wherein  cholera  is  always 
present  leprosy  also  is  most  common.  This  cannot  mean  that  any  direct 
causal  connection  exists  between  leprosy  and  cholera,  but  it  is  quite 
possible,  and  perhaps  even  probable,  that  those  factors  which  contribute 
to  the  prevalence  of  the  one  have  a  like  effect  on  the  other. 

We  should,  however,  remember  that,  in  contradistinction  to  this 
individual  disposition  which  applies  to  certain  individuals  of  a  species, 
there  is  also  a  racial  disposition  which  applies  to  all  members  of  a 
species.  Negroes  are  seldom  affected  by  yellow  fever,  and  the  same  is 
true  of  the  mulatto.  There  are  numerous  examples  of  such  phenomena 
in  the  laboratory.      Thus  of  dogs   which  are  relatively  resistant  to 


THE    GENERAL  PATHOLOGY  OF  INFECTION  5 si 

anthrax,  black  dogs  are  less  so  thau  white  ones.  Black  and  gra^y  rats 
are  less  susceptible  to  anthrax  than  white  rats.  Field-mice,  again,  are 
extremely  susceptible  to  mammalian  tuberculosis,  while  white  mice  are 
practically  immune;  white  mice,  on  the  other  hand,  easily  succumb  to 
an  infection  with  the  micrococcus  tetragonus,  while  gray  house-mice  are 
quite  refractory  to  it. 

Again,  age  is  a  disposing  factor,  for  young  individuals  acquire  certain 
affections  —  for  example,  enteric  fever — more  easily  than  adults;  this 
fact  also  is  amply  borne  out  by  animal  experiments.  Oemler  has  shown 
that  young  pigeons  are  much  less  refractory  to  anthrax  than  old  ones. 
But,  strange  to  say,  sucklings  appear  to  be  less  liable  to  some  infective 
fevers,  such  as  measles  and  scarlet  fever,  than  to  others ;  this  may  be 
due  to  the  protective  influence  of  mothers'  milk :  this  matter  will  be 
discussed  later. 

Here  we  must  leave  this  interesting  subject,  and  direct  our  attention 
to  the  effect  on  predisposition  of  certain  more  special  and  easily  defined 
interferences.  We  shall  find  that  apparently  slight  causes  are  capable 
of  destroying  the  balance,  and  of  removing  with  one  stroke,  as  it  were, 
the  resistance,  whether  natural  or  acquired,  of  the  tissues  to  a  particu- 
lar infection. 

Special  Interferences.  —  1.  It  was  once  thought  by  Tizzoni  and  Cat- 
tani  that  it  is  impossible  to  render  rabbits  immune  from  tetanus  after  the 
removal  of  their  sjdeens,  and  that  the  removal  of  the  spleen  will  destroy 
the  natural  immunity  of  dogs  from  tetanus  and  anthrax.  That,  how- 
ever, the  acquired  disposition  does  not  in  all  cases  depend  on  the  removal 
of  the  spleen  is  shown  by  the  experiments  of  Foa  and  Scabia  and  others, 
wlio  worked  with  the  diplococcus  of  pneumonia  and  the  B.  pyocyaneus, 
and  proved  that,  for  these  infections  at  least  and  the  immunity  from 
them,  the  spleen  is  of  no  importance ;  for  if  we  allow  the  animal  to  recover 
its  weight  and  strength  completely,  its  immunity  will  persist.  The 
Italian  authors,  on  repeating  their  experiments,  have  indeed  come  to  this 
conclusion.  The  temporary  loss  of  resistance  is  explained,  therefore, 
simply  by  the  shock  and  weakness  which  naturally  follow  the  operation. 

According  to  Canalis  and  Morpurgo,  pigeons  are  rendered  less 
resistant  to  anthrax  by  removal  of  the  pancreas.  This  operation  also 
predisposes  animals  to  septic  infections  ;  and  according  to  Sawtschenko, 
the  same  happens  after  section  of  the  spinal  cord  in  pigeons. 

It  is  true,  then,  that  the  destruction  or  removal  of  certain  organs 
may  cancel  the  insusceptibility  of  an  animal  to  an  infection,  either  as 
a  direct  result  of  the  ablation,  or  indirectly  by  the  production  of  some 
constitutional  change,  such,  for  instance,  as  the  diabetic  which  follows 
excision  of  the  pancreas. 

2.  Again,  there  are  many  experiments  to  prove  that  bacteria,  abso- 
lutely or  relatively  harmless  to  animals  when  injected  in  pure  cultures 
V)y  themselves,  become  intensely  virulent  when  at  the  same  time  tve  inject 
certain  chemical  bodies  at  tlus  seat  of  lesion.  Thus  Vaillard  and  Vincent 
have  shown  that  in  animals  immune  from  tetanus  a  characteristic  infec- 


552  SYSTEM   OF  MEDICINE 

tion  can  be  brought  about  by  injecting  lactic  acid  or  trimethylamine 
with  the  tetanus  bacillus.  Similarly  hydracetin  and  pyrogallol  will 
destroy  the  acquired  immunity  of  guinea-pigs  against  hog  cholera. 
IJujwid  found,  on  §,ntecedent  injection  of  sugar  solution  into  the  sub- 
cutaneous tissue  of  animals,  that  an  inoculation  of  the  staphylococcus 
pyogenes  aureus  was  in  most  instances  followed  by  marked  suppuration ; 
a  result  not  easily  achieved  by  means  of  the  staphylococcus  in  the  absence 
of  previous  sugar  injection.  Lastly,  hypodermic  injections  of  dextrose 
and  lactic  acid  will  render  guinea-pigs  and  white  mice  susceptible  to 
avian  tuberculosis,  and  white  mice  also  to  mammalian  tuberculosis. 
This  was  shown  by  Fermi  and  Salsano,  and  it  is  important  to  note  that 
avian  tubercle  bacilli,  repeatedly  inoculated  into  guinea-pigs  rendered 
susceptible  by  such  injections,  become  virulent  for  normal  gainea-pigs. 
Here  we  may  also  mention  Klein  and  Coxwell's  experiments,  which 
show  that  in  frogs  and  rats  the  natural  immunity  from  anthrax  may 
be  destroyed  by  means  of  a  chloroform-ether  narcosis. 

3.  Then,  again,  the  metabolic  products  of  certain,  it  may  he  harmless, 
micro-organisms  are  often  capable  of  rendering  a  non-pathogenetic  germ 
pathogenetic.  Examples  of  this  are  mentioned  by  Koger,  who  has  shown 
that  rabbits  will  succumb  to  quarter-evil,  if,  simultaneously  with  the 
bacilli,  the  chemical  products  of  the  bacillus  prodigiosus,  proteus  Tul- 
garis,  or  staphylococcus  be  administered.  Klein  and  others  have  given 
further  proof  of  this.  Other  allied  bodies  —  vegetable  ferments,  for 
instance  —  have  the  same  effect. 

On  the  other  hand,  many  of  these  chemical  products  of  bacteria 
possess  the  power  of  destroying  the  pathogenetic  property  of  specific 
organisms.  I  shall  only  refer  to  the  experiments  of  Blagovestchewski, 
who  showe.l  that  a  simultaneous  injection  of  anthrax  bacilli  and  the 
products  of  the  bacillus  pyocyaneous  prevents  the  lethal  effect  of  the 
anthrax  infection,  and  renders  the  animal  immune. 

4.  What  has  been  said  of  the  chemical  products  of  the  bacteria 
applies  with  equal  force  to  the  bacteria  themselves.     Klein  and  others 

,  have  shown  that  by  means  of  concur^'ent  inocidations  of  various  lands  of 
organisms  we  may  (1)  render  non-pathogenetic  bacteria  pathogenetic ; 
or  (2)  increase  or  decrease  the  virulence  of  pathogenetic  germs.  A  few 
examples  must  suffice:  thus  a  simultaneous  inoculation  of  anthrax  and 
pyocyaneous  bacilli,  or  of  anthrax  bacilli  and  erysipelas  cocci,  or  of 
anthrax  and  prodigiosus  or  Eriedlander's  bacilli,  protect  the  animal 
against  the  poisonous  effects  of  the  anthrax  bacillus.  On  the  other 
hand,  the  bacillus  prodigiosus  and  various  pyogenetic  germs,  if  simul- 
taneously administered  with  the  bacillus  of  tetanus,  render  the  latter 
extremely  pathogenetic  for  animals  capable  of  resisting  a  simple  infec- 
tion with  the  tetanus  bacillus.  Lastly,  the  virulence  of  the  bacillus 
diphtheriae  is  greatly  enhanced  by  means  of  a  concurrent  inoculation 
of  the  bacillus  pyocyaneus,  as  shown  by  Klein. 

Summary.  —  We  see,  then,  that  the  natural  resistance  of  animals  is 
easily  destroyed  by  various  processes:    (1)  hj  such  as  cause  general 


THE    GENERAL  PATHOLOGY   OF  INFECTION  553 

tissue  disturbances,  namely  hunger,  exposure  to  heat  or  cold  and  wet, 
fatigue,  insufficient  or  inadequate  feeding ;  and  (2)  by  more  special  inter- 
ferences, such  as  the  removal  of  organs,  essential  or  not  to  the  animal 
economy,  or  (3)  by  concurrent  inoculations  with  chemical  or  bacterial  prod- 
ucts, or  with  the  bacteria  themselves.  These  special  interferences  do 
not  all  act  in  the  same  manner  on  the  animal  organism  ;  some —  as,  for 
example,  the  removal  of  glands  —  produce  general  changes  in  the  body  ; 
but  others  may,  and  in  many  cases  do  cause  a  weakening  of  the  tissues 
at  the  seat  of  inoculation  whereby  the  local  defensive  processes  are  im- 
paired and  broken  down;  thus  a  foothold  is  given  to  the  organisms, 
enabling  them  to  grow  and  to  manufacture  their  toxins.  It  must  be  con- 
fessed that  our  knowledge  of  the  matter  of  concurrent  inociilations  or 
bacterial  association  and  interaction  is  still  defective.  In  the  meantime 
these  two  processes  (namely,  the  interferences  which  react  on  the  whole 
body  and  those  which  react  merely  locally  on  the  tissues  at  the  seat  of 
injury)  must  be  considered  apart  as  much  as  possible.  In  the  latter 
case  writers  often  speak  of  a  local  predisposition  produced  by  tissue 
lesion ;  this  is  a  misleading  expression  :  it  would  be  more  correct  to  say 
that  the  predisposition  has  become  evident  after  certain  local  changes. 
We  cannot  tell  how  far  such  local  changes  react  on  and  disturb  the  whole 
body,  although  we  must  admit  that  in  many  cases  it  may  not  be  a  mat- 
ter of  breaking  down  an  immunity  at  all,  but  merely  one  of  soil  —  one 
of  giving  the  organisms  a  chance  of  development  by  placing  them  under 
more  suitable  local  conditions  of  implantation.  The  whole  subject  re- 
quires research  rather  than  discussion ;  for  the  present  it  is  enough  to 
remember  that,  by  means  of  association  of  bacterial  or  chemical  sub- 
stances with  bacterial  infections,  we  may  either  break  down  an  existing 
immunity,  or  establish  the  existence  of  a  latent  predisposition, undetected, 
perhaps,  because  of  the  imperfections  of  our  method  of  inoculation. 

By  any  of  the  above  methods,  then  —  to  express  it  differently  —  a 
non-contagious  disease  can  at  once  be  rendered  highly  contagious.  The 
general  causes  are,  in  this  connection,  the  more  important,  because  they 
include  conditions  which  are  covered  by  the  vague  term  "unsound  hy- 
giene." Before  we  can  approach  the  question  of  the  prevention  of  the 
spread  of  an  infective  disease,  it  is,  therefore,  our  duty  in  all  sanitary  or 
other  inquiries  into  its  contagious  nature  to  ascertain  under  what  condi- 
tions it  becomes  contagious  for  a  particulax  community.  Contagionists, 
or  those  who  believe  in  the  direct  contagiousness  of  all  infective  dis- 
eases, ask  for  some  features  and  characters  by  which  a  disposition  may  be 
recognised.  Such  a  question,  while  it  discloses  a  want  of  appreciation 
of  the  difficulties  of  the  inquiry,  is  also  premature ;  our  knowledge  is 
not  yet  sufficiently  advanced  to  enable  us  to  define  the  special  dispo- 
sitions to  given  infective  diseases.  It  is  easy  to  scoff  at  vague  generali- 
ties about  unsound  personal  and  social  hygiene,  but  their  potency  in 
establishing  a  disposition  to  an  infective  disease  is  fully  borne  out  by 
animal  experiments  ;  the  precise  ajjplication  of  this  knowledge  to  a  certain 
community  can  be  niade  only  on  the  historical  and  epidemiological  experi- 


554 


SYSTEM  OF  MEDICINE 


ence,  and  the  scientific  evidence  obtainable  in  the  particular  case.  If  it 
be  found  that  the  removal  or  abatement  of  unsound  hygienic  conditions 
is  attended  by  a  concomitant  variation  of  the  disease,  we  may  be  a  step 
nearer  to  the  proof  of  a  correlation  between  those  vague  generalities 
about  unsound  hygiene  on  the  one  hand  and  contagion  and  susceptibility 
on  the  other.  In  many  cases  —  as,  for  instance,  in  tuberculosis  —  we 
have  to  fight  against  these  vague  causes,  for  we  believe  that  they  render 
the  disease  a  contagious  one  to  a  special  class  of  individuals ;  and  this 
method,  together  with  personal  disinfection,  is  the  only  possible  way 
of  dealing  with  the  problem.  That  the  removal  or  abatement  of  unfa- 
vourable hygienic  conditions  has  undoubtedly  brought  about  a  decrease 
of  phthisis,  in  England  and  in  the  large  continental  towns,  is  shown  by 
recent  statistics. 

Certain  writers,  such  as  Baumgarten,  deny  the  existence  of  a  dis- 
position to  tuberculosis ;  our  most  experienced  physicians  and  ablest 
pathologists,  however,  recognise  its  existence;  until  tlie  days  of  bac- 
teriology it  had  never  been  doubted.  Fliigge  goes  even  so  far  as  to  say 
that  "  in  tuberculosis  Ave  learn  from  experience  that  the  greater  or  less 
accumulation  of  resistant  infective  agents  plays  a  relatively  subordinate 
part  in  the  spread  of  the  disease."  (Fliigge's  Micro-organisms,  trans- 
lated by  Watson  Cheyne,  page  752.)  The  physician  counteracts  the 
disposition  by  removing  the  susceptible  individual  from  any  possible 
risk  of  infection  when  sending  him  to  warmer  and  sunnier  climates ; 
thus  he  isolates  the  predisposed  whenever  and  so  far  as  he  can. 

In  conclusion,  a  few  words  must  be  said  on  hereditary  predisposition. 

Hereditary  Predisposition. —Can  an  acquired  disposition  be  trans- 
mitted from  parent  to  offspring  ?  Such  a  disposition  may  be  called 
"hereditary,"  or  "inherited,"  and  must  be  carefully  distinguished 
from  a  "  congenital "  disposition,  which  the  child  brings  into  the 
world  independently  of  parental  endowment.  Tuberculosis  is  a  disease 
of  extra-uterine  life,  but  undoubtedly  cases  of  congenital  tuberculosis 
do  occur,  as  shown  by  Merkel,  Landouzy,  Hindfleisch,  Birch-Hirsch- 
feld  and  others ;  and  much  more  frequently  than  congenital  tuber- 
culosis do  we  find  tuberculosis  in  infants  and  children  during  the 
first  months  or  years  of  life,  as  shown  by  Queyrat,  Landouzy,  Miiller 
and  others.  Until  recently  it  was  almost  universally  believed  that  the 
undisputed  hereditary  succession  of  tubercular  processes  depends,  not  on 
a  direct  transmission  of  the  elements  of  the  disease  from  parent  to  off- 
spring, but  on  an  hereditary  transmission  of  a  proclivity.  Baumgarten, 
however,  believes  that  the  heredity  of  phthisis  depends  on  an  intra-uterine 
or  congenital  infection  of  the  foetus  with  tubercle  bacilli  from  the  mother, 
and  he  supports  these  views  with  the  following  arguments.  Besides  the 
existence  of  congenital  tuberculosis,  Birch-Hirschfeld  and  others  have 
demonstrated  that  in  man,  as  well  as  in  animals,  tubercular  infer-tion 
through  the  placental  circulation  is  not  only  possible  but  does  actually 
occur.     Observations  and  experiments  on  animals  show :  (a)  that  con- 


THE    GENERAL  PATHOLOGY  OF  INFECTION  555 

genital  tuberculosis  in  the  larger  susceptible  mammals  is  not  very  rare 
(Johne);  ih)  that  of  the  offspring  of  tubercular  guinea-pigs  twenty-five 
per  cent  are  born  with  congenital  tuberculosis  (de  Kenzi) ;  (c)  that  intra- 
uterine tubercular  infection  is  possible  in  rabbits  and  mice  (Gartner); 
(d)  that  chickens  hatched  from  eggs  inoculated  with  tubercle  bacilli 
manifest  tuberculosis,  and  the  eggs  of  canaries  inoculated  intra-abdom- 
inally  with  tubercle  bacilli  are  frequently  infected  (Mafucci,  Baum- 
garten  and  Gartner).  From  analogy,  therefore,  Baumgarten  assumes 
that  in  man  also  the  tubercle  bacilli  are  transmitted  congenitally  in  utero, 
and  that  if  the  disease  be  not  apparent  at  the  time  of  birth  the  bacilli 
remain  dormant  in  the  tissues  (of  the  liver  for  instance),  causing  at  first 
only  small  obscure  foci,  and  being  for  some  time  impaired  in  their  de- 
velopment ;  but  that  eventually  "  through  some  cause  or  another  "  they 
awake  and  produce  a  manifest  tuberculosis. 

It  is  evident,  if  we  accept  Baumgarten's  views,  we  have  no  longer 
any  right  to  speak  of  ''hereditary"  phthisis;  such  a  process  as  he  as- 
sumes and  describes  is  an  infection  from  parent  to  ovum  or  foetus,  and 
is  as  much  an  infection  as  the  transmission  of  pathogenetic  organisms 
from  one  adult  to  another.  We  must  then  agree  with  Armauer  Hanson 
that  no  specific  infective  disease  is  hereditary,  if  we  use  the  term  hered- 
ity in  the  sense  which  Darwin  and  modern  biologists  have  given  to  it. 
"If  it  appear  congenitally  it  is  simply  communicated  to  the  foetus  by  in- 
fection. It  would  be  absurd,  for  instance,  to  speak  of  an  inherited  gon- 
orrhoeal  infection  in  cases  in  which  newborn  children  are  unfortunate 
enough  to  acquire  a  venereal  ophthalmia  in  their  passage  into  the  world. 
Now,  if  heredity  be  not  a  factor  in  infection,  the  organisms  must  have 
been  passed  on :  (a)  from  the  ovary  of  the  mother  or  the  testes  of  the 
father ;  or  (6)  from  the  mother  through  the  placental  circulation ;  that  is, 
infection  may  have  been  germinal  or  placental.  Tubercles  and  tubercle 
bacilli  have  been  found  in  the  placenta,  as  already  stated ;  and,  further, 
there  is  sufficient  evidence,  anatomical  and  histological,  to  show  that  the 
bacilli  pass  from  the  placenta  into  the  foetal  circulation.  The  evidence 
of  germinal  infection  on  the  other  hand  is  weak,  so  that  it  is  safer  to 
account  for  true  congenital  tuberculosis  by  placental  infection. 

But  how  are  we  to  account  for  those  cases  in  v/hich  the  offspring  of 
tuberculous  parentage  fall  into  tuberculosis  years,  often  many  years, 
after  birth  ?  Baumgarten  assumes  that  in  these  cases  also  there  is  a 
latent  infection,  the  tubercle  bacilli  having  passed  through  the  placenta 
(or  from  the  ovum)  into  the  foetus,  as  already  explained.  That  there 
may  be  an  obscure  tubercular  process  in  many  children  of  tuberculous 
parents  must  be  acknowledged,  because  swollen  and  caseous  glands  con- 
taining virulent  tubercle  bacilli  have  been  found  both  in  man  and  animals 
at,  or  at  any  rate  soon  after,  birth.  Again,  Mafucci  working  on  animals 
often  found  tubercle  bacilli  in  the  liver  of  embryos  of  tuberculous  parent- 
age. Undoubtedly,  then,  tubercle  bacilli  may  be  stored  up  in  the  tissues 
of  the  foetus.  But  how  is  it  that  such  offspring  often,  or  indeed  gen- 
erally, do  not  manifest  the  disease  proper  until  years  afterwards  ?    The 


556  SYSTEM   OF  MEDICINE 

answer  must  be  because  their  tissues  are  sufficiently  resistant  to  keep  the 
activity  of  the  bacilli  in  abeyance,  or  in  some  cases  sufficiently  strong 
even  to  destroy  it  altogether.  But  if  later  they  lose  this  resistance,  the 
bacilli  are  then  placed  in  the  conditions  required  for  successful  activity. 
A  few  bacilli  in  an  obscure  focus  do  not  constitute  tuberculosis  any 
more  than  does  the  pathologist's  tubercle  or  wart.  We  are  thus  led 
again  to  assume  a  proclivity  in  the  cases  under  discussion.  And  is  it 
not  possible  that  the  appearance  of  this  proclivity  is  favoured  by  cer- 
tain tendencies  transmitted  by  inheritance  ?  Hereditary  peculiarities 
are  often  limited  to  a  definite  period  or  age ;  and  we  find  that  in  the 
offspring  the  disease  often  shows  itself  at  about  the  same  age  as  it  did 
in  the  parent  —  a  fact  of  importance  in  a  philosophical  consideration  of 
hereditary  transmission. 

Animal  experiments  cannot  prove  much  in  investigations  of  this 
nature,  for  in  questions  of  hereditary  transmission  we  must  consider  each 
species  by  itself.  Guinea-pigs,  rabbits,  mice,  hens,  and  canaries  —  the 
animals  generally  employed  —  are  naturally  highly  susceptible  to  tuber- 
culosis, and  hence  the  predisposition  is  an  inherent  property  of  the  parent, 
and  therefore  also  of  the  ovum  or  embryo.  As  the  tissues  of  the  normal 
parent  offer  no  resistance,  we  cannot  possibly  expect  those  of  the  off- 
spring to  do  so.  Baumgavten  and  his  followers  should  have  based  their 
arguments  and  observations  on  animals  of  marked  resistance  —  on  goats 
and  dogs  —  which  cannot  be  infected  without  an  artificially  acquired 
disposition.  Animal  experiments  do,  however,  make  it  certain  that  by 
no  means  all  the  offspring  of  tuberculous  animals  harbour  latent  bacilli 
in  their  tissues,  and  we  have  no  right  to  assume  that  such  a  condition  of 
things  commonly  exists  in  man.  How  then  are  Ave  to  explain  the  fre- 
quent occurrence  of  phthisis  in  the  offspring  of  tuberculous  parents  ? 
Tor  the  present  we  must  assume  that  in  most  cases  they  inherit  only  the 
proclivity,  and  subsequently  become  infected  from  without.  Hence  the 
so-called  "  heredity "  of  phthisis  finds  its  explanation  in  the  following 
possibilities :  —  (1)  Congenital  infection,  either  germinal  or  placental, 
followed  by  immediate  results ;  (2)  Congenital  infection  with  inherited 
disposition,  followed,  after  a  period  of  latency,  by  recrudescence  at  a  sub- 
sequent date ;  (3)  Inherited  disposition  with  infection  at  a  later  date. 
Now  since  in  the  case  of  tuberculosis  we  find  some  of  the  characteristic 
features  of  heredity — for  instance  that  atavism  is  not  uncommon,  and 
that  the  hereditary  tendency  is  often  limited  to  one  sex  and  to  a  definite 
age — and  since  it  requires  great  faith  to  believe  in  a  bacterial  sleep  lasting 
through  many  years  as  a  complete  explanation,  we  must  incline  to  Vir- 
chow's  doctrine  of  the  existence  and  influence  of  an  inherited  predisposi- 
tion to  tuberculosis,  even  though  our  modern  conception  of  predisposition 
differs  from  his.     [See  article  on  the  "Laws  of  Inheritance  and  Disease."] 

The  inherited  disposition  may  be  either  specific  or  non-specific.  The 
parental  disposition  may  have  been  due  to  many  agents  and  factors ; 
and  it  is  possible  that  some  of  these,  although  not  of  the  same  nature 
as  the  resulting  tuberculosis,  have  been  the  cause  of  the  congenital  bent 


THE    GENERAL  PATHOLOGY   OF  INFECTION  e?; 

transmitted  to  the  offspring.     This  evidently  could  not  be  an  inherited 

specific  predisposition ;  that  is,  it  is  quite  within  the  bounds  of  possibility 
that  a  non-tubercular  condition  of  a  parent  n:ay  lead  in  a  child  to  an 
inherited  predisposition  favourable  to  the  development  of  tuberculosis. 
A  predisposition  can  only  be  specifically  inherited  in  cases  in  which  the 
child  was  born  of  tuberculous  parents  or  ancestors.  A  child  born  of  a 
parent  who  becomes  phthisical  some  years  after  its  birth  cannot  with 
certainty  be  supposed  to  have  inherited  a  specific  tubercular  proclivity. 
The  eventual  acquirement  of  the  disease  by  the  parent  cannot  make  the 
inherited  proclivity  any  more  specific ;  it  can  prove  only  that  certain 
conditions  and  abnormalities  of  the  parent  which  eventually  favoured 
tuberculosis  have  been  transmitted  to  the  offspring.  For  practical  pur- 
poses the  distinction  between  a  specific  and  a  non-specific  inherited  ten- 
dency may  be  unimportant ;  but  in  a  scientific  discussion  of  heredity  it 
is  a  matter  deserving  of  the  fullest  attention. 

Germinal  infection,  though  doubtful  in  tuberculosis,  certainly  exists 
in  the  case  of  syphilis ;  the  contagium  being  derived  either  from  the 
father  or  the  mother.  But  since  we  have  no  direct  knowledge  of  the 
syphilitic  virus  we  cannot  generalise  from  our  observations  of  this  disease. 
Although  tubercle  and  also  leprosy  bacilli  have  been  found  occasionally  in . 
the  testes  and  ovaries,  and  even  in  the  seminal  fluid  of  diseased  individuals, 
there  is  no  evidence  whatever  that  germinal  infection  ever  does  occur: 
in  fact  Gartner  has  shown  that  in  animals,  even  if  numerous  tubercle 
bacilli  are  contained  in  the  seminal  fluid,  it  is  the  mother  Avhich  is  first 
infected,  and  not  the  ovum  or  embryo.  This  may  be  said  of  all  infective 
diseases  with  the  bacteriology  of  which  we  are  acquainted ;  and  for  such 
of  them  as  appear  congenitally,  infection  must  practically  always  take 
place  through  the  placental  circulation.  This  is  exactly  what  occurs  in 
animals  where  it  can  be  demonstrated  more  readily.  Placental  infection 
in  animals  has  been  conclusively  shown  to  occur  in  congenital  anthrax, 
chicken  cholera,  suppurative  lesions,  and  tuberculosis  :  in  man  it  is  found 
in  pneumococcus  and  suppurative  infections,  in  typhoid  fever,  anthrax 
(malaria),  relapsing  fever  and  tuberculosis ;  and  is  assumed  to  exist  in 
measles,  scarlatina,  and  small-pox,  diseases  the  bacteriology  of  which  is 
still  obscure.  Where  placental  infection  occurs  the  micro-organisms  are 
taken  up  chiefly  by  the  foetal  liver ;  there,  according  to  Mafucci,  a  keen 
struggle  for  supremacy  occurs,  the  embryonic  gland  as  much  as  the  adult 
one  being  possessed  of  marked  defensive  capacity.  If  the  bacteria  prove 
victorious,  then  the  foetus  may  present  the  characteristic  lesions  produced 
by  the  infection  —  as  for  instance  in  many  cases  of  tuberculosis,  septi- 
cemia, or  pyaemia;  or  it  may  present  them  in  a  modified  form,  Avhich 
after  birth  may  assume  the  ordinary  appearance,  the  embryo  being,  as 
already  explained,  apparently  endowed  in  these  cases  with  a  more  or  less 
marked  resistance.  For  instance,  although  anthrax  bacilli,  typhoid  ba- 
cilli, and  pneumococci  may  pass  through  the  placental  circulation,  yet, 
as  Dr.  Welch  says,  "no  instance  has  been  observed  in  the  foetus  of  fully 
developed  anthrax  of  croupous  pneumonia,  or  of  intestinal  lesions  by  the 


558  SYSTEM   OF  MEDICINE 

typhoid  bacillus,  although,  in  several  recorded  instances  these  bacteria 
have  unquestionably  invaded  the  foetus  from  the  mother.  The  charac- 
teristic lesions  have,  however,  been  found  so  soon  after  birth  as  to  indi- 
cate positively  congenital  infection."  It  is  still  a  debated  point  whether 
the  healthy  placenta  will  allow  pathogenetic  organisms  to  pass  into  the 
foetal  circulation;  some  writers  assume  that  a  lesion  such  as  a  haemor- 
rhage, for  instance,  is  necessary.  It  seems,  however,  that  the  factor  is 
rather  one  of  the  time  or  duration  of  infection  and  of  the  virulence  of  the 
pathogenetic  organisms.  The  lesson  which  we  derive  from  these  various 
experiments  and  observations  on  the  foetal  infection  is  one  on  the  use  of 
the  term  heredity  in  respect  of  infective  diseases ;  a  strict  terminology  is, 
if  possible,  the  more  necessary  now  that  Weissmann's  hypotheses  have  so 
great  an  ascendency. 

Immunity 

Immunity  is  the  converse  of  predisposition,  and  as  we  distinguish 
between  a  natural  and  an  acquired  predisposition,  so  must  Ave  distinguish 
between  a  natural  and  an  acquired  immunity.  Again,  as  natural  resist- 
ance may  be  racial  or  individual,  so  conferred  immunity  may  be  merely 
a  temporary  and  personally  acquired  property,  or  it  may  be  more  per- 
manent and  transmissible  from  parent  to  offspring.  All  this  follows 
from  what  has  already  been  said  of  predisposition. 

It  is  a  diiiicult  task  in  a  few  general  words  to  give  a  clear  and 
adequate  account  of  the  assumed  nature  and  meaning  of  immunity,  a 
subject  which  has  been  made  the  common  fighting  ground  of  pathologists, 
physiologists,  biologists,  and  chemists,  and  which  as  yet  we  are  far  from 
understanding.  Theory  has  succeeded  theory ;  most  of  them  have  been 
but  passing  opinions,  many  have  been  based  on  the  unfounded  premises 
of  incomplete  research,  a  few  bear  the  stamp  of  patient  Avork  and  of  care- 
ful observation.  Most  theories  fail  in  their  exclusiveness  :  the  founder  of 
a  theory  selects  one  phenomenon,  which  under  given  conditions  occurs 
constantly,  and  makes  it  the  corner-stone  of  his  creed;  but  over  his 
corner-stone  he  forgets  the  bricks.  While  attempting  to  peer  into  the 
mysteries  of  immunity,  we  must  clearly  remember  how  limited  is  our 
knowledge  of  the  finer  cellular  processes,  of  tissue  chemistry,  and  of 
vital  reactions  and  reactivity.  Again,  our  notions  of  infection,  and  of 
the  process  and  mechanism  of  infection,  are  changing  continually,  as  they 
become  more  extensive  and  move  gradually  from  one  field  to  another, 
touching  now  on  chemistry,  now  on  biology.  Endless  factors  are  con- 
cerned which  require  consideration  and  reconsideration;  but  of  many  of 
these  factors,  uufortimately,  we  know  as  yet  but  little. 

Acquired  immunity  will  most  conveniently  introduce  us  to  the  study 
before  us.  A  susceptible  animal  may  be  rendered  resistant  against 
subsequent  infection  in  different  ways. 

(a)  The  natural  proclivity  to  an  infective  disease  may  be  removed  in  re- 
covery from  it.  This  is  Nature's  way,  and  it  has  given  us  the  key  to  the 
situation ;  individuals  who  have  successfully  struggled  through  an  inf ec- 


THE    GENERAL  PATHOLOGY   OF  INFECTION  559 

tion  become  more  resistant  against  future  attacks.  In  some  cases  this 
immunity  is  pemnanent,  or  at  least  of  long  duration  ;  in  others  it  is  only 
temporary.  Thus  recovery  from  variola,  typhoid  fever,  and  the  acute 
exanthemata,  syphilis,  yellow  fever,  mumps,  and  whooping-cough  implies 
an  immunity  which  lasts  for  years ;  while  a  successful  stand  against 
pneumonia  and  diphtheria  leads  but  to  a  passing  security.  In  some 
instances  no  immunity  is  apparent,  or  it  is  of  extremely  short  duration, 
as  in  erysipelas,  influenza,  and  cholera.  In  a  general  sense  it  seems  to  be 
the  rule  that  recovery  from  an  acquired  infection  is  followed  by  increased 
resistance  against  the  same.  This  principle  was  applied  in  the  practice 
of  variolation,  which  was  revived  and  introduced  into  Great  Britain  by 
Lady  Mary  Wortley  Montagu.  The  intentional  inoculation  with  vario- 
lous matter  was  generally  followed  by  a  mild  attack  of  small-pox  which 
conferred  on  the  individual  a  certain  degree  of  immunity.  The  obvious 
objections  to  so  dangerous  a  practice  cannot  be  considered  here. 

(6)  An  artificial  resistance  may  also  be  brought  about  by  biocxdation 
with  attenuated  virus,  meaning  by  virus  not  the  bacterial  products,  but 
the  living  micro-organisms  or  their  spores.  Vaccination,  whether  with 
humanised  or  calf  lymph,  is  protection  by  means  of  inoculation  with 
attenuated  small-pox  virus.  .There  can  no  longer  be  any  doubt  that  the 
variola  poison  becomes  attenuated  by  transmission  through  calves  or 
cows,  and  that  the  cow-pock  is  a  modified  form  of  variola  vera.  [See 
article  on  "Vaccination."]  This  method  was  established  somewhat  em- 
pirically, but  in  a  strictly  scientific  manner,  by  Jenner.  It  was  Pasteur, 
however,  who  recognised  protection  by  means  of  attenuated  virus  as 
a  principle.  He  immunised  hens  with  weakened  cultures  of  the  B. 
cholerse  gallinarum,  as  animals  are  made  resistant  against  anthrax, 
quarter-evil,  and  swine  fever,  by  inoculating  them  with  attenuated 
cultures  of  the  organisms  of  these  diseases.  Against  these  animal 
infections  Pasteur's  method  of  vaccination  has  proved  a  successful 
preventive  measure.  Although  in  the  laboratory  animals  are  easily 
rendered  immune  in  this  manner  against  the  various  bacterial  lesions, 
and  although  this  method  of  establishing  an  artificial  resistance  against 
fully  virulent  organisms  by  means  of  vaccination  with  less  virulent 
organisms  is  one  which  has  been  widely  used  in  experimental  work, 
yet  in  medical  as  compared  with  veterinary  practice  the  application 
of  preventive  vaccination  has  necessarily  been  limited.  In  fact,  if  we 
except  .Tenner's  system  of  vaccination  against  variola,  it  must  be  said 
that  the  only  disease  against  which  attenuated  inoculation  has  been 
tried  —  or  rather  is  being  tried  —  is  Asiatic  cholera.  The  principle  of 
Haffkine's  an ti choleraic  inoculations  is  practically  the  same  as  that  first 
pursued  by  Pasteur.     [See  article  on  "  Asiatic  Cholera."] 

(c)  Instead  of  using  attenuated  cultures,  small  doses  of  living  and,  fully 
virulent  organisms  may  be  employed  to  produce  an  artificial  immunity. 
Thus  1  c.c.  of  a  'fresh  broth  culture  of  the  B.  pyocyaneous  will  without 
fail  produce  a  fatal  septicsemia  in  a  rabbit;  but  if  we  inject  0-25  c.c.  the 
animal,  though  it  will  certainly  be  ill,  will  show  merely  local  changes, 


56o  SYSTEM  OF  MEDICINE 


and  recover  with  an  acquired  immunity.  To  mention  other  examples 
would  take  us  too  far.  In  most  cases  the  animal  tissues  can  light 
against  minimal  doses  of  bacteria,  and  perhaps  there  is  no  infective 
process  which  can  be  produced  by  a  single  unaided  bacterial  cell.  It 
requires  a  certain  minimum  dose,  which  varies  with  the  individual  sus- 
ceptibility, to  produce  a  lethal  effect;  the  body  can  resist  the  action 
of  subminimal  doses  of  living  bacteria,  so  that  we  must  assume  that 
the  tissues  possess  defensive  or  protective  mechanisms,  primitive  and 
slight,  perhaps,  but  capable  of  further  development.  Lubarsch  has 
shown  that  mice  and  guinea-pigs,  which  are  highly  susceptible  towards 
anthrax,  may  be  fatally  infected  by  a  few  bacilli,  while  the  tissues  of 
rabbits  are  capable  of  destroying  hundreds  of  bacilli  before  their  resist- 
ance, slight  though  it  be,  is  overtaxed.  There  are,  indeed,  numerous 
instances  of  animals  possessed  of  great  natural  resistance  being  liable  to 
infection  when  inoculated  with  large  or  enormous  doses  of  bacterial  cult- 
ures. This  explanation  may  not  apply  to  all  cases,  but  it  is  sufficiently 
established  to  justify  the  opinion  that  some  of  the  factors  of  immunity — > 
those,  that  is,  which  are  concerned  with  the  destruction  of  the  bacteria — 
are  vital  tissue  properties ;  in  fact,  that  some  of  the  germs  of  immunity 
are  innate.  The  minimal  lethal  dose,  of  course,  rises  and  falls  with  the 
virulence  of  the  culture,  and  the  virulence  depends  on  the  activity  of  the 
toxins,  which  is  to  great  extent  governed  by  the  tissue  susceptibilities; 
so  that  it  is  difficult  for  us  from  ever-changing  premises  to  draw  definite 
conclusions  or  laws.  Judging  from  experiments,  all  we  can  say  is  that 
an  animal  is  often  able  to  resist  living  pathogenetic  organisms,  if  injected 
in  smaller  doses.  In  all  such  cases  the  bacteria  die,  as  mere  saprophytes 
would  do,  in  the  living  tissues,  or  lead  to  abortive  lesions ;  Avhile  larger 
quantities  —  often  only  slightly  larger — will  readily  bring  about  death, 
whether  by  means  of  a  general  septicgemia  or  of  an  intoxication  or  of 
a  toxaemia.  But  our  knowledge  of  all  these  processes  is  so  limited  that 
we  must  guard  against  an  ex  uno  onines  argument ;  we  must  penetrate  to 
the  deeper  relations  of  the  facts,  and  must  not  be  led  away  by  superficia.1 
similarities. 

(d)  One  of  the  most  important  discoveries  in  this  field  for  research, 
one  which  has  entirely  altered  our  opinions  regarding  artificial  immunity, 
is  that  of  Salmon  ancl  Smith.  Until  their  investigations  were  made,  im- 
munity was  attempted  exclusively  by  bacterial  vaccination;  these  authors 
showed,  however,  that  it  is  possible  to  protect  against  an  infection  by 
means  of  the  inoculation,  not  only  of  the  living  bacteria,  but  also  of 
their  metabolic  products  or  toxins,  that  is,  by  means  of  chemical  vaccina- 
tion. Salmon  and  Smith  injected  pigeons  with  the  sterilised  products  of 
cultures  of  the  hog  cholera  bacillus,  and  thereby  rendered  them  resistant 
against  subsequent  infection  with  the  bacillus  itself.  The  matter  was 
taken  up  by  the  various  schools,  and  chemical  or  toxin  vaccination  soon 
became  the  most  useful  and  accepted  laboratory  method  for  procuring 
artificial  immunity ;  it  is  unnecessary,  therefore,  to  give  instances  of  the 
process. 


THE    GENERAL  PATHOLOGY  OF  LNFECTLON  561 

Until  this  discovery  was  made  iminimity  was  supposed  to  depend 
on  offensive  or  germicidal  influences  emanating  from  the  tissues ;  but 
then  it  became  evident  that  chemical  processes  must  be  concerned  in 
the  removal  of  a  natural  predisposition ;  that  is,  either  during  or  after 
the  act  of  protective  vaccination,  biochemical  changes  must  occur  in  the 
tissues  and  their  fluids,  by  which  the  body  is  rendered  resistant  against 
subsequent  infection  with  virulent  bacteria. 

In  most  cases  the  toxins  used  are  held  in  solution  by  the  liquid  cult- 
ure medium,  but  it  is  quite  immaterial  in  what  form  the  metabolic  prod- 
ucts are  given.  They  are  equally  potent  in  purer  forms  as  albumoses,  or 
peptones,  or  toxalbumins.  Indeed,  in  many  cases  it  suffices  to  inject 
the  dead  bodies  of  the  bacteria  —  that  is,  the  protoplasmic  substances  or 
proteins  of  their  cells  —  in  order  to  produce  an  immunity.  There  is 
probably  no  essential  difference  betiveen  the  processes  of  2)rotection  by  means 
of  toxin  and  protein  vaccination.  We  have  some  grounds  for  the  assump- 
tion that  the  toxins  which,  as  we  have  already  seen,  are  most  likely 
secreted  by  the  bacterial  cells,  must  at  one  time  or  another  exist  as  such 
in  the  substance  of  the  bacteria;  so  that,  while  injecting  these  so-called 
proteins,  we  inject  the  toxins.     To  this  subject  I  shall  retiirn. 

To  render  animals  immune  by  means  of  chemical  vaccination  we 
generally  use  either  attenuated  toxins,  or  minute  doses  of  the  virulent 
poison ;  and  gradually,  by  repeated  inoculations,  we  accustom  the  animal 
to  withstand  larger  doses :  we  aim,  that  is,  at  establishing  a  tolerance 
of  the  poison,  or,  as  the  German  expresses  it,  at  making  the  animal 
'' giftfest."  The  more  potent  the  toxin  the  more  cautiously  must  we 
proceed :  impatience  or  haste  may  destroy  the  careful  work  of  weeks  or 
months.  By  often  repeated  administration  of  toxins,  beginning  Avith 
minute  sublethal  doses  of  fully  virulent  poisons  or  with  larger  doses  of 
attenuated  toxins,  and  gradually  proceeding  with  increasing  doses  of 
highly  virulent  toxins,  the  degree  of  immunity  may  be  greatly  and  even 
enormously  raised.  Or  in  like  manner  we  may  begin  with  attenuated 
bacteria,  and  gradually  continue  with  increasing  quantities  of  living  viru- 
lent cultures.  This  method  of  continuous  vaccination  is  the  best  means 
of  obtaining  the  highest  degrees  of  protection  :  the  more  toxin  the  animal 
absorbs  the  greater  its  immunity  becomes.  If  for  a  time  we  give  sublethal 
doses  of  bacterial  toxins,  the  animal  soon  becomes  resistant  against  the 
minimal  lethal  doses,  and  even  against  larger  quantities,  showing  that 
the  process  of  immunisation  is  ''  accumulative."  Again,  although  at  first 
we  must  proceed  slowly  and  cautiously  with  subminimal  doses,  yet  when 
the  animal  has  been  once  rendered  proof  against  the  lethal  dose,  we  may 
proceed  more  quickly.  However,  although  in  this  manner  we  can  produce 
extremely  high  degrees  of  immunity,  there  is  a  limit  beyond  which  the 
acquired  resistance  cannot  be  raised.  If  we  persevere  with  our  injections, 
the  animal  may  gradually  lose  its  immunity  again,  waste,  or  die  acutely. 

Bouchard's  Hypothesis.  — Although  we  shall  leave  the  theoretical  dis- 
cussion of  immunity  until  we  have  reviewed,  more  or  less  in  historical 
ord(;r,  the  various  mcjthods  hitherto  employed,  it  is  well  to  discuss  an  im- 

VOL.    1  2    o 


562  SYSTEM  OF  MEDICINE 

portant  doctrine  which  is  associated  with  Bouchard's  name,  although 
many  other  investigators  have  concerned  themselves  with  it.  Because  it  is 
possible  to  produce  immunity  by  means  of  bacteria  deprived  of  their  toxins 
or  rendered  atoxic  by  means  of  attenuation,  Bouchard  and  Hiippe  assumed 
that  the  bacteria  secrete  protecting  substances  besides  their  deadly  toxins, 
and  that  these  protective  substances  —  which  either  enter  into  solution  if 
the  organisms  are  grown  in  liquid  media  or  are  retained  in  the  bacterial 
cells,  and  must  not  be  confounded  with  the  bacterial  proteins  —  when  in- 
corporated by  the  tissues  bring  about  the  immunity ;  so  that  the  immunity 
conferring  substances  and  the  toxic  bodies,  though  both  the  products  of 
bacterial  activity,  are  essentially  distinct.  The  fact  that  the  highest  degree 
of  immunity  is  produced  by  employing  the  most  virulent  toxins  or  cultures 
in  the  largest  possible  dose  reduces  this  notion  to  an  absurdity.  We  are 
capable  of  protecting  animals  against  snake  venom  or  tetanus  by  means 
of  continued  injections  of  the  respective  poisons,  beginning  with  minute 
doses  and  slowly  passing  on  to  large  doses,  till  eventually  we  render 
them  intensely  immune.  Since,  up  to  a  certain  limit,  the  resistance  pro- 
duced varies  with  the  amount  of  poison  injected,  we  cannot  logically  be- 
lieve that  the  toxic  substances  injected  into  the  tissues  are  combined  with 
an  immunising  substance  from  the  beginning,  but  we  must  suppose  that 
the  changes  in  the  animal  organism  which  result  in  immunity  are  pro- 
duced by  the  toxins.  Without  the  use  of  highly  virulent  cultures  or  of 
toxins  of  great  activity  it  is  impossible  to  obtain  a  high  degree  of  immunity. 
Another  point  of  importance,  especially  for  subsequent  theoretical  con- 
siderations, is  the  fact  that  after  successful  protection  the  animal  is  capable 
of  resisting  both  the  toxin  and  the  living  culture.  By  means  of  chemical 
or  toxin  vaccination  it  becomes  refractory  to  suhsequent  inoculation  tmtli  living 
cultures,  that  is,  to  a  bacterial  infection;  and  by  means  of  bacterial  vaccina- 
tion it  becomes  refractory  to  subsequent  inoculation  with  the  toxins,  that  is,  to 
bacterial  intoxication.  Though  it  is  easy  to  protect  an  animal  by  means  of 
toxin  against  the  bacteria  producing  that  toxin,  we  frequently  observe  that 
it  will  successfully  resist  the  bacterial  infection  at  a  time  when  it  is  still 
very  sensitive  to  the  toxin  itself.  But  if  we  persevere  it  will  in  time  become 
tolerant  of  the  poison  as  well.  Metschnikoff  at  one  time  thought  that  an 
animal  vaccinated  against  a  bactei-ial  culture  is  not  necessarily  proof 
against  the  poison  produced  by  that  culture.  He  quotes  experiments 
performed  by  others,  showing  that  by  chemical  vaccination  we  may  confer 
upon  rabbits,  in  a  few  days,  an  immunity  from  certain  infections  (vibrio 
Metschnikovii,  B.  pyocyaneus,  bacillus  of  hog  cholera,  pneumococcus)  yet 
the  animals  remain  as  sensitive  towards  the  toxins  of  these  organisms  as  if 
they  had  not  been  vaccinated  at  all.  These  observations,  however,  are 
based  on  insufficient  experiment ;  for  if  we  only  continue  long  enough  Avith 
the  inoculation  of  toxin  we  invariably  succeed  in  rendering  the  animal 
proof  against  intoxication.  Of  course  we  could  not  expect  an  animal 
treated  with  small  doses  of  poison  at  once  to  become  refractory  to  large 
doses  of  the  poison ;  there  are  proportions  in  all  things.  But  we  do  find 
—  for  instance,  in  the  case  of  cobra  poison  —  that  after  a  comparatively 


THE    GENERAL   PATHOLOGY   OF  INFECTION  563 

short  course  of  a  0-25  milligramme  dose,  the  animal  will  successfully 
resist  a  whole  milligramme  :  it  is  simply  a  question  of  time  and.  patience. 
The  same  is  true  of  all  bacterial  toxins  whether  we  use  tetano-toxin, 
diphtheria  toxin,  or  other  poisons  ;  if  the  animal  has  been  properly 
treated  with  gradually  increasing  doses  of  a  toxin,  it  becomes  proof 
against  both  infection  and  intoxication.  Immunit[i,  therefore,  implies 
resistance  against  the  bacteria  and  their  products.  The  importance  of 
this  law,  for  such  it  is,  we  shall  grasp  more  fully  presently  when  we 
come  to  discuss  the  theoretical  aspects  of  the  subject. 

(e)  The  experimental  study  of  immunity  gradually  disclosed  remark- 
able properties  of  the  animal  serum  and  the  tissue  fluids,  the  recognition 
of  which  formed  the  foundation  of  methods  of  protection  and  treatment 
adopted  at  the  present  time.  Fodor  showed  in  1887  that  the  fluids  of 
the  normal  living  body,  and  especially  blood,  are  germicidal,  are  capable, 
that  is,  of  destroying  bacterial  life.  Buchner,  Behring,  •Nuttall  and 
Nissen  extended  Fodor's  observations,  and  it  was  soon  learned  that  the 
antimicrobic  influences  of  blood  exist  also  in  the  serum,  and  moreover 
that  the  capacities  of  various  animals  are  very  diverse ;  that  is  to  say, 
the  blood  or  serum  of  the  various  species  of  animals  is  not  equally 
destructive  to  all  bacterial  forms  alike :  in  some  animals  it  either  has 
no  such  power,  or  it  is  harmful  only  to  certain  micro-organisms,  and 
harmless  to  others.  The  final  outcome  of  these  observations  we  find  in 
one  of  the  greatest  triumphs  of  preventive  medicine  since  Pasteur's 
earlier  discovery,  in  the  prevention  and  cure  of  infective  and  intoxica- 
tive  lesions  by  means  of  the  injection  of  serum  derived  from  protected 
animals.  Behring  step  by  step  built  up  the  law,  that  if  an  animal  has 
been  artificially  protected  against  a  piarticular  infective  agent,  its  blood  or 
serum  acquires  the  power,  when  injected  in  sufficient  quantity  into  another 
animal,  of  directly  transmitting  an  immunity  from  that  agent. 

Experimentally  this  law  is  so  firmly  established,  that  it  is  now  one 
of  the  articles  of  bacteriological  faith.  A  few  examples  may  be  men- 
tioned :  — 

(1)  Having  succeeded  in  the  artificial  protection  of  rabbits  and  other 
animals  against  tetanus,  Behring  and  Kitasato  (1890)  by  injecting  highly 
susceptible  white  mice  with  serum  derived  from  the  protected  animals, 
rendered  them  insusceptible  to  tetanic  infection  and  intoxication. 

(2)  Similarly  Behring  and  Wernicke  (1890  and  1891)  demonstrated 
that  the  blood  serum  of  animals  artificially  vaccinated  against  diphtheria 
has  the  power  of  protecting  susceptible  animals  against  an  infection  with 
the  diphtheria  bacillus,  or  against  an  intoxication  with  the  diphtheria 
toxin. 

(3)  Babes  and  Lepp  had  already  (1889)  shown  by  experiments  that 
the  blood  of  dogs  vaccinated  against  rabies,  when  injected  into  susceptible 
animals,  confers  a  certain  amount  of  protection  against  subsequent  in- 
oculation, and  concluded  from  their  observations  that  the  possibility  of 
vaccinating  with  the  fluids  and  codls  of  animals  which  have  been  rendered 
refractory  to  the  disease  must  be  admitted. 


5.64 


SYSTEM   OF  MEDICINE 


(4)  Ehiiich  (1891)  clearly  brought  forward  the  important  fact  that 
Behring's  law  applies  not  only  to  bacterial  intoxication,  but  also  to 
intoxications  with  other  organic  toxins.  He  succeeded  in  establishing  in 
mice  a  marked  tolerance  of  ricin  (obtained  from  castor  oil  beans),  and  of 
abrin  (obtained  from  jequerity  seeds),  by  administering  gradually  increas- 
ing doses  either  under  the  skin  or  by  the  mouth;  and  he  found  that  the 
serum  of  ricin-proof  animals  possesses  the  power  of  directly  transmitting 
a  resistance  against  ricin,  and  that  the  serum  of  abrin-proof  animals  is 
capable  of  producing  the  same  effect  with  regard  to  abrin.  These  obser- 
vations are  of  far-reaching  importance,  because  they  open  up  a  wider 
field  for  the  application  of  Behring's  method ;  and,  as  we  shall  see  later, 
they  emphasised,  from  the  theoretical  point  of  view,  the  conflicting  opin- 
ions on  immunity  which  at  that  time  Avere  stovitly  defended. 

It  would  take  us  too  far  to  enumerate  all  the  various  bacterial  infec- 
tions on  which  Behring's  law  has  been  tested  in  the  laboratory.  To 
give  a  convincing  proof,  however,  to  those  who  may  be  still  in  doubt,  it 
may  be  stated  that  the  protective  power  of  serum  obtained  from  animals 
rendered  immune  from  the  effects  of  bacterial  inoculations  has  been 
demonstrated  for  infections  with  mouse  septicsemia,  Friedlander's  pneu- 
monia bacillus,  Frankel's  pneumococcus,  the  typhoid  bacillus,  the  vibrios 
of  Asiatic  cholera,  B.  py  ocyaneus,  streptococci  and  staphylococci  pyogenes, 
B.  prodigiosus,  and  the  B.  coli  communis.  The  extensive  experiments  of 
Calmette,  recently  confirmed  by  Professor  Eraser,  prove  that  a  protec- 
tive serum  may  also  be  obtained  from  animals  gradually  rendered  proof 
against  various  kinds  of  aiiimal  poisons  such  as  snake  venoms,  physio- 
logically and  chemically  closely  allied  to  bacterial  toxins.  If  we  arrange 
these  facts  systematically,  we  shall  find  that  the  lesions  for  which  serum 
protection  has  been  tried  are  very  diverse.     They  include  — 

(i.)  Bacterial  infections  which  are  pre-eminently  intoxicative,  such 
as  tetanus  and  diphtheria,  in  which  the  bacilli,  in  larger  or  smaller 
numbers,  are  found  only,  or  chiefly,  at  the  seat  of  infection,  where  they 
produce  their  deadly  toxins. 

(ii.)  Bacterial  infections  in  which  the  organisms  spread  widely  into 
the  tissues  from  the  seat  of  inoculation,  either  along  the  lymph  channels 
or  by  means  of  the  circulation  (hsemic  infections). 

(iii.)  Direct  intoxications  with  the  poisons  manufactured  by  the  bac- 
teria, intoxications  with  other  animal  or  vegetable  poisons  belonging  to 
the  group  of  so-called  toxalbumins,  and  lastly,  intoxications  produced  by 
substances  the  real  nature  of  which  is  still  unknown,  for  example,  rabies. 

The  protective  serum  is,  therefore,  in  some  cases  active  against  the 
bacteria  themselves ;  in  others  against  their  products,  and  in  yet  others 
equally  powerful  against  the  effects  of  the  living  organisms  and  of  their 
toxins.  No  doubt  the  pathogenetic  bacteria  call  forth  the  lesions  and 
general  symptoms  of  the  disease  which  they  produce  by  means  of  their 
poisonous  activity ;  so  that,  although  the  obvious  pathological  phenomena 
considered  generally  appear  extremely  heterogeneous,  yet  the  common 
principle  of  intoxication  underlies  them  all.      It  would  almost  seem 


THE    GENERAL  PATHOLOGY   OF  INFECTION  565 

that  the  stronger  the  toxic  faculty  of  a  particular  organism,  the  less  dis- 
posed is  the  latter  to  invade  the  tissues  and  the  blood.  This  much  is  cer- 
tain that  an  animal,  whether  vaccinated  with  the  living  bacteria  or  with 
their  metabolic  products,  will,  when  once  protected,  give  a  serum  which 
is  essentially,  though  perhaps  not  indifferently,  active  both  against  a 
subsequent  infection  with  the  living  organisms  and  against  a  subsequent 
intoxication  with  the  toxins.  Since  the  poisonous  products  are  the  chief 
weapons  of  infection,  we  must  regard  the  action  of  the  protective  serum 
as  directed  especially  against  the  effect  of  the  poison  5  hence  this  serum 
has  been  called  "  antitoxin,"  an  ill-chosen  name. 

It  was  further  shown  by  Behring  and  his  pupils,  that  the  protective 
serum  can  exert  its  marvellous  power  even  afler  a  preceding  infection  — 
when  the  symptoms  of  disease  or  intoxication  have  already  appeared;  the 
protective  serum  is  therefore  also  curative.  It  is  obvious  that  to  bring  about 
a  cure  must  require  larger  quantities  of  serum  than  are  necessary  for  pro- 
tection ;  moreover,  the  chances  of  a  cure  vary  directly  with  the  promptness 
of  administration.  That  protective  serum  is  also  curative  is  firmly  estab- 
lished, so  far  as  experiment  goes,  for  all  the  various  processes  mentioned 
above,  including  intoxications  with  vegetable  and  animal  toxalbumins. 

There  is  a  striking  difference  between  immunity  produced  by  the 
inoculation  of  the  bacteria  themselves  and  their  toxins  —  whether  attenu- 
ated or  not,  and  immunity  produced  by  serum  injections.  In  the  former 
case  the  animal  gains  its  immunity  after  an  active  struggle  with  the 
disease  or  lesions  following  the  injection  or  intoxication;  in  the  latter 
case  there  is  no  struggle  with  disease,  and  no  reaction;  the  animal 
remains  passive,  while  the  immunity-conferring  substances  are  applied 
to  its  tissues.  On  account  of  this  essential  difference,  Ehrlich  distin- 
guished active  and  passive  immunity.  Passive  immunity  is  effected 
quickly,  is  less  persistent,  and  varies  with  the  amount  of  serum  used 
and  with  the  degree  of  immunity  of  the  animal  which  supplies  the 
serum.  Active  immunity,  on  the  other  hand,  does  not  appear  for  days, 
not  until  the  animal  has  passed  through  the  reactive  stage ;  then  it 
becomes  permanent,  and  is  proportional  to  the  intensity  of  the  reaction 
rather  than  to  the  amount  of  vaccine  used. 

(/)  Within  recent  years  it  has  also  been  shown  that  an  artificial 
immunity  may  be  produced  in  animals  by  feeding  them  either  with  the  living 
organisms  or  their  products.  Ehrlich  and  Fraser  have  applied  this  method 
in  the  case  of  the  vegetable  toxins  (abrin  and  ricin)  and  the  snake  venoms. 
An  animal  can  be  protected  also  against  tetanus,  diphtheria,  cholera, 
and  other  infections  in  this  manner;  and  what  is  more,  the  serum 
obtained  from  them  has  acquired  preventive  and  curative  powers. 

Although  other  methods  of  producing  artificial  immunity  in  animals 
have  been  described,  it  is  more  convenient  to  defer  the  consideration  of 
them ;  because  these  six  processes,  briefly  described,  form  a  progressive 
series  which  much  facilitates  the  theoretical  discussion.  To  this  discus- 
sion we  shall  now  pass  on. 

Theory  of  Acquired  Immunity.  —  A  number  of  hypotheses  have  been 


566  SYSTEM  OF  MEDICINE 

built  up  to  explain  the  processes  in  the  animal  body  by  which  the 
immunity  is  gradually  developed.  Many  of  these  have  been  but  ingen- 
ious speculations,  based  often  upon  a  single  process  observed,  it  may  be, 
with  brilliant  genius  and  acuity.  It  must  be  remembered  that  a  theory 
can  take  no  other  foundation  than  the  observation  and  experience  of 
conditions  recognised  or  recognisable  at  the  time ;  nor  can  it  be  tested 
in  advance  of  contemporary  knowledge.  Retrospectively  we  now  dis- 
card many  theories,  the  discussion  of  which  in  the  period  of  their 
ascendency  led  to  much  heated  controversy;  for  in  the  light  of  new 
discoveries  they  are  seen  to  be  incorrect  or  insufficient.  Many  theories 
fail  because  they  attempt  to  explain  a  process  by  selecting  a  particular 
factor  as  the  cause,  instead  of  recognising  in  it  what  it  actually  is,  a 
concomitant  variation.  As  I  have  given  the  methods  of  producing 
artificial  immunity  more  or  less  in  historic  order,  it  will  be  well  to 
consider  the  theories  of  acquired  immunity  in  the  same  manner. 

(a)  Pasteur's  hypothesis  of  exhaustion,  which  was  shared  by  Klebs, 
assumed  that  the  attenuated  micro-organisms,  which  were  injected  into 
the  animal  tissues  for  the  purpose  of  establishing  a  protection,  used  up 
and  thus  removed  from  the  body  certain  substances  of  vital  necessity 
for  the  bacteria  in  question;  and  that  the  animal  body  once  deprived 
of  these  substances  remained  permanently  exhausted,  so  that  if  bacteria 
of  the  same  kind  subsequently  obtain  access  to  the  tissues  they  find  no 
suitable  soil  for  further  development.  This  hypothesis  was  deduced 
from  test-tube  observations ;  for  evidently  a  given  amount  of  nutrient 
matter  can  only  offer  nourishment  to  a  certain  quantity  of  micro-organ- 
isms, and  when  the  soil  is  exhausted  growth  must  cease. 

(/3)  This  hypothesis  was  doomed  to  fall,  as  soon  as  it  became  known 
that  artificial  immunity  is  better  produced  by  the  administration  —  sub- 
cutaneous, intravenous,  or  gastric  —  not  of  the  bacteria,  but  of  their  metar- 
bolic  products,  substances  which  possess  no  life  and  cannot,  therefore, 
use  up  tissue  materials.  Starting  from  other  observations  on  the  growth 
of  bacteria  in  artificial  media,  Chauveau  and  others  had  already  preached 
the  theory  of  retention  ;  according  to  this  theory  the  bacteria  not  merely 
deprive  the  body  of  material  necessary  to  their  growth,  but  also  leave 
products  behind  which  are  absorbed,  accumulated,  and  retained.  The 
retention  of  these  substances  was  supposed  to  make  the  tissues  unsuitable 
for  subsequent  infection.  This  hypothesis  was  apparently  supported  by 
the  facts  of  protection  by  means  of  chemical  vaccination,  —  that  is,  protec- 
tion Avith  bacterial  toxin,  —  but  it  is  also  a  test-tube  argument ;  for  we 
know  that  many  organisms,  especially  those  which  produce  active  fer- 
mentations, either  by  primary  secretion  or  secondary  fermentation, 
manufacture  substances  which  are  deleterious  to  their  .own  further 
growth  and  activity.  The  yeast  cells,  for  instance,  by  forming  alcohol 
compass  their  own  death  and  destruction. 

Although  the  retention  hypothesis  is  much  nearer  the  truth  than 
Pasteur's  cruder  notion,  there  are  serious  objections  to  it  which  compel 
us  to  abandon  it,  and  these  are  — 


THE    GENERAL   PATHOLOGY  OF  INFECTION  567 

(i.)  The  artificial  immunity  is  frequently  of  long  duration,  and  we 
cannot  possibly  assume  that  such  a  xjermanent  change  from  suscepti- 
bility to  insusceptibility  could  be  due  to  the  absorption  and  retention  of 
soluble  toxins,  which,  so  far  as  we  know,  are  not  retained  by  the  body, 
but,  as  clinical  and  pathological  observations  prove,  are  readily  elimi- 
nated. In  many  cases  the  speciiic  toxins  can  easily  be  traced  in  the 
urine  during  the  development  of  immunity  by  chemical  vaccination. 

(ii.)  In  most,  or  in  almost  all  cases,  the  blood,  serum,  or  tissue 
juices  of  animals  artificially  protected  by  the  administration  of  bacterial 
poisons,  form  good  culture  media  for  the  micro-organisms  concerned. 
We  shall  discuss  this  point  more  fully  hereafter. 

(iii.)  An  artificial  immunity,  as  shown  above,  may  be  readily  broken 
down  by  interferences  which  can  hardly  affect  the  retention  of  the 
metabolic  bacterial  products.  There  can  be  no  doubt  that  the  stability 
of  an  acquired  immunity  must  be  due  to  reactive  virtues  acquired  by 
the  tissues  and  the  cells  themselves,  and  not  to  something  left  behind 
by  the  micro-organisms. 

(iv.)  Immunity  may  be  produced  by  the  injection  of  micro-organ- 
isms which  have  iDCCome  so  attenuated  as  to  be  little  more  than  mere 
saprophytes. 

(y)  It  is  the  merit  of  Metschnikoff  to  have  searched  for  a  cellular 
theory  of  immunity,  and  to  have  formulated  tlie.  theory  of  phagocytosis. 
This  has  already  been  fully  considered  in  the  article  on  Inflammation, 
where  all  the  important  phenomena  of  phagocytosis  are  described ;  the 
matter  need  not,  therefore,  be  re-opened  here.  Metschnikoff,  who  it 
must  be  remembered  built  up  his  theory  at  a  time  when  chemical  vac- 
cination with  bacterial  products  was  unknoAvn,  assumed  that  by  means 
of  inoculation  of  attenuated  micro-organisms  the  leucocytes  and  phago- 
cytes, incapable  at  first  of  fighting  against  bacteria  possessed  of  their 
full  virulence,  gradually  acquire,  by  adaptation  and  selection  of  the 
fittest,  the  power  of  ingesting  and  destroying  even  these.  If  such  ac- 
quired cell  properties  be  transmitted  from  cell  generation  to  cell  gener- 
ation, the  animal  body  becomes  protected  against  future  invasions. 

With  the  discovery  of  chemical  vaccination  and  serum  protection, 
Metschnikoff,  reluctant  to  abandon  his  theory,  had  to  modify  his  views 
continually.  He  assumed  that  the  injection  of  soluble  toxic  or  protective 
substances  into  the  body  has  an  "  educational  effect "  on  the  phagocytes, 
by  which  they  are  taught  to  overcome  bacteria  which  previously  were 
invincible.  Undoubtedly  phagocytosis  exists,  and  is  perhaps  one  of  the 
commonest  phenomena  of  immunity ;  but  it  is  not  permissible  to  speak,  as 
Metschnikoff  does,  of  an  "  education  of  leucocytes  to  attack  and  destroy 
bacteria";  let  us  substitute  the  real  word,  and  it  reads  ''acquired  im- 
munity of  leucocytes  enabling  them  to  remove  the  bacteria  which  come 
in  their  way."  If  we  do  this,  then  we  find  that  we  are  little  farther  than 
before;  we  have  merely  thrown  the  mystery  a  step  farther  back,  that  is, 
from  the  body  as  a  whole  to  a  small  cellular  portion  of  it,  the  phagocytes. 
Immunity  of  the  body  would  depend  on  immunity  of  the  leucocytes  and 


568  SYSTEM  OF  MEDICINE 

their  conversion  into  phagocytes.  But  how  do  the  leucocytes  acquire  im- 
munity ?  Metschnikoff  says  they  are  "  educated  "  to  attack,  "  educated  " 
to  conquer ;  obviously  this  is  no  explanation.  Furthermore,  no  pathol- 
ogist who  views  the  animal  body  as  a  complex  structure,  and  not  merely 
as  a  congeries  of  amoebae,  and  who  appreciates  the  adaptation  of  the  tis- 
sues to  diseased  conditions,  —  as  illustrated,  for  instance,  by  the  phenom-" 
ena  of  compensation,  —  can  assume  that  immunity,  a  general  process,  is 
brought  about  by  one  specified  set  of  cells.  Metschnikoff's  observations 
are  extremely  beautiful  and  almost  dramatic ;  we  admire  his  zeal  and 
penetration ;  but  the  advances  of  recent  years,  apart  from  any  other  con- 
siderations, compel  us  to  give  up  his  theory  unconditionally.  As  soon 
as  we  realise  that  the  symptoms  of  infective  lesions  depend  in  the  first 
instance  on  the  bacterial  toxins,  and  that  acquired  immunity  implies 
protection  against  the  poisons  as  svell  as  against  the  bacteria,  it  becomes 
evident  that  no  theory  of  artificial  immunity  can  be  correct  unless  it  ex- 
plains both  processes.  Phagocytosis  cannot  do  this,  hence  it  was  doomed 
as  an  exclusive  theory  to  fall.  So  long  as  the  bacterial  poison  is  not 
neutralised  or  destroyed  in  the  body,  it  matters  not  whether  the  bacteria 
are  eventually  killed  or  not.  An  animal  made  immune  from  a  living 
microbe  can  also  resist  the  toxin  of  such  microbe  to  varying  degrees,  and, 
conversely,  an  animal  rendered  proof  against  the  toxin  will  also  resist  the 
living  microbe.  Immunity  from  the  toxic  effects  cannot  be  explained 
by  means  of  phagocytosis.  The  proof  that  the  animal  body  possesses 
other  defensive  means  quite  independent  of  phagocytosis  has  contributed 
greatly  to  the  decline  and  fall  of  this  attractive  and  once  dominant  theory, 

(8)  This  proof  was  first  demonstrated  by  Grohmann  in  1884  and  by 
Fodor  in  1887,  who  clearly  showed  that  tlie  normal  tissue  fluids,  and  more 
especially  the  blood,  possess  marked  antimicrobic  p>Toperties.  These  earlier 
observations  were  followed  up,  especially  by  Nuttall,  Behring,  and  Buch- 
ner,  who  established  fvxrther  that  the  offensive  action  of  the  blood  has  its 
source  in  the  albuixunous  bodies  of  the  cell-free  serum,  which  no  doubt  are 
primarily  derived  from  the  cells,  wandering  or  fixed,  phagocytic  or  non- 
ingestive.  Buchner  and  Hankin  took  the  lead  in  explaining  this  action, 
and  suggested  that  the  destructive  power  of  serum  is  due  to  certain  pro- 
teid  substances  to  which,  unfortunately,  he  gave  the  name  of  alexins.  It 
must  not  be  assumed,  however,  that  the  blood  of  any  animal  has  a  general 
antimicrobic  action,  or  even  any  at  all.  In  some  cases  it  is  quite  power- 
less, and,  moreover,  its  potency  frequently  varies  in  different  members  of 
the  same  species.  As  these  observations,  however,  relate  to  natural  rather 
than  acquired  immunity,  their  discussion  must  be  deferred  for  a  while. 
Here  I  shall  make  an  attempt  to  explain,  if  this  be  possible,  the  law 
discovered  by  Behring,  that  an  animal  whose  resistance  to  a  bacterial 
disease  has  been  considerably  increased,  possesses  a  blood  capable  of 
neutralising  an  infection  or  intoxication  of  the  same  bacterial  origin. 

(e)  It  was  shown  by  Behring  and  others  that,  speaking  generally,  the 
blood  serum  of  naturally  immune  animals  does  not  possess  any  or  but  slight 
antimicrobic,  antitoxic,  or  protective  properties.     Thus,  for  instance,  the 


THE    GENERAL  PATHOLOGY   OF  LNFECTIOM  569 

serum  of  a  hen,  which  is -naturally  refractory  to  tetanus,  cannot  protect 
other  animals,  nor  can  it  "  neutralise  "  the  tetanus  poison.  There  are 
instances,  it  is  true,  where  the  serum  of  naturally  immune  animals  pos- 
sesses a  germicidal  power  J  rat's  serum,  for  example,  will  destroy  anthrax 
bacilli,  but  that  of  mice,  guinea-pigs,  rabbits,  sheep  and  cattle,  all  nat- 
urally susceptible  animals,  is  without  effect.  There  are  a  few  cases  of 
such  correlation  between  natural  immunity  and  the  antimicrobic  power 
of  the  blood,  but  they  must  be  regarded  as  exceptions ;  we  cannot  ex- 
plain a  specifically  acquired  immunity  by  merely  assiiming  that  an  in- 
crease of  a  natural  pre-existing  germicidal  power  has  taken  place ;  it 
must  be  due  to  accpiired  and  superadded  changes.  The  best  corrobora- 
tion of  this  opinion  is  the  fact  that  if  tetanus  bacilli  or  their  toxin  be 
injected  into  the  refractory  hen,  its  serum  is  thereby  rendered  active 
against  tetanus.  Hence,  in  the  first  place,  it  is  necessary  that  even  in 
refractory  animals  reactive  changes  should  be  produced  before  their  se- 
rum becomes  in  any  way  protective  for  others.  The  tissue  cells,  there- 
fore, are  primarily  brought  into  conflict  with  the  bacteria  and  their 
products,  and,  if  they  conquer,  it  is  by  virtue  of  antagonistic  substances, 
which  are  produced  by  them  partly  anew,  partly  out  of  existing  ele- 
ments, are  absorbed  or  dissolved  by  the  body  fluids,  and  are  thus  dis- 
tributed through  the  animal  organism.  By  renewing  the  struggle  from 
time  to  time  we  can  raise  the  power  of  these  antagonistic  substances ; 
and  the  keener  the  battle,  that  is,  tlie  more  susceptible  the  animal  ivas,  the 
stronger  this  j^ower  ivill  be.  Further,  the  action  of  the  protective  serum  is 
specific,  that  is,  the  serum  of  an  animal  rendered  immune  from  a  par- 
ticular infection  will  with  certainty  protect  other  animals  against  this 
infection  only.  Although  this  assertion  must  be  accej)ted  with  certain 
reservations,  at  present  the  evidence  against  it,  as  a  general  jDrinciple, 
so  far  as  bacterial  infections  or  intoxications  are  concerned,  is  not  strong 
enough  to  raise  grave  doubt  or  to  invite  discussion  here.  There  are 
numerous  varieties  of  cholera  vibrios  which  apparently  are  closely  allied ; 
yet  an  animal  rendered  immune  by  specific  inoculation  from  the  infec- 
tion of  one  of  these  will  produce  a  serum  active  against  this  variety, 
powerless  against  others.  Again,  closely  as  the  pathological  effects  pro- 
duced by  the  streptococci  and  staphylococci  resemble  each  other,  yet  an 
anti-streptococcus  serum  is  useless  against  the  staphylococci.  And  yet 
again,  although  by  means  of  intra-peritoneal  injections  of  the  B.  pro- 
digiosus  it  is  possible  to  protect  rabbits  against  intra-peritoneal  injec- 
tions of  the  B.  pyocyaneus,  nevertheless  the  serum  of  an  animal  protected 
against  the  B.  profligiosus  cannot  render  another  animal  immune  with 
regard  to  the  B.  pyocyaneus,  although  the  serum  of  animals  protected 
simultaneously  against  both  the  B.  prodigiosus  and  the  B.  pyocyaneus  will 
pi-otect  against  both  infections.  We  shall  come  back  to  this  argument. 
IIov:  does  the  protective  serum  act?  Does  it  act  (1)  as  an  antidote  to 
the  toxins,  or  (2)  as  lethal  to  the  bacteria  ?  If  we  mix  in  a  test-tube  a 
certain  quantity  of  diphtheria  or  tetanus  toxin  with  the  necessary  amount 
of  the  corresjjonding  serum,  the  mixture  injected  into  an  animal  is  harm- 


570  SYSTEM  OF  MED  I  CINE 


less,  the  poison  appears  to  be  neutralised.  Recent  observations  by  Buchner 
and  others  seem,  however,  to  contradict  this  assumption,  seductive  as  it 
is  on  account  of  its  simplicity.  A  neutralisation,  as  Behring  pictured  it 
to  his  mind,  comparable  to  that  combination  of  an  acid  with  an  alkali, 
which,  by  means  of  chemical  or  physiological  interaction,  leads  to  a  neu- 
tral compound,  can  hardly  be  the  explanation  of  the  marvellous  phe- 
nomena, because  it  has  been  found  that  the  apparently  neutralised  mixt- 
ure, though  harmless  for  less  susceptible  animals,  possesses  a  highly  toxic 
action  on  more  susceptible  animals  or  on  weakened  individuals  of  the 
same  species.  Thus  Buchner  has  demonstrated  that  a  mixture  of  tetano- 
toxin  with  tetanus  serum,  in  the  exact  proportion  which  renders  it  impo- 
tent for  mice,  is  still  toxic  for  guinea-pigs  which  are  much  more  susceptible 
than  the  smaller  rodents;  and  Roux  and  Vaillard  have  shown  that  a  mixt- 
ure of  diphtheria  toxin  and  antitoxin,  harmless  for  vigorous  guinea-pigs, 
will  kill  weakened  individuals.  We  cannot  then  assume  that  the  poison 
has  been  permanently  destroyed  by  the  serum.  It  has,  therefore,  been 
thought  that  the  protective  bodies  do  not  directly  attack  the  toxins,  but 
act  by  producing  a  resistance  of  the  tissues  so  rapidly  that  on  injecting 
the  toxin  together  with  the  antagonistic  serum  we  have,  so  to  speak,  a 
race  between  immunity  and  intoxication.  Objections  may  be  raised  to 
this  view  also,  and  with  our  imperfect  knoAvledge  we  cannot  give  a  cast- 
ing vote  for  one  theory  or  the  other.  Frankel  assumes,  so  far  as  the  anti- 
toxic power  of  the  protective  serum  is  concerned,  that  the  toxin  and  the 
antagonistic  substances  (generally  called  antitoxins),  though  they  do  not 
neutralise  one  another  so  as  to  form  a  harmless  stable  compound,  enter 
nevertheless  into  a  looser  combination  which  results  in  a  temporary  sus- 
pension of  the  poisonous  activity  of  the  toxic  constituent ;  a  combination 
which  may,  however,  under  special  conditions  be  split,  and  the  toxic  con- 
stituent once  more  become  free.  We  have  as  yet  no  proof  in  favour  of 
such  an  hypothesis.  Moreover,  we  must  not  forget  that  there  is  no  abso- 
lute standard  of  virulence  or  toxic  effect,  that  the  toxic  coefficient  must 
naturally  vary  for  each  animal ;  thus  in  estimating  whether  a  poison  has 
been  really  rendered  inocuous  we  must  use  the  most  susceptible  animals. 
We  shall  then  find  that  a  toxin  to  which  serum  has  been  added  so  as  to 
neutralise  it  for  such  animals  will  be  harmless  for  all  others.  A  more  or 
less  refractory  animal  is,  from  its  very  nature,  able  to  account  for  a 
greater  or  less  fraction  of  the  poison,  so  that  the  protective  serum  is  only 
called  upon  to  neutralise  the  surplus.  This  may  explain  Buchner's  diffi- 
culty, that  a  mixture  of  tetanus  toxin  and  anti-tetanic  serum,  though 
harmless  to  the  more  refractory  mouse,  is  still  harmful  to  the  more  sus- 
ceptible guinea-pig.  At  present  it  seems  more  reasonable  to  accept  the 
antitoxic  or  neutralising  power  of  the  protective  serum  —  not  indeed  as 
an  ordinary  test-tube  reaction,  but  rather  as  a  vital  cellular  change.  Yet 
since  the  toxic  value  is  a  relative  quantity  varying  with  each  species  of 
animals,  the  antitoxic  value  must  also  be  a  relative  quantity. 

In  the  next  place  we  must  ask  (2)  whether  this  serum  possesses  any  de- 
structive action  on  the  bacteria  themselves ;  is  it  antimicrobic  ?  Though 
formerly  it  was  assumed  to  act  as  a  direct  poison  to  the  bacteria,  after 


THE    GENERAL   PATHOLOGY  OE  INFECTION  ll\ 


the  manner  of  a  disinfectant ;  or  to  contain  substances  which,  when  in 
contact  with  the  tissues  and  their  juices,  render  these  destructive  to 
microbic  life ;  yet  it  was  soon  recognised  that  acquired  immunity  can- 
not be  explained  by  the  germicidal  effect  of  the  serum  itself,  or  by  a 
germicidal  quality  induced  in  the  animal  body. 

Experiments  show  that  anti-diphtheritic  and  anti-tetanic  serum  form 
by  no  means  unfavourable  culture  media  for  the  respective  bacilli, 
though  it  is  certain  that  on  administering  these  protective  fluids  to- 
gether with  the  organisms,  the  latter  are  arrested  in  their  growth  or 
eventually  even  destroyed.  Earlier  observations  made  it  appear  that  the 
serum  of  a  protected  animal  is  distinctly  germicidal;  thus,  although  the 
vibrio  of  Metschnikoff,  for  instance,  thrives  well  in  a  serum  obtained 
from  a  normal  gitinea-pig,  when  this  animal  has  been  rendered  immune 
its  serum  will  no  longer  allow  the  vibrios  to  flourish.  But  as  in  the  case 
of  natural  immunity,  it  is  quite  the  exception  to  find  a  germicidal  serum, 
so  we  find  also  that  the  serum  obtained  from  a  protected  animal  seldom 
has  this  property.  So  far  as  the  direct  destructive  power  of  protective 
serum,  measured  by  test-tube  reactions  and  phenomena,  is  concerned,  we 
find  so  little  correlation  between  artificial  immunity  and  bacterial  de- 
struction, that  we  cannot  look  for  an  explanation  of  acquired  immunity  in 
a  change  of  the  serum  from  a  nutritive  to  a  destructive  one.  Yet  we  find 
that  in  the  animal  body  the  protective  serum  will  prevent  lesions  essen- 
tially infective,  such  lesions,  for  example,  as  a  septicaemia  dependent  on  a 
general  overgrowth  and  diffusion  of  the  bacteria  throughout  the  tissues. 

Bouchard  and  his  school  assumed  that  the  process  of  protection  alters 
the  serum  in  such  a  manner  as  to  render  it  attenuating ;  so  that  although 
it  may  be  unable  to  destroy  bacterial  life,  it  nevertheless  becomes  capable 
of  altering  the  chemical  and  toxic  activity  of  the  organism  concerned  to 
such  an  extent  that  it  ceases  to  be  virulent.  Thus  anthrax  bacilli  grown 
in  the  serum  or  blood  of  vaccinated  sheep  apparently  lose  their  virulence ; 
so  do  erysipelas  cocci  cultivated  in  serum  of  protected  animals  ;  and  the 
same  rule  applies  to  the  pneumococcus  and  B.  pyocyaneus.  Although 
these  observations  directly  refute  the  theory  which  assumes  that  artificial 
protections  lead  to  the  formation  of  germicidal  substances  in  the  blood, 
they  would  seem  to  show  that  these  processes  endow  the  tissue  fluids 
with  a  marked  attenuating  power,  so  that  deadly  organisms  grown  in  them 
become  capable  of  producing  more  than  a  passing  and  insignificant  lesion. 
Metschnikoff,  however,  has  conclusively  demonstrated  the  incorrectness 
of  this  supposition.  Firstly,  this  attenuating  effect  is  not  a  constant 
result  of  acquired  immunity ;  secondly,  it  is  merely  apparent  and  very 
transitory,  while  true  attenuation  is  a  more  lasting  change ;  thirdly,  if 
we  separate  the  bacteria  from  the  serum  in  which  they  grow  by  means 
of  filtration  and  washing,  we  find  their  virulence  restored,  so  that  the 
diminished  virulence  must  be  due  to  the  specific  action  on  the  animal 
organism  of  a  protective  substance  hidden  in  the  serum.  Artificial  im- 
mumtj/,  therefore,  depends  neither  on  a  ^^ direct"  germicidal  nor  on  an 
attenuating  pouter  acquired  by  the  serum  and  fluids  of  the  protected  animal. 


572 


SYSTEM  OF  MEDICINE 


Although,  while  working  in  the  laboratory  with  test-tubes  and  serum, 
we  find  that  the  protective  serum  itself  is  neither  attenuating  nor  con- 
sistently bactericidal,  nevertheless  it  is  certain  that  the  processes  in  the 
body  are  very  different.  There  can  be  no  doubt,  in  spite  of  Metschnikoff's 
objections,  that  when  we  inject  cholera  vibrios  intra-peritoneally  into  a 
protected  animal,  crowds  of  them  die  in  the  peritoneal  fluid  without  any 
direct  interference  on  the  part  of  the  cells  —  without  phagocytosis.  Con- 
versely if  we  administer  the  a.nti-diphtheritic  serum  to  patients  and  ex- 
amine their  tonsillar  or  faucial  membranes  from  day  to  day,  we  shall 
frequently  find  that  legions  of  diphtheria  bacilli  die  an  extracellular 
death.  Similarly  after  the  pneumonic  crisis,  which  marks  the  period  of 
acquired  immunity,  the  diplococci  die  in  large  numbers  without  direct 
conflict  with  the  cells.  Hence,  though  our  test-tube  observations  may 
point  the  other  way,  we  are  forced  to  assume  that  during  the  process  of 
recovery  which  ends  in  acquired  immunity  the  body  becomes  so  greatly 
altered  that  its  tissues  and  fluids  become  not  only  antitoxic,  but  also 
germicidal.  These  are  two  distinct  and  specifically  acquired  properties 
which  serve  to  protect  the  body  when  its  immunity  is  threatened. 

Hence  the  secret  of  an  artilicial  specific  immunity  must  be  sought  for 
in  peculiar  vital  changes  produced  in  the  animal  organisms  by  various 
processes,  either  actively  or  passively  specific.  An  active  immunity,  as 
already  explained,  is  produced  by  inoculation  with  living  organisms  and 
their  products,  the  resistance  being  acquired  after  an  active  struggle 
against  the  causes  of  disease ;  a  passive  immunity  is  produced  by  the 
administration  of  the  specific  serum,  the  resistance  being  acquired,  with- 
out an  active  struggle,  by  a  peculiar  modification  brought  about  under  the 
influence  of  certain  specific  substances.  The  chief  difference  between  the 
unprotected  and  the  actively  protected  animal  is  that  the  serum  or  tissue 
extracts  of  the  latter  possess  a  specifically  immunising  power.  Since 
this  change  affects  all  tissues,  it  is  evident  that,  as  the  animal  passes 
from  the  susceptible  to  the  immune  state,  we  are  dealing  not  merely 
with  a  modification  of  this  or  the  other  fluid  or  cell,  but  with  a  general 
reaction.  Acquired  immunity  does  not  depend  on  resistance  acquired 
by  certain  cells  or  elements  alone ;  Avhen  once  produced  it  finds  expres- 
sion in  vital  germicidal  and  antitoxic  properties  acquired  by  the  tissues 
and  their  fluids.  It  is  obvious  that  a  struggle  against  pathogenetic  bac- 
teria can  only  end  successfully  if  these  are  eventually  destroyed,  and 
their  toxic  products  rendered  harmless.  The  conception,  therefore,  of  an 
acquired  immunity  depending  on  phagocytosis  alone,  is  absurdly  narrow 
and  incomplete.  The  toxins  being  the  most  dangerous  weapons  of  the 
bacteria,  the  antitoxic  reaction  of  the  tissues  is  no  doubt  the  more  im- 
portant modification;  but  histological  bacterioscopic  and  clinical  investi- 
gations show  clearly  that  with  the  appearance  of  immunity  and  recovery 
the  micro-orga-nisms  also  die.  Their  death  is  due  (a)  to  action  of  the 
cells,  or  phagocytosis,  but  also  (h)  to  extracellular  destruction.  Phago- 
cytosis is  therefore  merely  one  factor  of  immunity,  one,  indeed,  not 
invariably  present,  nor,  when  present,  equally  important  in  all  cases. 


THE    GENERAL   PATHOLOGY   OF  INFECTION  573 

It  may  be  present  although  the  animal  die  from  the  effect  of  intoxication. 
It  is  futile  then,  as  we  have  seen,  to  enter  at  the  present  time  into 
further  discussion  when  the  advances  of  our  knowledge  so  clearly  indi- 
cate the  limitations  of  the  phagocytic  theory. 

Artificial  immunity,  therefore,  to  state  it  once  more,  depends  on 
processes  which  render  the  tissues  capable  of  (a)  destroying  bacterial  life, 
and  (&)  of  rendering  the  products  of  bacterial  activity  inert ;  destruction 
of  the  bacteria  themselves  is  not  sufficient  to  save  the  animal,  unless  the 
toxins  are  also  accounted  for,  or  unless  the  bacteria  are  destroyed  before 
they  have  time  to  form  their  toxins.  It  is  conceivable  that  an  animal 
may  survive,  if  the  poison  alone  be  destroyed  or  rendered  inert,  but  it 
is  a  matter  of  experimental  as  well  as  of  clinical  observation  that  antitoxic 
processes  in  the  body  are  almost  invariably  accompanied  by  antimicrobic 
effects.  A  protected  animal  reacts  to  an  infection  with  local  inflammatory 
changes  which  soon  pass  off ;  the  bacteria  disappear  without  their  prod- 
ucts having  had  a  fair  chance  of  displaying  their  existence  and  activity. 
Inasmuch  as  phagocytosis  is  a  common  j^henomenon  in  an  inflammatory 
process,  leading  to  resolution  and  repair,  it  will  also  show  itself  concur- 
rently with  immunity ;  but  the  essence  or  cause  of  immunity  it  cannot 
possibly  be. 

As  yet  we  have  no  certain  knowledge  of  these  antimicrobic  and 
antitoxic  substances.  It  seems  erroneous  to  assume  that  the  germi- 
cidal serum  or  tissue  extracts  contain  these  matters  in  the  form  in 
which  they  subsequently  appear  in  the  animal  body.  It  is  more  reason- 
able to  assume  that  they  are  called  into  existence  by  the  action  of  the 
serum,  or  of  substances  contained  in  the  serum,  on  the  tissues ;  this  is 
certainly  the  case  so  far  as  the  germicidal  properties  of  the  immunised 
tissues  are  concerned,  for  the  protective  serum  in  the  test-tube  but  rarely 
possesses  any  such  properties,  while  the  animal  body  certainly  does. 
Again,  by  means  of  chemical  vaccination  we  render  an  animal  refractory, 
so  that  its  tissues  are  able,  both  by  intracellular  and  extracellular  action, 
to  destroy  the  microbe,  and  yet  this  germicidal  virtue  is  rarely  trans- 
mitted to  the  serum.  It  has  also  been  shown  that  after  heating,  which, 
as  we  know,  removes  all  possible  germicidal  and  antitoxic  powers  it  may 
possess,  the  protective  serum  inoculated  into  an  animal  is  still  capable  of 
conferring  immunity  to  the  tissues  and  their  juices  by  virtue  of  which  they 
are  able  to  overcome  a  bacterial  infection.  With  regard  to  the  antitoxic 
effect  it  is  still  more  difficult  to  come  to  a  definite  conclusion.  At  first 
sight  we  might  ask  why  we  shoidd  require  a  different  explanation  here  ? 
In  almost  all,  if  not  in  all  cases,  it  takes  a  long  course  of  inoculation  with 
toxins  to  generate  a  weak  antitoxic  serum  ;  but  when  the  animal  is  once 
immune  its  total  serum  will  give  much  more  antitoxin  than  corresponds  to 
the  dose  of  poison  against  which  it  has  been  protected.  Roux  has  further 
shown  that  the  same  quantity  of  toxin  given  in  many  small  doses  leads  to 
a  greater  store  of  antitoxin  in  the  tissues  than  when  given  in  a  single  large 
dose.  Lastly,  wo  have  the  observations  alluded  to  above,  that  a  mixture 
of  serum  and  toxin,  apparently  neutral  for  one  group  of  animals,  is  still 


574  SYSTEM   OF  MEDICINE 

toxic  for  more  susceptible  animals;  or  to  put  it  otherwise,  "clinically 
cure  does  not  follow  the  introduction  of  the  serum  with  the  certainty 
and  precision  of  a  chemical  reaction  "  (Welch).  It  is,  therefore,  in  all 
probability  incorrect  to  suppose  that  the  protective  serum  has  a  "direct" 
antitoxic  and  germicidal  action  which  it  shares  with  the  tissues ;  the 
changes,  induced  by  the  injected  serum,  which  render  the  tissues  and  their 
fluids  both  antimicrobic  and  antitoxic,  have  a  specifically  vital  character. 

Buchner  has  made  attempts  to  separate  the  antitoxic  bodies  from 
serum  in  a  more  definite  form.  All  attempts  to  obtain  them  in  a  pure 
state  have  failed,  and  in  the  present  state  of  physiological  chemistry 
must  fail.  The  serum  may  be  dried  in  vacuo  and  still  retain  its  remark- 
able properties ;  it  may  be  precipitated  by  sodium-ammonium  sulphate  in 
the  form  of  a  highly  antitoxic  powder.  Heat  destroys  the  action  of  the 
antitoxins,  but  with  some  difficulty,  they  are  resistant  also  to  light  and 
putrefaction,  and  in  many  respects  they  resemble  the  enzymes.  Buch- 
ner's  own  view  is  that  the  antitoxins  are  substances  directly  derived  from 
the  bacterial  plasma.  There  is,  however,  no  definite  evidence  in  favour 
of  this  assumption,  and  for  the  time  being  we  must  confess  our  ignorance 
of  the  nature  of  these  protective  and  curative  substances. 

Whatevel'  the  nature  of  these  so-called  antitoxins  of  bacterial  origin 
may  be,  their  action  is  specific;  that  is,  an  anti-diphtheritic  serum,  from 
whatsoever  animal  obtained,  will  immunise  against  diphtheria  alone. 
Most  experiments,  as  I  have  said,  tend  to  prove  this  point ;  and  the  recent 
attempt  made,  especially  by  the  French  school,  to  cast  doubt  on  this  prop- 
osition, does  not  as  yet  carry  conviction.  It  is  true  that  Calmette  has 
shown  not  only  that  by  gradually  rendering  animals  proof  against  snake 
poison,  their  serum  in  this  case  likewise  becomes  protective  and  curative, 
but  also  that  the  serum  of  an  animal  inoculated  against  cobra  venom  will 
counteract  the  effects  of  the  venom  of  other  snakes ;  yet  this  exception  is 
but  apparent,  as  it  appears  from  their  physiological  or  pathological  action 
that  the  snake  venoms  generally  employed  belong  to  one  physiological 
group.  Calmette,  however,  claims  that  anti-tetanic  serum  also  works 
antagonistically  to  snake  poison.  But  recent  experiments  show  that  this 
view  of  the  absence  of  specificit}^  rests  on  an  insufiiciently  sound  basis,  and 
applies  perhaps  more  to  the  antitoxins  prepared  for  poisons  of  non-bacte- 
rial origin ;  so  that  the  specificity  of  antitoxic  serum,  for  infective  lesions 
at  least,  cannot  as  yet  be  denied.  The  most  important  feature  of  the  ob- 
servations on  snake  poison  is  the  fact,  already  demonstrated  by  Ehrlich, 
that  what  can  be  done  against  the  bacterial  toxins  can  also  be  effected 
against  the  chemically  and  physiologically  allied  animal  or  vegetable  poi- 
sons. Attempts  to  obtain  a  protective  serum  against  the  vegetable  alka- 
loids by  means  of  gradually  increasing  inoculations  have  hitherto  failed. 

The  view  that  the  aiititoxins  are  modified  toxins  or  direct  derivatives 
from  the  mycoproteins  is  disproved  by  Houx's  experiments,  who  showed 
that  a  horse  strongly  protected  against  diphtheria  toxin,  if  bled,  gives  a 
serum  of  certain  value ;  if  bled  again  a  little  time  later,  its  serum  will 
have  the  same  value  as  that  first  removed,  although  no  poison  has  been 


THE    GENERAL   PATHOLOGY   OF  LNFECTION  575 

administered  in  the  meantime  to  raise  the  immunity.  Hence,  fresh 
antitoxin  must  have  been  produced  without  fresh  inoculation  with  toxin. 
Antitoxin  must,  tlierefore,  be  a  direct  product  of  tlie  cells  by  virtue  of 
acquired  secretory  changes,  and  its  action  must  also  be  directly  cellular. 

This  sketchy  and  elementary  survey  of  the  subject  of  Acquired 
Immunity  must  suffice,  since  the  whole  subject  is  one  which  readily 
invites  siDCCulation  which  may  hardly  prove  profitable,  and  would  at  any 
rate  fall  beyond  the  scope  of  a  general  article. 

Natural  Immunity.  —  While  discussing  predisposition  we  have  fre- 
quently alluded  to  natural  resistance  and  immunity,  so  that  here  a  few 
brief  remarks  will  suffice.  Natural  immunity,  like  predisposition,  may  be 
individual  or  personal,  or  may  belong  to  all  the  members  of  a  species  or  a 
race.  Amongst  animals,  for  instance,  we  find  that  Algerian  sheep  are 
resistant  to  anthrax,  an  infection  very  fatal  to  other  sheep ;  and  we  have 
already  commented  upon  the  marked  insusceptibility  of  negroes  to  yellow 
fever  and  ague,  which  amounts  almost  to  immunity.  Carnivora  generally 
are  distinguished  by  a  marked  degree  of  resistance  to  anthrax  and  septic 
infection,  which  is  almost  equivalent  to  exemption.  Racial  immunity  to  a 
great  extent  must  have  been  acquired  by  natural  selection  and  inheritance, 
as  the  more  refractory  members  survive ;  and  since  the  properties  to 
which  they  owe  their  survival  are  of  benefit  to  the  species,  we  may  assume 
that  they  are  readily  transmitted  by  heredity.  The  influence  of  bacterial 
diseases  on  the  origin  of  species  has  not  received  as  yet  due  attention,  nor 
again  this  influence  on  the  extermination  of  species.  This  is  not  the  place 
to  consider  this  question ;  but  I  may  point  out  that  there  is  sufficient 
historic  evidence  to  suggest  that  continued  exposure  to  an  infection  tends 
to  establish  a  racial  resistance,  for  we  find  that  the  commoner  infective 
fevers  when  introduced  amongst  a  population  unacquainted  with  them, 
assume  a  most  malignant  and  fatal  form. 

Natural  immunity  may  be  either  absolute  or  relative  according  to  its 
intensity.  But  few  animals  are  absolutely  immune,  for  in  most  cases  it 
is  possible  to  infect  them,  without  otherwise  interfering  with  them,  by 
inoculating  excessive  quantities  of  bacteria  into  their  tissues,  or  by 
introducing  the  germs  in  special  regions  of  the  body.  An  animal  though 
able  to  resist  large  doses  injected  subcutaneously,  may  readily  succumb 
to  intra-peritoneal  inoculations ;  while  in  other  cases  intra-peritoneal 
inoculations  may  be  resisted  when  subcutaneous  infection  proves  fatal. 
This  opens  up  the  broad  question  of  local  immunity,  which  at  present  is 
beyond  the  reach  of  an  answer.  A  personal  immunity  may  be  merely 
temporary,  and  then  it  is  often  apparent  rather  than  real.  When  we 
find,  for  instance,  that  during  an  epidemic  a  certain  number  of  people  re- 
main intact,  this  exemption  is  not  necessarily  due  to  a  natural  insuscepti- 
bility, but  in  some  cases  may  be  explained  by  assuming  (1)  that  there 
was  no  exposure  to  the  contagion,  or  (2)  that  certain  external  conditions 
required  for  a  successful  infection  were  absent.  An  individual  who  has 
escaped  during  one  epidemic  may  become  infected  subsequently  ;  either 
because  his  immunity  was  only  temporary,  or  because  in  the  meantime  he 


576  SYSTEM  OF  MEDICINE 


has  acquired  the  Becessary  disposition.  We  must  draw  a  hard  and  fast 
line  between  temporary  and  relative  immunity  on  the  one  hand,  and  loss 
of  resistance  on  the  other. 

When  an  animal  is  naturally  immune  from  a  bacterial  infection,  it  is 
also  proof  against  intoxication,  an  important  consideration,  as  we  shall  see 
hereafter,  for  no  theory  of  immunity  can  be  advanced  unless  it  explains 
also  this  essential  factor  of  natural  resistance.  The  temporary  or  per- 
manent immunity  jvhich  some  individuals  enjoy  may  be  due  to  the 
intolerance  of  poisons,  especially  when  pathogenetic  organisms  find  an 
abode  in  the  body  without  producing  an  infection,  as,  for  example,  is  the 
case  with  the  pneumococcus,  whose  presence  is  borne  with  impunity 
by  a  large  percentage  of  people.  It  is,  however,  also  possible  that  such 
organisms  while  growing  in  the  various  secretions  and  excretions  display 
bat  little  or  no  virulence.  Altogether  we  are  on  ground  so  very  unsafe, 
and  surrounded  by  so  many  fallacies,  that  it  is  wiser  to  attack  the  prob- 
lem of  natural  immunity  in  its  simplest  form. 

We  find  that  some  animals  are  refractory  to  certain  bacterial  infec- 
tions, susceptible  to  others.  How  are  we  to  explain  this  ?  Various  views 
of  the  matter  have  been  brought  forward  from  time  to  time. 

Theory  of  Natural  Immunity.  —  (a)  Metschnikoff  preached  pliago- 
cytosis,  but  we  have  alrea.dy  seen  that  in  an  exclusive  form  this  theory 
is  untenable,  especially  as  in  most  bacterial  infections  we  are  dealing  with 
the  toxins  as  well  as  with  the  micro-organisms  themselves.  Again  phago- 
cytosis may  be  present  to  a  marked  degree,  although  the  animal  die  (for 
example,  diphtheritic  infection  in  guinea-pigs).  As  in  acquired  so  also  in 
natural  immunity  phagocytosis  is  merely  a  phenomenon  of  natural  resist- 
ance. 

(^)  It  has  been  assumed,  especially  by  Buchner  and  Hankin,  that  in 
the  condition  of  natural  immunity  the  blood,  lymph,  and  tissue  fluids  are 
germicidal,  and  that  this  property  is  due  to  certain  albuminous  or 
albuminoid  substances  which  may  be  separated  in  an  impure  form  from 
the  blood,  spleen  and  other  tissues  of  most  animals.  To  these  bodies 
Buchner  gave  the  name  of  alexins.  They  are  secreted  by  certain  cells  of 
the  body,  according  to  Hankin  more  especially  by  the  leucocytes,  and 
pass  into  solution.  Certainly,  as  we  have  already  seen,  the  serum  of 
many  animals  has  some  germicidal  properties,  and  from  the  spleen  and 
lymphatic  glands  albaminous  substances  capable  of  destroying  or  impair- 
ing bacterial  life  can  be  removed.  These  so-called  alexins  differ  from  the 
antitoxins  in  these  points :  (i)  they  are  very  sensitive  to  light  or  heat ;  (ii) 
they  have  a  distinct,  though  unequal,  germicidal  power,  which  (iii)  varies 
both  in  intensity  and  effects  with  the  species  of  the  animal ;  in  one  spe- 
cies they  are  active  against  one  microbe,  in  another  species  against  an- 
other.    There  is  in  them  no  uniformity  or  common  principle  of  action. 

There  are  many  weak  points  in  such  a  doctrine,  of  which  I  may 
mention  a  few.  Thus,  the  experimental  evidence  is  unsatisfactory,  since 
it  rests  mostly  on  test-tube  reactions  which  often  differ  materially  from 
those  in  the  animal  body.    Frequently  the  serum  shows  slight  antimicrobic 


■      THE    GENERAL   PATHOLOGY   OF  LNFECTION  577 

powers  outside  the  animal  body,  while  the  living  tissues  exert  no  such 
power.  Again,  there  is  no  complete  correlation  between  natural  immunity 
and  this  property  of  the  serum,  and  without  it  the  theory  must  fall  to 
ground.  Even  in  the  most  refractory  animals  the  destructive  power  of 
the  serum  over  the  micro-organism  is  too  slight  to  tempt  us  seriously  to 
accept  this  theory.  Thus,  we  find  that  frogs'  serum  in  a  test-tube  will 
destroy  but  a  very  small  percentage  of  the  anthrax  bacilli  added  to  it,  and 
that  even  this  slight  germicidal  power  is  lost  after  a  short  time.  There 
can  be  no  doubt  that  the  serum  or  plasma  does  contain  such  substances 
(or  alexins,  if  we  wish  to  use  a  mystic  language) ;  for  the  germicidal 
power,  slight  as  it  is,  is  readily  destroyed  by  heat  or  cold.  There  are 
no  doubt  destructive  substances  in  the  blood  of  many  animals,  yet  for 
the  above  reason  it  seems  impossible  thereby  to  explain  natural  immu- 
nity, especially  since  it  has  been  found  impossible  hitherto  to  produce 
specific  cures  by  means  of  repeated  injections  of  such  bodies.  Again, 
the  alexins  have  never  been  shown  to  have  an  antitoxic  effect,  and  it  is 
a  matter  beyond  dispute  that  an  immune  animal  is  also  toxin  proof. 
But  we  must  confess  that  the  serum  of  certain  refractory  animals  is 
antitoxic  to  snake  poison;  yet  here  again  there  is  no  constancy,  since 
some  venom-proof  animals  yield  no  antitoxic  serum,  while  on  the  other 
hand  some  susceptible  animals  yield  an  antitoxic  serum.  Natural  im- 
munity, therefore,  must  depend  on  vital  reactions  which  are  called  forth 
by  the  conflict  between  the  tissues  and  the  bacteria  with  their  products, 
the  final  outcome  being  death  of  the  micro-organisms  and  neutralisation 
of  the  toxins.  The  destruction  of  bacterial  life  is  assisted  by  the  innate 
germicidal  and  antitoxic  power  of  the  serum,  plasma,  or  lymph  found  in 
many  animals,  and  by  the  phagocytic  properties  of  the  wandering  cells. 

(y)  This  reactionary  vitality  of  the  tissues  and  their  cells  may  be 
increased  in  many  ways.  Thus,  Wooldridge  showed  that  the  injection  of 
thymus  extract  may  protect  rabbits  against  anthrax,  and  Kossel,  Vaughan, 
and  M'Clintock  have  rendered  animals  refractory  to  bacterial  infections  by 
the  administration  of  nuclein  and  nucleinic  acid.  Since  it  requires  in  the 
case  of  susceptible  animals  a  certain  minimal  number  of  micro-organisms 
to  produce  infection,  it  follows  that  every  animal  possesses  the  elements 
or  the  germs  of  immunity.  These  will  destroy  acertain  number  of  bacteria, 
but  if  we  pass  beyond  the  limit,  disease  will  occur.  If  now  in  one  way 
or  another  we  increase  this  innate  resisting  power  by  cell-stimuli,  the  ani- 
mal will  be  able  to  resist  a  larger  number ;  it  will  appear,  that  is,  to  be 
immune,  or  to  have  acquired  an  immunity.  We  may  increase  this  innate 
resisting  power  in  two  directions :  (a),  specifically  against  a  particular 
infection  by  administering  repeated  or  increasing  doses  of  the  bacteria, 
their  proteins,  or  their  toxins;  or  (6),  generally  against  all  infections 
by  giving  such  substances  as  nuclein,  niicleo-albumins,  nucleinic  acid. 

In  either  case  we  increase  the  reacting  powers  of  the  tissues ;  it  appears, 
however,  that  only  when  we  do  so  specifically  we  can  obtain  a  protective 
serum.  Thus,  Hildebrandt  has  shown  that  by  means  of  enzymes  of 
various  kinds  we  may  alter  animals  to  such  an  extent  that  they  are 

VOL.   I  2  P 


578  SYSTEM  OF  MEDICINE 

capable  of  resisting  acute  infections ;  yet  if  the  serum  of  animals,  which 
have  been  treated  with  ferments  and  enzymes,  be  injected  into  normal 
animals,  it  has  no  antidotal  value.  The  enzyme  injections,  therefore, 
raise  the  natural  resistance,  but  do  not  produce  an  immunity  which  can 
be  transmitted  from  one  individual  to  another  by  means  of  the  serum. 

We  stand,  therefore,  before  a  question  which  we  are  quite  unable  to 
answer;  namely,  what  is  the  difference  between  natural  resistance  and 
acquired  specihc  immunity  ?  The  former  is  an  innate  property  of  the 
individual  or  species,  one  which  cannot  be  transmitted,  except  by  heredity, 
from  parent  to  offspring ;  the  latter  is  readily  transferred  from  one  indi- 
vidual to  another  by  serum  injections.  Yet  we  find  that  by  producing  a 
specific  transferable  immunity  the  natural  general  resistance  is  frequently 
raised,  for -clinically  it  may  be  shown  that  recovery  from  an  infective 
fever  often  renders  the  individual  less  susceptible  to  other  infective  fevers ; 
occasionally,  hoAvever,  it  may  render  the  individual  even  more  susceptible. 

Hereditary  Tnimunlty.  —  An  acquired  specific  immunity  may  also  be 
transmitted  from  parent  to  offspring.  ISTumerous  experiments  prove  this, 
but  the  most  important  are  those  of  Ehrlich,  and  of  Tizzoni  and  his  school. 
These  observers  worked  especially  with  strong  toxins,  and  while  Ehrlich 
showed  that  immunity  is  exclusively  transmitted  through  the  maternal 
tissues,  the  Italians  claim  to  have  demonstrated  that  the  transmission 
may  also  be  through  the  spermatic  fluid.  Maternal  transmission  is 
hardly  inheritance,  since  the  foetus  is  nourished  by  the  blood  and  fluids 
of  the  mother ;  it  is  rather  intraruterine  protection.  Ehrlich  has  also 
shown  that  an  immunity  may  be  acquired  through  the  milk  of  protected 
animals,  so  that  sucklings  may  drink  to  their  own  protection  at  their 
mothers'  breasts.  Needless  to  say  the  action  of  the  milk  is  specific. 
The  importance  of  these  observations,  both  as  concerns  the  individual 
and  society  at  large,  will  be  readily  seen.  The  results  of  Tizzoni  and 
Cattani  have  not  yet  been  confirmed,  and  on  the  other  hand  have  been 
negatived  by  other  observers,  so  that  at  present  we  may  doubt  the  pos- 
sibility of  the  germinal  transmission.  As  in  extra-uterine  life  immu- 
nity may  be  acquired  through  recovery  from  an  infective  process,  so 
also  the  embryo  or  foetus  may  gain  protection  after  a  successful  strug- 
gle with  a  disease  contracted  in  utero.  In  most  cases,  however,  this 
protection  is  called  into  existence,  or  increased  through  the  protective 
and  curative  substances  developed  in  the  mother.  Amongst  human  be- 
ings an  artificial  specific  immunity  may  be  transmitted  to  the  foetus  for 
small-pox  and  syphilis,  which  may  be  due  either  to  a  simple  transmission 
of  the  maternal  immunity,  brought  about  through  the  protective  circu- 
lation, or  may  be  due  to  the  fact  that  concurrently  with  the  pregnant 
mother,  the  foetus,  sharing  her  blood,  was  impregnated  with  the  anti- 
dotal substances  introduced  into  or  developed  in  the  mother.  The 
mechanism  qf  immunity  conferred  by  inheritance  is  as  yet  in  obscurity. 

Indeed  the  mechanism  of  immunity,  whether  acquired  or  natural,  spe- 
cific or  general,  is  still  hidden  from  us  ;  and  we  cannot  as  jet  lift  the  veil 
which  is  interposed  between  us  and  the  facts.    We  cannot  enter  into  all 


THE    GENERAL  PATHOLOGY   OF  LNFECTLON  579 

the  seductive  hypotheses  to  which  scientific  enthusiasm  gives  expression : 
"  from  entliusiasra  to  imposture  the  path  is  perilous  and  slippery."  We 
must  therefore  receive  the  discoveries  of  the  day  with  the  open  and  im- 
partial mind  of  the  historian,  trusting  that  the  future,  perhaps  the  near 
future,  will  arrange  them  in  their  proper  order  and  proportions,  so  that 
retrospectively  we  may  learn  their  lesson.  At  present  the  thinker  stands 
bewildered  before  the  problem  of  immunity;  and  when  two  recent 
writers  (Freund  and  Grosz)  assert  that  a  close  relation  appears  to  exist 
between  the  process  of  coagulation  and  serum  immunisation,  we  may 
remember  that  we  are  equally  ignorant  of  the  inner  working  of  either 
process.  It  is  because  of  these  limitations  of  our  understanding  that  I 
have  passed  over  numberless  observations,  such  as  local  immunity,  or 
the  production  of  immunity  by  bacteria  or  chemical  substances  not 
specifically  related  to  the  disease  in  question.  Yet  the  recent  past  has 
revealed  so  many  marvellous  facts  unto  us  that  we  may  confidently 
look  to  the  future  for  more  light. 

Serum  Therapeutics 

If  any  arguments  be  needed  to  justify  those  high  aims  of  the  patholo- 
gist or  bacteriologist  which  are  attained  through  the  sacrifice  of  animal  life 
in  carefully  devised  experiments,  we  may  point  with  pride  to  the  number 
of  lives  saved  by  means  of  the  treatment  with  curative  serum  ;  this  treat- 
ment, great  even  in  its  present  success,  and  based  on  sound  experience 
and  observation,  invites  us  to  expect  more  success  in  the  future  than  the 
past  has  already  given  us.  The  principles  of  the  new  therapeutic  method 
have  been  fully  discussed  in  the  previous  pages.  It  is  founded  on  the 
generally  established  fact  that  susceptible  animals,  adequately  protected 
so  as  to  reach  the  highest  possible  degree  of  immunity  from  infections 
with  pathogenetic  bacteria  or  from  intoxications  with  their  chemical 
products,  are  capable  of  supplying  a  serum  which,  injected  into  other 
susceptible  animals,  will  protect  them  also  against  like  infections  or  in- 
toxications ;  and,  even  when  injected  after  the  earlier  symptoms  of  the 
infection  or  intoxication  have  appeared,  may  determine  the  cure  of  the 
diseased  animals.  Obviously  it  requires  larger  doses  to  remove  a  lesion 
than  to  prevent  an  infection  or  intoxication.  Experimental  work  has 
further  shown  that  the  serum  of  one  animal  will  display  this  specific 
activity  in  animals  belonging  to  widely  different  species.  The  practical 
and  clinical  application  of  these  laboratory  observations  has  opened  up  a 
new  method  of  treating  bacterial  and  toxic  lesions,  which  consists  in  the 
injection  of  curative  substances  obtained  from  the  blood  of  highly  pro- 
tected animals  into  the  diseased  individuals ;  and  since  these  substances 
are  contained  in  the  serum,  this  therapeutic  method  is  called  the  '■'■  serum 
treatment."  These  specific  substances  may  be  kept  in  a  staVjle  and  durable 
form,  either  in  the  form  of  liquid  serum,  or  in  the  dried  state  after 
desiccating  tlie  serum  m  varjio ;  so  that  they  may  be  used  as  quantities 
measurable  by  weight  or  volume  and  constant  in  potency. 


580  SYSTEM   OF  MEDICINE 

Behring  had  first  shown  that,  as  far  as  animals  are  concerned,  this 
method  is  followed  by  successful  results  in  tetanus,  diphtheria,  and  the 
various  streptococcus  infections.  Now  these  lesions  differ  greatly  in 
principle :  tetanus  is  an  acute  intoxicative  process  of  the  most  rapid  de- 
velopment ;  diphtheria  resembles  it,  but  is  less  rapid ;  the  streptococcus 
infections  are  less  intoxicative,  and  in  their  severity  depend  chiefly  on  the 
distribution  and  growth  of  the  micro-organisms  themselves :  these  also  have 
a  marked  tendency  to  infect  the  blood  and  the  tissues  generally,  while  the 
tetanus  bacilli  always,  and  diphtheria  bacilli  generally  remain  at  the  seat 
of  inoculation,  multiplying  to  a  limited  extent  and  manufacturing  their 
more  active  poisons.  Thus  we  have  learned  that  a  curative  serum  may  be 
prepared  for  intoxicative  as  well  as  for  infective  lesions  of  bacterial  origin. 

The  next  step  was  Ehrlich's  discovery  that  Behring's  principle  may  be 
employed  also  in  the  treatment  and  protection  of  animals  against  poisoning 
with  vegetable  toxalbmnins,  such  as  abrin  and  ricin.  The  field  and  scope 
of  the  serum  treatment  thus  at  once  became,  fundamentally  at  least, 
much  wider  and  more  promising.  How  far-reaching  are  these  earlier 
observations  we  have  noAV  realised  on  Calmette's  demonstration  that  it  is 
possible  to  render  animals  proof  against  snake  venoms,  and  to  obtain  from 
these  animals  a  serum,  capable  of  protecting  other,  even  highly  susceptible 
animals,  against  the  poison;  and  powerful  enough  to  save  them  even 
when  the  first  symptoms  have  already  appeared.  These  toxic  bodies  are 
not  of  bacterial  origin,  but  they  bear  close  resemblance  to  the  mycotic 
poisons.  Attempts  to  prepare  a  serum  antagonistic  to  the  recognised 
chemical  poisons,  inorganic,  organic,  or  alkaloidal  in  nature,  have  utterly 
failed,  so  that  there  is  a  near  limit  to  the  scope  of  the  serum  treatment,  even 
in  the  laboratory ;  it  seems  that  only  certain  substances  of  distinctive 
chemico-physiological  action  are  capable  of  producing  the  kind  of  reaction 
in  the  animal  body  which  results  in  the  formation  of  antitoxic  substances. 
We  have  some  grounds  for  suspecting  a  correlation  between  chemical  con- 
stitution and  physiological  action  in  other  branches  of  therapeutics  and 
pharmacology ;  and  some  such  principle,  at  present  obscure,  may  underlie 
both  the  changes  produced  in  the  animal  organism  when  protected  against 
so-called  toxalbumins  and  enzymes,  and  those  which  happen  in  the  case 
of  the  alkaloids  which  are  bodies  of  entirely  different  chemical  structure. 

The  curative  value  of  a  serum  varies  directly  as  its  protective  power, 
so  that  to  obtain  an  active  serum  the  anima.1  must  be  endowed  Avith  the 
highest  possible  degree  of  immunity.  Since  in  every  animal,  according 
to  its  size  and  susceptibility,  there  is  a  limit  beyond  which  its  immunity 
cannot  be  pushed,  the  larger  animals,  such  as  horses,  must  be  used  for 
the  purpose  of  obtaining  a  curative  serum.  These  must  be  treated  by 
methods  which  will  result  in  the  shortest  possible  time  in  the  strongest 
resistance  obtainable  without  damage  to  their  tissues. 

Broadly  speaking,  there  are  two  methods  by  which  the  animals  may 
-/c  prepared..  Firstly,  they  may  be  inoculated  with  gradually  increasing 
doses  of  the  toxins  ;  secondly,  they  may  be  treated  with  the  living  or  dead 
bodies  of  the  bacteria,  also  injected  in  gradually  increasing  quantities. 


THE    GENERAL  PATHOLOGY  OF  LNFECTLON  581 

The  increase  must  be  gradual,  because  the  animal  acquires  resistance 
gradually,  and  our  aim  must  be  to  get  as  near  as  possible  to  the  maximum 
immunity,  and  then  to  keep  it  at  this  level.  If  from  time  to  time  we 
remove  blood  from  the  animal  under  preparation,  we  shall  find  its  serum 
gradually  increasing  in  protective  power.  Behring  and  Ehrlich  have 
suggested  the  following  as  a  standard  of  value.  In  the  case  of  anti- 
diphtheritic  serum,  a  serum  Ovl  c.c.  of  which  when  mixed  in  a  test-tube 
with  ten  times  the  fatal  dose  of  diphtheria  toxin  is  capable  of  rendering 
the  latter  harmless  to  a  guinea-pig  weighing  about  300  grammes,  is  taken 
as  the  standard,  and  is  called  "  normal  serum."  1  c.c.  of  such  serum  is 
the  protective  unit,  so  that,  for  instance,  a  serum  of  which  0-01  c.c.  suf- 
fices for  complete  protection  possesses  ten  units.  E-oux's  standard  differs 
from  that  of  the  Germans.  His  constant  is  a  toxin  solution  of  which 
0*1  c.c.  kills  a  guinea-pig  weighing  500  grammes  in  48  hours.  If  1  c.c. 
of  this  toxic  solution  be  rendered  harmless  by  0-05  c.c.  of  serum,  then 
evidently  1  c.c.  of  serum  is  capable  of  protecting  100,000  grammes  of 
guinea-pig  against  0-1  c.c.  of  toxin;  hence  the  protective  value  of  such 
serum  is  100,000.  By  his  method  of  protection,  which  consists  essentially 
in  injecting  toxins,  Behring  has  succeeded  in  obtaining  an  anti-diphthe- 
ritic serum  of  600-1500  units.  During  the  artificial  protection  of  animals 
it  is  regularly  found  that  each  injection  is  followed  by  a  marked  reaction, 
during  which  the  temperature  rises,  the  weight  falls,  and  the  animal  is 
ill.  During  this  period  of  reaction  the  immunity,  and  therefore  also 
the  proteative  value  of  the  serum,  is  considerably  lowered ;  but  when  the 
animal  has  recovered  both  are  considerably  raised.  Hence  the  protective 
inoculations  should  not  be  made  during  these  periods  of  reaction,  nor 
should  the  blood  of  the  animal  be  taken  for  therapeutic  purposes  until 
it  is  well  and  sound  again.  While  administering  diphtheria  toxins  to 
horses  it  has  frequently  been  found  that  at  first  the  antitoxic  value  steadily 
ascends,  but  that  when  large  doses  of  toxins  have  been  reached  this  value 
decreases.  This  would  seem  to  show  that  in  the  eagerness  of  obtaining 
a  potent  serum  the  protective  substances  stored  up  in  the  animal  organ- 
ism have  been  overtaxed ;  or,  to  express  it  in  other  words,  the  animal 
having  been  brought  to  the  limit  of  its  immunity,  inordinate  demands 
have  been  made  on  its  own  antitoxic  substances  by  injecting  enormous 
doses  of  fresh  toxin,  in  the  hope  of  raising  its  immunity  indefinitely. 
There  is,  however,  a  point  beyond  which  we  cannot  go. 

Dr.  Klein  established  an  important  fact  when  he  showed  that  an 
anti-diphtheritic  serum,  obtained  after  toxin  injections,  attains  to  a  high 
degree  of  antitoxic  potency,  but  to  a  lower  degree  of  protective  potency 
than  a  serum  obtained  after  injections  of  living  cultures.  Further,  he 
showed  that  by  administration  of  living  cultures  the  same  degree  of 
protective  power  is  acquired  by  horse's  serum  in  a  considerably  shorter 
space  of  time  than  after  repeated  toxin  inoculations.  It  follov/s  that  for 
the  preparation  of  the  most  useful  serum  the  injection  of  toxin  in  in- 
creasing doses  should  be  combined  with  inoculations  of  living  bacteria; 
for  in  this  way  a  serum  possessed  both  of  higlily  antitoxic  and  preventive 


582  SYSTEM  OF  MEDICINE 

virtues  might  be  obtained.  In  disease  as  it  appears  in  man,  we  have 
to  deal  both  with  the  poison  already  produced  and  with  the  bacteria 
capable  of  producing  more;  it  must  be  our  aim,  therefore,  to  attack  the 
sources  of  disease  on  all  sides,  at  any  rate  in  such  lesions  as  diphtheria 
where  the  bacilli,  although  they  are  generally  localised  in  the  membranes, 
are  nevertheless  extremely  numerous ;  in  the  case  of  tetanus  and  h,  fortiori 
in  snake  poisoning  we  require  merely  a  highly  antitoxic  value. 

If  now  we  shortly  review  the  scope  of  the  serum  treatment,  we  find 
(1)  that  every  infection  requires  for  its  prevention  and  cure  a  specially  and 
apparently  a  specifically  prepared  serum.  We  have  already  referred  to 
the  attempt  made  by  Calmette  to  shake  this  law,  perhaps  too  exclusively 
conceived  by  Behring,  and  we  have  seen  that,  so  far  as  bacterial  diseases 
are  concerned,  the  law  still  holds  good.  In  fact,  from  a  practical  point  of 
view,  this  very  specificity  of  the  curative  serum  must  limit  its  application. 
Thus  Pfeiffer  has  shown  that  although  the  various  vibrios  obtained  from 
choleraic  dejecta  are  closely  allied,  and  morphologically  and  biologically 
frequently  inseparable,  yet  each  special  form  of  vibrio  has  its  own  anti- 
choleraic  serum  :  a  protective  serum  prepared  against  one  variety  is  not 
necessarily  antidotal  to  another.  In  cholera  the  clinical  lesions  are  uni- 
form and  characteristic,  but  they  may  be  caused  by  several  closely  allied 
forms  of  vibrio.  Accordingly,  we  find  that  it  is  not  possible,  in  the  labora- 
tory at  any  rate,  to  obtain  a  universal  anti-choleraic  serum.  Again,  both 
staphylococci  and  streptococci  produce  suppuration,  septicaemia,  erysipe- 
las and  pyteinia ;  and  although  with  our  clinical  imperfections  we  are 
unable  to  detect  essential  differences,  or  any  at  all,  between  processes 
associated  with  one  or  other  group  of  cocci,  yet  a  serum  antagonistic 
to  an  infection  by  one  is  useless  against  infections  by  the  others.  It 
seems,  then,  that  in  the  treatment  of  infective  diseases  by  this  new 
method  conditions  seem  most  favourable  in  those  specific  cases  —  such 
as  tetanus,  diphtheria,  enteric  fever  —  which,  in  their  uncomplicated 
form,  are  due  to  a  single  organism.  In  other  cases,  such  as  cholera, 
suppuration,  and  septicaemic  lesions,  obvious  difficulties  must  arise  in 
the  iincertainty  and  diversity  of  the  bacteria  flora. 

(2)  Specific  curative  effects  cannot  be  attained  by  means  of  blood  of 
refractory  animals  in  their  normal  state,  that  is,  not  specifically  pro- 
tected. In  this  direction  laboratory  experiments  have  invariably  led 
to  failure.  Eichet  and  Hericoiirt,  and  others,  claimed  to  have  dis- 
covered powers  curative  of  tuberculosis  in  the  serum  of  goats,  sheep, 
and  dogs,  animals  almost  absolutely  refractory  to  this  microbe.  Ex- 
perimentally, however,  the  blood  of  these  animals  has  been  shown  by 
Bouchard  and  others  to  be  devoid  of  protective  power,  and  it  follows 
therefrom  that  it  is  devoid  of  curative  power. 

(3)  Since  the  action  of  the  curative  serum  is  specific,  we  cannot 
expect  it  also  to  counteract  any  secondary  infections  by  other  organ- 
isms. Thus,  in  diphtheria,  complications  due  to  the  interference  of 
pyogenetic  cocci,  especially  streptococci,  are  not  infrequent ;  against  these 
the  anti-diphtheritic  serum  is  powerless ;  it  can  counteract  the  effects 


THE    GENERAL   PATHOLOGY   OF  LNFECTLON  583 

of  diphtheria  bacilli  and  their  toxins,  but  of  these  only.  The  secondary 
infections  must  be  dealt  with  by  other  means,  it  may  be  by  injections 
of  serums  specially  prepared  for  these  cocci,  it  may  be  by  vigorous 
means  of  general  disinfection. 

(4)  In  all  cases  an  adequate  dose  of  antitoxin  seriim  is  to  be  admin- 
istered. Now,  as  the  dose  of  toxin  present  in  a  patient,  and  the  number 
of  bacteria  settled  in  his  tissues  cannot  be  estimated,  it  is  of  importance 
not  to  use  too  little  of  the  antidote,  and  rather  to  force  the  treatinent 
than  to  remain  more  or  less  expectant.  Both  in  the  case  of  tetanus  and 
diphtheria  copious  dosage  at  frequent  intervals  has  led  to  the  best  results. 
Of  course  in  cases  of  slight  severity  less  serum  and  a  less  energetic 
treatment  is  required  than  in  graver  cases.  Many  failures  in  the  treat- 
ment of  diphtheria  have  undoubtedly  been  due  to  inadequate  dosage. 

(5)  By  the  researches  of  Calmette,  mentioned  above,  the  scope  of  the 
serum  treatment  has  been  considerably  enlarged.  Having  succeeded  in 
rendering  animals  so  firmly  resistant  against  snake  poison  as  to  obtain 
a  highly  antitoxic  serum  from  them,  he  further  showed  that  the  serum 
active  against  the  venom  of  one  serpent  is  also  potent  against  that  of 
another.  Herein  he  has  been  confirmed  by  Professor  Fraser  of  Edin- 
burgh and  others.  The  future  must  show  how  far  these  observations 
are  applicable  outside  the  precincts  of  the  laboratory. 

(6)  The  antitoxic  treatment  has  hitherto  been  tried  in  man  in  several 
diseases,  and  a  short  summary  of  results  may  be  acceptable  at  this  point. 
Its  success  is  so  undoubted  in  diphtheria  as  to  silence  all  opposition, 
and  to  lead  us  to  hope  for  better  and  better  results.  It  is  a  specific 
remedy,  and  it  surpasses  any  other  which  has  ever  been  employed  for 
the  treatment  of  this  disease. 

The  anti-tetanic  serum  has,  unfortunately,  been  less  successful ;  chiefly 
because  of  the  extraordinary  severity  of  the  disease  against  which  it  is 
employed.  In  acute  cases  with  a  short  incubation  period  and  a  rapid 
onset  of  spasms  it  has  so  far  been  useless  ;  but  chronic  cases  with  a  long 
incubation  period  and  a  slow  onset  of  spasms  seem  to  be  benefited  \yide 
art.  "  Tetanus  "].  These  latter  cases,  however,  frequently  do  well  under 
other  methods  of  treatment.  Again,  under  ordinary  circumstances  treat- 
ment is  begun  too  late,  and  the  prospect  of  success  is  therefore  not  very 
hopeful  in  any  really  serious  case. 

Attempts  have  been  made  to  cure  pneumonia,  erysipelas,  puerperal 
fever,  pneumococcus  meningitis,  typhoid  fever,  and  also  cholera  in  the 
human  subject  by  means  of  injections  of  a  specific  serum.  The  facts 
which  we  possess  as  yet  are  too  meagre  for  discussion ;  yet  so  much 
has  already  been  achieved  by  careful  observation  in  the  laboratory  that 
further  triumphs  may  be  confidently  anticipated.  Success,  however,  can- 
not be  forced :  one  serum  after  another  has  been  vaunted  as  a  curative 
agent  in  tuberculosis ;  the  dog,  the  goat,  and  the  ass  have  had  false  pre- 
tensions thrust  upon  them;  and  recently  Maragliano  has  come  forward 
with  an  auti-tuberciilons  so.nnn,  which,  however,  is  evidently  not  a  true 
antitoxic  or  immunity-conferring  serum  :   it  seems  rather  to  act  as  a 


584  SYSTEM  OF  MEDICINE 

modified  tuberculin,  raising  the  temperature  considerably  on  injection, 
and  producing  other  physiological  changes  as  a  rale  not  observed  with 
protective  serums.  Moreover,  Maragliano's  observations  are  not  based 
on  sound  experiments ;  he  fails,  at  any  rate,  to  record  any  successful 
preventive  inoculation  of  susceptible  animals.  Our  great  difficulties  in 
tuberculosis  are  the  protection  of  the  individual  from  secondary  infections, 
and  the  removal  of  the  latter  when  they  have  once  made  their  appearance. 

In  conclusion  a  few  words  must  be  said  on  the  dosage  and  adminis- 
tration of  curative  serum.  Carefully  prepared  and  preserved  it  is  harm- 
less ;  and  local  inflammation  or  suppuration,  if  they  appear,  are  generally 
due  to  a  contamination  of  the  serum  during  its  use,  or  to  want  of  asepsis 
in  the  injection  of  it  into  the  tissues.  Cleanliness  is  an  imperative 
necessity,  although  local  infections  are  excessively  rare.  The  serum 
may  be  obtained  either  in  a  liquid  or  dried  state ;  in  tlie  latter  case  a 
certain  weight  of  it  must  be  carefully  suspended  and  ground  up  in  sterile 
water,  or  saline  solution,  or  sterile  camphor,  or  thymol  water.  The  dried 
serum  will  dissolve  only  in  part :  after  shaking  it  vigorously  it  is  allowed 
to  stand,  in  order  to  allow  the  insoluble  matter  to  fall  down.  The  water 
extracts  the  active  principles  and  holds  them  in  solution.  The  skin  at 
the  seat  of  injection  must  be  carefully  washed  and  cleansed  Avith  anti- 
septic lotion,  and  the  syringe  boiled  before  use;  a  proper  instrument 
which  can  be  readily  sterilised  must  be  chosen. 

The  injections  should  be  made  into  the  subcutaneous  tissues  of  the 
flanks  or  buttocks,  and  as  soon  as  possible;  a  day's,  nay  a  few  hours' 
delay  may  mean  the  patient's  death :  the  prompter  the  treatment  the 
greater  the  chances  of  success.  The  quantity  of  serum  to  be  used,  as 
already  explained,  varies  Avith  each  case,  with  the  strength  of  the  serum 
and  the  age  and  weight  of  the  patient ;  but  as  a  rule  in  a  severe  case  it 
is  advisable  to  administer  the  antitoxin  boldly.  If,  as  in  the  ease  of 
tetanus,  large  doses  (up  to  100  c.c.)  have  to  be  injected,  the  quantity  must, 
of  course,  be  distributed  over  different  places ;  more  than  25  c.c.  should 
never  be  injected  at  any  one  spot.  After  use  the  syringe  and  needle 
must  again  be  thoroughly  cleaned,  first  with  sterile  water,  then  with 
alcohol,  and  lastly  Avith  ether. 

Although  Ave  possess  in  the  antitoxin  a  remarkable  therapeutic  agent, 
"we  must  not  in  our  enthusiasm  forget  older  established  methods.  Thus 
in  the  case  of  diphtheria  local  antiseptics  and  tonics  should  be  employed 
as  far  as  possible ;  in  the  case  of  tetanus  physostigmin  and  other  drugs, 
and  operative  treatment  must  not  be  neglected.  There  is  no  reason  Avhy 
we  should  disregard  measures  of  a  useful  kind  Avhich  may  hasten  recovery 
by  removing  the  source  of  infection. 

Rashes  occasionally  occur  after  the  administration  of  serum,  generally 
of  erythematous  or  urticarial  character ;  they  appear  either  around  the 
seat  of  injection,  or  they  may  affect  the  Avhole  body,  or  certain  areas  of 
it,  especially  the  extensor  surfaces  of  the  limbs.  These  eruptions  are 
produced  by  substances  in  the  serum  other  than  the  specific  antitoxic 
substances,  since  they  may  occur  on  injecting  normal  horse's  serum  ; 


THE    GENERAL  PATHOLOGY  OF  INFECTION  585 

undoubtedly  in  time  they  may  be  eliminated,  indeed  it  appears  that  on 
using  dried  serum  they  are  less  frequent. 

Joint-pains  are  also  said  to  occur  occasionally  ;  there  may  be  redness 
around  the  articulation,  and  even  effusion  into  the  synovial  cavity,  the 
hips,  ankles,  and  wrists  being  most  frequently  affected.  No  ill  result 
of  these  complications  has  ever  been  recorded,  but  they  retard  recovery  ; 
it  must  be  our  aim,  therefore,  to  obtain  a  serum  free  from  such  contami- 
nation. Serious  harm,  such  as  nephritis  or  suppression  of  the  urine, 
never  results,  — -  although  statements  have  been  made  to  the  contrary. 
Dr.  Caiger  speaks  emphatically  on  this  point,  and  we  may  take  it  for 
granted  that,  given  a  pure  serum-supply,  care  in  administration,  and 
responsible  circumspection,  all  serious  complications  can  be  avoided. 

It  has  already  been  mentioned  that  the  protective  value  of  curative 
serum,  at  least  so  far  as  our  laboratory  animals  are  concerned,  is  very 
high,  even  although  the  immunity  produced  is  only  temporary.  Fre- 
quent proposals  have  been  made  by  Behring,  Roux,  Vaillard,  and  others, 
to  use  the  antitoxin  for  purposes  of  prevention  in  the  case  of  diphtheria 
and  tetanus;  so  far,  however,  this  suggestion  has  not  had  the  recogni- 
tion it  undoubtedly  deserves.  Behring,  in  fact,  expects  that  "by  the 
combination  of  prophylactic  and  actual  treatment  with  antitoxic  serum, 
we  must  eventually  succeed  in  abolishing  diphtheria  and  in  confining  it 
to  the  pages  of  history."  In  local  epidemics  of  diphtheria  serum  pro- 
tection might  be  practised;  and,  although  tetanus  is  a  rare  disease,  pro- 
tective injections  are  also  advisable  in  cases  of  wounds  contaminated 
with  sand,  earth,  or  dust:  prevention  is  frequently  easy  ;  cure  may  be 
impossible.  It  is  fair  to  add,  however,  that  the  protective  value  of  the  anti- 
diphtheritic  serum,  in  man  at  any  rate,  does  not  seem  to  be  considerable. 

A.  A.  Kanthack. 

REFERENCES 

Text-Books:  —  !.  Flugge.  Die  Mikro-organismen.  Leipzig,  1886.  —  2.  De  Bary. 
Morphol'jf/ie  and  Physiologie  der  Pilze.  Leipzig,  1866. — 3.  De  Bary.  Vurr/leichende 
Morphologie  u.  Biologie  der  Pilze,  Mycetozoen  u.  Bacterien.  Leipzig,  1884.  — 4.  Nageli. 
Untersachun.g'in  uherniedere  Pilze.  Miinchen,  1882.  — 5.  Nageli.  Die  iiiederen  Pilze. 
Miincheu,  1877.  —  6.  Sternberg.  Manual  of  Bacteriology.  New  York,  1892.  —  7. 
HuppE.  Naturwissejtschuftllche  Elnfdhrung  in  die  Bakteriologie.  Wiesbaden,  1805. 
—  8.  JoRGENSEN.  Micro-orgcinisms  in  Fermentation.  Trans! .  by  A.  K.  Miller  and 
A.  E.  Lennholm.  London,  189:3.  Variability  of  Micro-organisms :  — 9.  Ad  ami. 
Medical  Chronicle,  Sept.  1892. — 10.  D.  D.  Cunnixghaji.  Sclvit.  Memoirs  by  Med. 
Officer.'!  of  Army  in  India,  Part  viii.  1894.  Thermophile  Micro-organisms:  — 11. 
Macfadyen.  Britl.fh  Medical  Journal,  1894,  vol.  ii.  Action  of  Sunlight  on  Bac- 
teria:— 12.  P.  and  G.  C.  Frankland.  Micro-organisins  in  Water,  ;!o2-.;93,  where 
an  exhaustive  bibliography  will  be  found.  London,  1894.  Bacteriological  Chem- 
istry:— 13.  Neumeister.  Lehrhuch  der  Physiologisehen  C'hende.  Jena,  1893. — 14. 
Brieger.  Ueber  Ptomaine.  Berlin,  1885.  — 15.  Vaughan  and  Now.  Ptomaine.^  and 
Leucomaim.'i.  Philadelphia,  1891.  — Ki.  Sidney  Martin.  Annual  Reports  of  Local 
Gov.  Board.  Supplement,  1889,  1890,  1891,  1892. —17.  Brieger  and  Frankel. 
Berliner  kiln.  Wochenschr.  18110,  p.  li:!3.  — 18.  Hankin.  Brit.  Med.  Jour?!.  1889, 
p.  810. —  19.  UscHixsKi.  CentruJb.  f.  B.  u.  P.  xiv.  10,  and  Bv chn er,  Miinch.  med. 
Wo'-Mnac'ir.  W.Y.',,  Nos.  24  and  25.  — 20.  Wesbrook.  Ann.  de  V  Inst.  Paatew,  1894, 
p.  ];5S.— 21.  A.  A.  Kanthack  and  WEsriROOK.  Brit,  Med.  Journal,  Sept.  9,  189;>. — 22. 
Klein.  "Oh  the  Antagonisms  of  Microbes,"  A?inval  Rep.  Local  Gov.  Board.  Supple- 
ment, 1892-18;)3.— 23.   Nencki.       Ber.  d.   Deutsch.  chem.    Gesellsch.  vol.  xvii.  1884, 


586  SYSTEM   OF  MEDICINE 

p.  2605.  —  24.  WiNOGRADSKi.  Ann.  ds  r  Inst.  Pasteur,  l^'dd. — 25.  Frankland.  Phil. 
Trans,  clxxxi.  p.  107.  — 2(j.  Warington.  J.  of  Chein.  Soc.  1891,  and  Chun.  News, 
Ixi.  1890. — 27.  Brunton  and  Macfadyen.  Rji/.  Soc.  Pruc.  vol.  xlvi.  p.  542. 
Infection,  Contagion,  and  Predisposition:  —  28.  Wolters.  Centrahl.  f.  B.  u.  P.  xiii. 
14,  15. — 29.  Roger-  Rev.  de  ined  1(-J91,  p.  169  and  p.  500. — 30.  Blagovest- 
scHEWSKi.  Ann.  de  V  Inst.  Pasteur,  1890,  ii.  p.  68i>.  —  31.  Sander.  Ari-hiv  f. 
Il!/!/l3n?,xvL  No.  3,  p.  238. — .32.  Canalis  and  Morpurgo.  Fortschr.  d  .M^d.  1890, 
18  and  19.  —  33.  Sacchi.  C'entralb.  f.  B.  u.  P.  1892,  xi.  21. — 34.  Pjernice  and 
Alessi.  La  Rif.  nied.  1891,  p.  220.  —  35.  Charrin  and  Rjger.  Li  Sz.nains  med. 
189'),  No.  4.  —  36.  Leo.  Zzitschr.  f.  Hygiene,  vii-  2.  —  37.  Fermi  and  Salsa.no. 
dntralh.  f.  B.  u.  P.  xii.  21. — 38.  Oemler.  Arch.  f.  wiss2nsch.  u.  prakt.  Thlerheil- 
kunde,  1877,  iii.  4.  —  39.  Foa  and  Scabia.  Gaz.  med.  di  Torino,  1892,  13,  14,  15. — 
40.  Vaill.vrd  and  Vincent.  Ann.  dz  I'  Inst.  Pasteur,  1891.  —  41.  Bujwid.  C'entralb. 
f.  B.  u.  P.  iv.  19. —42.  Klein  and  Coxwell.  Ibidem,  xi.  15.  —  43.  Tizzoni  and 
Cattani.  Centrnib.f.  B.  u.  P.  xi.  11. — 44.  A.  A.  Kanthack.  Centralb.  f.  B.  v.  P. 
xii.  7,  8.  —  45.  Dina  Sandberg.  Zeitsch.  f.  Ili/giene,  ix.  p.  370. — 46.  Bollinger. 
"  Ueber  S:'liwindsuclatssterblichkeit,"  Miinch.  Died.  Wochensch.  189'),  1  and  2. — 47. 
Rosenblatt.  "Die  Lungenkranklieiten  in  der  Sahweiz,"  Deutsche  Vierfljahreshr.  f. 
Uffentiichi  Gisundh^ltspflzge,  xxvi.  1894,  2.  p.  292. — 48.  Baumgarten.  Deutsche  med. 
Woc.henschr.  1891,  No.  42.  Festnunimer,  p.  1168;  Arbeiten  a.  d.  path.  Inst.  Tiibinr/en, 
vol.  i.  1892,  2.  p.  322. —49.  Hansen  and  Looft.  Leprosi/.  Trans,  by  Norman  Walker, 
Bristol,  1895.  —50.  Mafucci.  Centi-alb.  f.  B.  u.  P.  v.  7  ;  Rif.  med.  1889,  209  and  213; 
Glornale  di  Anat.  Fisiol.  e  Patologia  degli  Animali,  1889,  fasc.  ii. — 51.  Gaertneb. 
Zsitschr.f.  Ilyglem,  xiii.  1893,  p.  101. 

Immunity:  — Besides  the  larger  text-books  the  following  special  papers  may  be  con- 
sulted: —  52.  Metschnikoff's  articles  in  Virchow's  Arehiv,  and  in  the  Ann.  de  V  Inst. 
Pasteur. — 53.  Buchxer.  Numerous  articles  in  the  Centralb.  f.  Bikt.,  the  Arehiv  f. 
Hgriien",  and  an  important  paper  in  the  Munch,  med.  Wochensch.  1893,  Nos.'24  and  25. 
—  51.  FoDOR,  Deatsch"  med.  Wochensch.  1887,  No.  34:  Nuttall,  Z^its^hr.  f.  Tlyg.  iv. 
1888,  p.  353;  Nissen,  Zeitsc'ir.  f.  Ilijg.  vi.  1889,  p.  487.  —  5"'.  Behrixg.  B'utsprum- 
therapie,  i.  and  ii.,  Leipzig,  1892;  and  numerous  articles  by  him  and  his  pupils  in  the 
Deutsche  med.  Wochensch.  18.0-1895;  and  also  in  the  Z'iilschr  f.  Ilgg.  1890-1895. — 
5(5.  Ehrlich.  Deutsche  med.  Wochensch.  1891,32  and  34.  —  57.  Lubarsch.  Unter- 
suchung';n  ii.  d.  Ursachen  der  angeborenen  und  erworbenen  Immuidtut,  1891 ;  Ueber  Im- 
m,unitut  und  SrJiutzimpfung,  1892;  also  Centralb.  f.  Bakt.  vi.  1889,  Nos.  18-20.  —  58. 
Bouchard,  Les  microbes pathogenes,  1892 ;  Virchoiv's  B^estschrift,  1891.  — 59.  Calmette. 
Ann.  de  V  Inst.  Pasteur,  181)4,  No.  5,  and  1895,  No.  4.  —  60.  Frankel.  Schutzimpfung 
und  Impfschntz.  Marburg,  1895.  Further  references  relating  to  Phagocytosis  and 
Immunity  will  be  found  under  "  Inflammation." 

Serum  Therapeutics :  —  61.  Behring.  Blutserwntherapie,  i.  and  ii.  Leipzig,  1892.  — 
62.  Behring.  Deutsche  med.  Wochenschr.  1^^)5,1:^0.  38.  —  63.  Behring.  B''kumpfung 
der  Infectionskrankheiten.  Leipzig,  1894.  —  64.  British  Medical  Journal,  1895,  Aug.  17, 
24,  31. — 65.  W.  H.  Welch,  "Treatment  of  Diphtheria  by  Antitoxin,"  Trans.  Ass.  of 
American  Physicians,  vol.  x.  1895. — 66.  B.  Hunt.  "The  so-called  Antitoxic  Treat- 
ment of  lufective  Disease,"  Trans.  Path.  Soc.  1894,  p.  266. 

A.  A.  K. 


SEPTICEMIA   AND    PYEMIA 

Introduction. — Under  this  general  heading  are  usually  inchided  three 
constitutional  affections  which,  both  pathologically  and  etiologically,  are 
quite  distinct.  Speaking  broadly,  it  may  be  said  that  they  are  due  to 
the  entrance  into  the  general  system  either  of  micro-organisms  or  of  their 
products  ;  and  as  a  rule  they  are  met  with  in  connection  with  some  wound 
or  breach  of  surface,  the  discharges  from  which  have  become  contami- 
nated with  bacteria.  Three  different  results  may  follow  the  entrance  of 
bacteria  into  a  wound^  and  it  is  not  uncommon  to  find  two  or  more  of 


SEPTICMMTA   AND  PYEMIA  587 

them  in  combination;  indeed,  in  the  great  majority  of  cases  the  condi- 
tion of  sapraemia  accompanies  that  of  septicaemia  or  pyaemia. 

The  first  of  these  aitections  is  saprcHtnia,  which  is  also  spoken  of  as 
septic  or  putrid  poisoning  or  intoxication.  Sapraemia  is  a  general  con- 
stitutional disorder  exclusively  due  to  chemical  poisoning  by  the  products 
of  bacteria,  and  not  to  the  entrance  of  the  bacteria  themselves  into  the 
blood.  The  poison  so  introduced  cannot  increase  in  the  system  except 
by  the  absorption  of  fresh  doses ;  and  the  blood  of  an  animal  that  has 
died  of  the  disease  only  contains  a  diluted  solution  of  the  amount  of 
poison  it  had  received,  so  that  small  quantities  of  this  blood,  when  in- 
jected into  another  animal  equally  susceptible,  will  not  set  up  symptoms 
of  poisoning.  Hence  the  disease  is  in  no  sense  an  infective  one ;  more- 
over the  poison  absorbed  is  being  so  constantly  and  rapidly  eliminated 
from  the  system  that,  provided  the  dose  already  taken  up  be  not  a  fatal 
one  and  that  all  further  supplies  are  stopped,  the  disease  will  of  itself 
come  to  a  spontaneous  and  favourable  termination. 

The  second  form  of  septic  disease,  septiccemia,  or  septic  infection,  is  a 
disorder  caused  not  only  by  the  absorption  of  poisons  from  a  woimd,  but 
also  by  the  entrance  of  living  micro-organisms  into  the  body  and  their 
growthand  multiplication  therein.  Although  in  this  case,  as  in  sapraemia, 
it  is  probable  that  the  constitutional  effects  are  due  solely  to  the  chemical 
poisons  produced  by  the  organisms,  and  not  to  the  presence  of  the  organ- 
isms themselves  in  the  blood  stream,  yet  there  is  this  cardinal  ditference, 
that  in  septicaemia  the  poison  is  being  continually  produced  inside  the 
body  ;  whereas  in  sapraemia  the  poison  is  produced  in  the  wound  —  that 
is  to  say,  outside  the  body  —  and  is  absorbed  from  that  part.  Hence 
it  generally  happens  in  the  case  of  septicaemia  —  in  contra-distinction 
to  sapraemia — that,  if  the  disease  be  firmly  established,  it  cannot  be 
moderated  by  the  removal  of  the  original  source  of  infection. 

Thirdly,  we  have  to  consider  pycemia,  an  acute,  general,  infective 
disease,  due  to  the  entrance  of  living  pyogenetic  micro-organisms  into 
the  blood,  and  especially  characterised  by  the  formation  of  abscesses  in 
various  organs  and  parts  of  the  body.  Here  we  have  not  only  poisoning 
of  the  body  with  the  products  of  micro-organisms  which  have  already 
established  themselves  in  the  living  body,  but  we  have  in  addition  the 
occurrence  of  septic  emboli,  either  the  result  of  suppurative  phlebitis  or 
thrombosis,  or  formed  in  other  ways  which  will  be  afterwards  discussed ; 
these  give  rise  to  the  abscesses  characteristic  of  the  disease. 

By  some  authors  a  second  form  of  pyaemia  is  spoken  of  under  the 
term  Chronic  Pycemia.  This  is  a  disease  which  arises  also  in  connection 
with  wounds,  which  is  caused  by  pyogenetic  organisms,  and,  like  pyaemia 
proper,  is  characterised  by  the  formation  of  local  abscesses  in  various  parts 
of  the  body.  These  abscesses,  however,  are  fewer  in  number  than  in  true 
pyaimia;  they  chiefly  occur  in  subcutaneous  tissues  or  joints,  and  appar- 
ently they  are  not  due  to  embolism.  For  my  own  part,  I  prefer  to  designate 
this  disease  by  the  name  "  Multiple  Abscesses  ;  "  for,  except  that  it  is  due 
to  pyogenetic  organisms,  it  diifcrs  widely  from  pyaemia  in  its  pathology, 
and  should  not,  in  my  opinion,  be  described  as  a  variety  of  this  disease. 


588  SYSTEM  OF  MEDICINE 

So  much  for  definition ;  but,  while  for  this  purpose  they  are  described 
as  quite  distinct  from  each  other,  it  must  be  confessed  that  in  practice  it 
is  not  always  easy — even  at  the  post-mortem  table — to  assign  definitely 
its  exact  part  to  each  of  the  three  forms  in  the  production  of  symptoms; 
for,  as  I  have  said,  two  or  more  of  them  very  often  concur.  The  sharp 
separation  between  the  three  forms  depends  more  on  the  results  of  the 
experiments  on  animals  than  on  clinical  observation ;  it  may  be  interest- 
ing, therefore,  to  refer  shortly  to  the  experiments  which  have  established 
the  pathology  of  these  affections. 

Saprcemia.  —  At  the  beginning  of  this  century  Albert  von  Haller, 
Gaspard  and  many  others,  injected  infusions  of  putrefying  meat  and  other 
putrid  animal  fluids  into  animals,  and  observed  the  poisonous  effects. 
They  did  not,  however,  attempt  to  determine  the  particular  constituents 
on  which  these  effects  depended,  and  Panum  was  really  the  first  who 
thoroughly  studied  this  side  of  the  subject.  He  showed  that  the  poison- 
ous properties  of  putrid  solutions  were  unaltered  by  boiling,  which  would 
of  course  destroy  all  living  elements ;  further,  he  found  that  the  poison 
was  in  solution  in  the  material,  and  he  was  able  to  separate  substances  in 
the  form  of  a  powder  from  putrefying  materials  which  produced  all  the 
symptoms  that  occurred  when  the  raw  material  was  employed.  This 
was  done  in  the  first  place  by  filtering  the  fluid,  and  then  adding  abso- 
lute alcohol  until  a  precipitate  was  obtained.  This  precipitate  was 
collected  and  further  purified  by  repeatedly  dissolving  it  in  distilled 
water  and  reprecipitating  it.  Finally  it  was  dried  at  a  temperature  of 
100"  Centigrade.  Even  this  treatment  by  alcohol,  heat  and  drying  did 
not  destroy  the  poisonous  products,  0-012  grammes  of  the  powder  so 
prepared  being  sufiicient  to  kill  a  large  dog. 

Selmi  attempted  to  carry  the  investigation  further  in  order  to  deter- 
mine the  nature  of  the  substances  present  in  this  powder ;  and  he  de- 
scribed a  number  of  different  substances,  or  more  probably  groups  of 
substances,  which  he  had  isolated  from  putrefying  animal  tissues.  To 
these  substances,  some  of  which  were  harmless  and  some  intensely  poi- 
sonous, he  gave  the  name  of  animal  alkaloids  or  ptomaines,  these  sub- 
stances being  transition  products  formed  by  the  breaking  up  of  the  highly 
complex  organic  molecule  on  its  way  to  form  simple  inorganic  substances. 
Brieger  has  also  thoroughly  investigated  this  subject,  and  has  isolated 
and  named  a  number  of  these  ptomaines,  such  as  putrescine,  cadaverine, 
neurine,  etc.  The  organisms  which  produce  these  substances  are  not  as  a 
rule  pathogenetic,  that  is  to  say,  they  are  not  as  a  rule  able  to  live  in  the 
animal  body.  In  cases  in  the  lower  animals  (and  also  in  man)  where  this 
intense  poisoning  has  resulted,  the  organisms  are  not  necessarily  present 
in  the  blood  during  life,  unless,  indeed,  the  condition  of  sapraemia  be 
complicated  with  some  infective  condition  such  as  septicaemia. 

When  a  quantity  of  putrefying  material  is  injected  into  an  animal 
—  say  a  dog  —  in  sufficient  quantities  to  kill  the  animal,  the  most 
prominent  symptoms  are  fever,  vomiting,  and  diarrhoea :  great  restless- 
ness and  muscular  twitchings  may  occur  at  first,  but  are  soon  followed 


SEPTICEMIA   AND   PYEMIA  589 

by  loss  of  muscular  power ;  the  diarrhoea  becomes  profuse,  serous,  and 
frequently  blood-stained,  and  is  accompanied  by  much  pain  and  tenes- 
mus ;  the  temperature  falls,  and  usually  becomes  subnormal ;  the  respi- 
ratory movements  become  very  feeble ;  the  pupils  are  dilated ;  there  is 
marked  cyanosis,  and  death  ensues,  apparently  from  cardiac  failure.  A 
fatal  result  usually  takes  place  within  twenty-four  hours,  depending 
directly  on  the  dose  injected  and  on  the  size  and  susceptibility  of  the 
animal.  Koch  describes  the  symptoms  in  mice  as  follows:  —  "The 
animal  becomes  restless,  running  about  constantly,  but  showing  great 
weakness  and  uncertainty  in  all  its  movements.  It  refuses  food,  respi- 
ration becomes  irregular  and  slow,  and  death  takes  place  in  four  to 
eight  hours."  When  a  smaller  dose  is  employed  the  effects  are  similar 
but  less  severe,  and  the  animal  after  a  few  hours  rapidly  recovers. 

On  post-mortem  examination  in  these  fatal  cases  we  find  no  very 
prominent  characteristics.  Rigor  mortis  is  transient  and  slightly  marked ; 
decomposition  sets  in  early ;  there  is  no  inflammation  of  the  tissues  in 
the  neighbourhood  of  the  site  of  injection.  The  chief  changes  occur  in 
the  blood,  which  is  dark  in  colour,  coagulates  slightly  and  very  imper- 
fectly, and  stains  the  lining  wall  of  the  veins  and  endocardium.  Occa- 
sionally serous  effusions  are  met  with  in  some  of  the  serous  cavities,  and 
these  are  also  blood  stained.  Small,  dark  extravasations  of  blood  are 
also  commonly  seen  beneath  the  skin  and  serous  membranes,  and  occa- 
sionally elsewhere  throughout  the  body ;  the  spleen  is  greatly  swollen, 
often  pulpy  and  dark,  from  engorgement  with  blood ;  there  may  be 
signs  of  severe  gastro-enteritis  with  intense  inflammation  of  the  mucous 
membrane  of  the  stomach  and  intestines,  and  with  partial  or  almost 
complete  desquamation  of  the  epithelial  lining  (Burdon-Sanderson). 
Microscopical  examination  of  the  blood  shows  that  the  red  corpuscles 
tend  to  form  clumps  instead  of  the  usual  rouleaux;  it  is  found  also  that 
the  staining  of  the  vessel  walls  depends  partly,  at  least,  on  the  fact  that 
many  of  the  red  corpuscles  are  disintegrated,  and  their  liberated  hgemo- 
globin  is  contained  in  solution  in  the  blood  plasma. 

Septicaemia.  —  Koch,  in  confirmation  of  Panum's  experiments,  found 
that  if  a  considerable  quantity  of  putrefying  blood  were  injected  into 
animals,  poisoning  of  the  animals  advancing  to  a  fatal  result  was 
brought  about ;  the  blood  of  the  animals  so  killed  did  not  contain  any 
bacteria,  and  was  not  capable  of  transmitting  the  disease.  He  further 
found  that  the  rapidity  and  severity  of  the  result  were  proportionate  to 
the  amount  of  putrid  material  injected;  but  when  small  quantities  (one 
■ar  two  minims)  of  putrid  blood  were  injected  into  mice,  although  no 
immediate  symptoms  were  produced,  yet  in  about  one-third  of  the  cases 
evidence  of  disease  appeared  within  twenty-four  hours,  and  if  so  a  fatal 
result  usually  ensued.  The  same  events  also  took  place  where  much 
smaller  doses  were  employed,  but  in  this  case  the  proportion  of  animals 
affected  was  still  less. 

The  symptoms  so  set  up  were  as  follows:  —  After  about  twenty-four 
hours  greatly  increased  conjunctival  secretion  came  on  which  appeared  to 


590  SYSTEM  OF  MEDICINE 

glaze  the  eye,  and  ultimately  glued  the  lids  together;  the  animal  soon 
ceased  to  eat,  appeared  overcome  with  lassitude,  and  moved  but  little ; 
soon  it  sat  still  with  its  back  bent  and  its  legs  drawn  up ;  the  respi- 
ratory movements  were  slow  and  feeble ;  the  weakness  increased,  and 
death  slowly  ensued  in  forty  to  sixty  hours.  On  post-mortem  examina- 
tion there  was  slight  oedema  at  the  site  of  the  injection ;  the  spleen  was 
considerably  enlarged,  but  no  other  marked  changes  Avere  found  except 
in  the  blood.  Under  a  high  power  of  the  microscope  numerous  extremely 
minute  bacilli  were  found  in  the  blood,  some  free,  others  filling  up  the 
white  corpuscles.  The  minutest  quantity  of  this  blood  inoculated  into 
a  healthy  mouse  led  to  the  disease,  which  was  therefore  a  true  infective 
one.  Koch  was  subsequently  able  to  cultivate  these  organisms,  and  the 
disease  resulted  from  the  inoculation  of  the  cultivated  organisms  in  the 
same  way  as  from  the  inoculation  of  the  blood. 

Since  this  time  a  number  of  organisms  have  been  found  which  pro- 
duce similar  symptoms  in  various  classes  of  the  lower  animals ;  thus,  in 
the  case  of  rabbits,  at  least  three  different  kinds  of  organisms  set  up 
these  symptoms.  This  disease  in  the  lower  animals  is  spoken  of  as  sep- 
ticgemia,  and  is  looked  upon  as  the  counterpart  of  septicsemia  in  man ; 
but,  in  human  septicaemia,  as  will  be  presently  pointed  out,  organisms 
cannot  be  demonstrated  in  the  blood  in  numbers  at  all  comparable  to 
those  in  the  lower  animals,  or  indeed  in  sufficient  numbers  to  account 
for  the  disease,  supposing  it  to  be  a  simple  blood  infection. 

Pycemia.  —  In  the  course  of  Koch's  researches  on  mice  and  rabbits  he 
came  across  an  organism  which  produced  the  condition  comparable  in 
these  animals  to  pyaemia  in  man ;  and  he  found  that  this  condition  was 
due  to  the  development  of  micrococci  in  the  blood.  It  differed  from 
human  pyaemia  in  not  being  associated  with  thrombosis  and  embolism 
of  portions  of  the  thrombus,  but  that  similar  plugs  were  formed  in  the 
vessels  in  another  way,  which  is  also  of  interest  in  connection  with 
human  pyaemia  wherein  it  is  possible  that  something  similar  may  take 
place.  He  found  that  this  organism  grew  in  the  blood,  and  formed  col- 
onies in  which  masses  of  red  blood  corpuscles  became  incorporated ;  in 
this  way  emboli  were  formed  which  stuck  in  the  smaller  vessels.  An- 
other way  in  which  a  similar  result  Avas  produced  was  that  the  organ- 
isms seemed  to  attach  themselves  to  the  endothelial  cells,  and,  growing 
there,  ultimately  filled  up  the  lumen  of  the  blood-vessel  and  formed  a 
plug.  It  is  possible  that  a  similar  thing  may  occur  in  man,  more  espe- 
cially in  connection  with  the  streptococcus  pyogenes.  Numerous  exper- 
iments have  also  been  made  to  determine  the  part  which  embolism  plays 
in  the  production  of  pyaemia,  but  I  may  leave  the  reference  to  these 
until  we  come  to  speak  of  the  pathology  of  pyaemia  in  man. 

The  clinical  characters  of  these  diseases  as  met  with  in  practice 
must  next  be  briefly  described. 

They  may  occur  in  connection  with  surgical  operations,  injuries,  or 
diseases.  Pure  acute  sapraemia,  as  above  defined,  is  rarely  found  in 
surgical  practice,  and  can  only  occur  in  the  cases  of  large  wounds  or 


SEPTICEMIA   AND  PYALMIA  591 

cavities,  such  as  the  peritoneum,  which  are  imperfectly  drained ;  but  it 
probably  is  not  uncommonly  seen  in  a  milder  form,  and  plays  a  part 
in  the  traumatic  fever  which  so  usually  accompanies  a  septic  wound. 
Hectic  fever  may  be  either  a  chronic  sapraemia  or  a  chronic  septicaemia ; 
that  is  to  say,  it  is  a  state  in  which  small  doses  of  septic  poison  are  con- 
stantly being  absorbed  either  from  the  wound  or  from  the  tissues  in 
which  the  organisms  are  situated.  Septicaemia  may  result  from  wounds 
of  any  size,  even  from  mere  scratches  if  they  happen  to  be  infected  with 
the  necessary  virus  of  sufficient  virulence.  Pysemia  may  also  result 
from  wounds  of  any  kind,  or  from  surgical  diseases  associated  with 
suppuration.  Usually  thrombosis  occurs  in  the  veins  leading  from  the 
affected  part,  and  the  emboli  resulting  from  the  breaking  down  of  the 
thrombus  lodge  in  the  first  capillaries  at  which  they  arrive ;  conse- 
quently in  most  cases,  where  the  systemic  veins  are  affected,  the  lungs 
are  the  chief,  or,  it  may  be,  the  only  part  attacked.  Pyaemia  following 
acute  osteo-myelitis  is  of  the  same  type  and  due  to  the  same  causes ; 
and  although  commonly  described  as  a  distinct  variety  of  the  disease  it 
presents  no  special  characteristics.  The  same  may  be  said  of  the  rarer 
cases  occurring  in  connection  with  cellulitis,  local  abscesses,  etc. 

Puerperal  fever,  again,  can  no  longer  be  considered  as  a  separate 
disease.  The  uterus  after  parturition  or  abortion  presents  a  large  raw 
surface  exactly  comparable  to  that  of  a  recent  wound ;  and  any  of  the 
forms  of  septic  disease,  or  any  admixture  of  them,  may  arise  as  the 
result  of  the  retention  of  decomposing  materials  in  its  cavity,  or  of  in- 
fection 'of  the  discharges.  It  may,  however,  be  here  noted  that  in  these 
cases  there  is  a  special  liability  to  the  retention  of  a  large  mass  of  putre- 
fying material  in  contact  Math  a  large  absorbing  surface,  so  that  pure 
sapraemia  is  more  often  found  in  this  than  under  any  other  conditions 
\yide  art.  on  *' Puerperal  Septic  Disease"]. 

Ulcerative,  infective,  or  malignant  endocarditis  may  occur  in  the 
course  of  an  ordinary  pyaemia,  or  may  appear  to  be  the  starting-point  of 
the  disorder.  In  either  case  the  pathological  picture  is  peculiar,  in  that 
the  primary  affection  occurs,  in  the  great  majority  of  cases,  on  the  left 
side  of  the  heart ;  thus  the  emboli  given  off  from  it  lodge  in  the  systemic 
arteries  or  capillaries,  and  lead  to  a  true  arterial  pyaemia  (Wilks).  Be- 
yond this,  and  the  fact  that  the  emboli  are  usually  in  great  abundance, 
and  that  the  lungs  are  not  affected  in  the  first  instance,  this  disease  does 
not  differ  from  ordinary  pyaemia  \yide  art.  "Infective  Endocarditis"]. 

Suppurative  Pyle-phlebitis  is  a  true  pyaemia,  where  the  original  site 
of  infection  is  situated  somewhere  in  the  area  drained  by  the  portal  sys- 
tem of  veins.  It  is  then  in  the  radicles  of  these  veins  that  thrombosis 
occurs ;  and  the  resulting  emboli  will  lodge,  in  the  first  instance,  in  the 
portal  veins  or  capillaries  of  the  liver.  It  may,  in  short,  be  accurately 
described  as  portal  pyaemia.  A  rare  form  of  this  disease  is  occasionally 
seen  in  the  newly  born,  and  is  sometimes  described  as  umbilical  pyaemia. 
It  results  from  suppurative  phlebitis  of  the  unoV)literated  umbilical  vein. 

Idiopathic  or  spontaneous  pyaemia  and  septicuiuiia  are  names  applied 


592  SYSTEM   OF  MEDICINE 


to  those  cases  wliicli  present  the  ordinary  clinical  features  and  post- 
mortem appearances  of  this  disease,  but  in  which  the  source  of  the  in- 
fection cannot  be  discovered.  These  cases  will  be  further  discussed 
later,  but  it  may  be  here  remarked  that  most  of  the  published  cases 
seem  to  be  examples  of  multiple  abscesses  rather  than  of  true  pygemia. 
Infective  myositis,  an  exceedingly  rare  disease  characterised  by  multi- 
ple abscesses  in  the  muscles  throughout  the  body,  has  also  been  classed  un- 
der pyaemia,  but  its  pathology  has  not  as  yet  been  properly  worked  out. 

A.    Sapr.emia 

Etiology  in  Man.  —  The  following  conditions  may  be  taken  as  neces- 
sary factors  in  the  production  of  this  disease  in  man :  (1)  There  must  be 
a  large  mass  of  dead  material,  whether  injured  tissues,  blood-clot  or  dis- 
charge, which  is  undergoing  putrefactive  changes ;  (2)  This  putrefying 
material  must  be  in  contact  with  a  large,  rapidly  absorbing  surface  such 
as  would  be  furnished  by  a  fresh  wound,  a  serous  surface,  and  tlie  like ; 
(3)  Tension  in  the  wound,  keeping  the  discharges  under  pressure,  and 
mechanically  aiding  their  absorption. 

It  may  also  be  accepted  that  the  poisons  will  produce  greater  effects, 
or,  coirversely,  that  a  smaller  dose  will  be  required,  in  persons  who  are 
debilitated,  who  are  at  either  extreme  of  life,  or  in  whom  the  excretory 
functions,  which  play  so  important  a  part  in  the  elimination  of  the 
poison,  are  in  any  way  impaired. 

These  demands  will  be  satisfied  by  such  conditions  as  the  following: 
After  parturition  or  abortion,  portions  of  placenta,  membranes,  or  blood- 
clot,  if  retained  in  the  uierus,  are  very  apt  to  become  infected  with 
putrefactive  organisms  and  to  undergo  rapid  decomposition.  The  in- 
terior of  the  uterus  furnishes  a  large,  raw,  rapidly  absorbing  surface,  so 
that  a  large  dose  of  the  poison  must  be  absorbed.  In  many  cases,  also, 
the  patient  may  be  suffering  from  a  certain  amount  of  physical  exhaustion 
or  mental  distress  which  renders  her  more  susceptible  to  the  poisonous 
influence  \yide  art.  on  "Puerperal  Septic  Disease"].  In  surgical  practice 
it  may  be  met  with  after  severe  injuries,  when  a  large,  deep  wound  con- 
tains gangrenous  tissue,  blood,  or  discharges  undergoing  decomposition  ; 
also  after  operations  when  large  cavities  are  left,  as  after  the  removal  of 
large  tumours,  or  the  serous  cavities  of  the  pleura,  peritoneum  or  large 
joints  are  laid  open,  and  a  quantity  of  decomposing  material  is  pent  up  in 
an  ill-drained  cavity.  Again,  if  a  large  chronic  abscess — such  as  a  psoas 
abscess  —  be  imperfectly  opened  and  drained,  and  putrefactive  bacteria 
gain  access  tc  it,  sapraemia  may  occur;  and  when  in  these  instances  it 
does  occur,  the  symptoms  set  in  very  shortly  after  the  injury  —  within 
a  few  hours. 

It  has  long  been  known  to  surgeons,  and  especially  urged  by  Sir 
Joseph  Lister,  that  absorption  does  not  take  place,  or  at  any  rate  but 
imperfectly,  after  a  wound  becomes  completely  covered  with  healthy 
granulation  tissue;  hence  it  is  that  the  traumatic  fever,  the  result  of 


SEPTICEMIA   AND  PYEMIA 


593 


septic  absorption,  comes  to  an  end  about  the  fourth  or  fifth  day.  It  may- 
be said  here  tliat  cases  of  saprsemia  at  all  comparable  to  those  artificially 
produced  on  animals,  or  to  those  occurring  in  obstetric  practice,  are  rare 
in  surgical  practice.  In  a  special  report  on  the  subject  of  septic  diseases 
to  the  Pathological  Society  of  London  156  clinical  records  are  published, 
and  in  28  of  these  there  were  no  metastatic  abscesses.  Of  these  28 
only  two  are  considered  cases  of  sapraemia,  and  even  these  are  not 
beyond  suspicion ;  it  may  fairly  be  urged,  however,  that  these  statistics 
do  not  give  a  comj^lete  view  of  the  facts,  for  in  a  large  proportion  (24 
out  of  the  26  remaining)  septic  poisoning,  which  could  not  be  excluded, 
probably  played  some  part  in  the  production  of  the  symptoms  and  fatal 
result ;  and,  secondly,  the  statistics  deal  only  with  fatal  cases,  and  this 
disease,  as  is  well  known,  is  overcome  by  proper  treatment  in  a  large 
proportion  of  cases. 

But  while  acute  and  pure  cases  of  sapraemia  are  rare,  mild  cases 
are  commonly  seen;  it  probably  plays  a  great  part  in  the  so-called 
traumatic  fever,  that  is,  in  fever  occurring  on  the  second  or  third  day 
after  injuries  or  operations,  where  sepsis  has  been  allowed  to  take  place 
in  a  wound.  These  mild  cases  are  important  from  another  point  of 
view ;  the  poisons  irritate  and  set  up  an  unhealthy  state  of  the  wound, 
and  from  their  debilitating  action  on  the  patient  they  so  lower  the 
resisting  powers  of  his  tissues  as  to  make  him  far  more  susceptible  to 
the  graver  forms  of  septic  infection. 

Sapraemia,  again,  is  not  uncommon  in  operations  on  the  peritoneum ; 
and  there  can  be  no  doubt  that  a  good  many  of  the  cases  of  death  from 
exhaustion,  and  of  those  cases  where  there  has  been  fever  but  no  peri- 
tonitis, are  really  cases  of  saprasmia  due  to  the  introduction  of  non- 
pathogenetic  saprophytic  organisms  into  the  peritoneal  cavity.  Further, 
the  poison  being  a  chemical  one,  it  may  readily  be  absorbed  from  the 
alimentary  canal ;  and  it  may  be  remarked  that  some  of  the  symptoms 
following  strangulation  of  the  gut  or  intestinal  obstruction,  usually 
ascribed  to  collapse  or  recurrent  shock,  are  in  all  probability  due  to  ab- 
sorption of  poisons  generated  in  the  intestinal  tract  above  the  obstruction. 

Symptoms.  —  The  symptoms  begin  suddenly,  and  usually  apj)ear 
within  twenty-four  hours  of  the  time  that  the  discharges  from  the  wound 
were  noticed  to  be  putrid.  The  temperature  rises  abruptly  to  103°, 
104°,  or  sometimes  even  higher,  being  accompanied,  but  by  no  means 
invariably,  by  a  rigor.  This  initial  rigor  may  be  very  severe,  lasting 
half  an  hour  or  more,  and  usually  is  not  repeated ;  in  exceptional  cases, 
however,  repeated  rigors  may  occur.  At  the  same  time  the  skin  be- 
comes hot,  dry  and  flushed,  the  patient  complains  of  intense  headache, 
the  tongue  becomes  coated  with  white  fur,  and  there  is  intense  thirst. 
Anorexia  is  complete ;  vomiting  is  common,  and  may  be  severe  even  from 
the  commencement.  Other  common  febrile  symptoms  also  appear :  the 
pulse  is  rapid  and  full ;  the  respirations  are  hurried  ;  the  urine  is  scanty, 
high-coloured,  and  dey)()sits  urates  on  cooling.  Locally  a  sufficient  cause 
for  the  a})ove   symptoms   is   usually  obvious.     The  wound  may  show 

VOL,.    1  2    Q 


594  SYSTEM  OF  MEDICINE 

signs  of  inflammatory  disturbance,  or  even  appear  gangrenous ;  and  in 
all  cases  there  is  a  considerable  amount  of  very  foul  smelling  discharge. 

If  the  case  be  a  severe  one,  and  treatment  not  immediately  adopted, 
signs  of  severe  prostration  rapidly  supervene.  There  is  delirium,  es- 
pecially at  night,  at  first  noisy  but  soon  assuming  the  low  muttering 
type,  and  becoming  almost  constant.  There  is  excessive  muscular  weak- 
ness as  evidenced  by  tremors.  The  tongue  is  now  dry,  brown  and  very 
tremulous;  the  mouth  and  lips  are  covered  with  sordes.  Diarrhoea 
may  come  on,  and  motions  and  urine  be  passed  unconsciously.  The 
skin  may  be  slightly  jaundiced  and  petechise  may  appear.  The  tem- 
perature may  fall,  even  to  subnormal ;  coma  comes  on  and  gradually 
deepens  into  death.  Death  usually  occurs  about  the  second  or  third  day 
of  the  disease ;  but  in  other  cases  may  be  postponed  for  as  long  as  a 
week,  the  patient  passing  into  a  typical  *'  typhoid  state,"  and  dying  of 
exhaustion. 

In  less  severe  cases,  those  most  commonly  seen  in  surgical  practice, 
the  symptoms  are  similar  but  less  marked.  Usually  improvement  fol- 
lows at  once  when  the  wound  is  freely  opened,  the  putrid  material 
removed,  and  free  drainage  established ;  but  all  fever  may  not  cease 
until  granulation  is  complete,  and  has  formed  an  efficient  barrier  against 
further  absorption.  Even  in  the  most  severe  cases  recovery  rapidly 
follows  removal  of  the  cause. 

A  brief  abstract  of  a  case  quoted  by  Dr.  Matthews  Duncan  may  be 
given  here,  as  it  serves  well  to  illustrate  some  of  the  more  marked  features 
of  this  disease.  It  is  in  every  respect  a  pattern  case,  and  indicates  the 
happy  result  that  may  be  anticipated  if  treatment  be  properly  carried  out. 

"  A  young  woman  after  a  natural  labour  gave  birth  to  her  second 
child.  For  the  first  week  slight  bleeding  took  place,  and  on  the  seventh 
day  the  discharges  were  noticed  to  be  putrid.  The  following  day,  the 
eighth,  rigors  occurred,  and  these  were  repeated  daily  until  the  eleventh 
day  after  delivery.  The  patient  was  then  noticed  to  be  very  pale,  fre- 
quently sick,  and  there  was  profuse  diarrhoea.  The  uterus  was  tender, 
the  breath  sweet,  respirations  44,  pulse  146,  temperature  104-2°  F.  The 
lochia  were  copious  and  stinking.  She  had  been  delirious  all  the  pre- 
vious night.  Chloroform  was  administered,  and  large  pieces  of  decom- 
posing placenta  removed  from  the  uterus,  which  was  thoroughly  irri- 
gated. The  next  day  the  patient  had  slept  well  without  delirium,  pulse 
100,  respirations  36,  and  the  highest  temperature  1014°.  Recovery 
henceforth  was  uninterrupted."  Dr.  Duncan  remarks,  "  In  twenty -four 
hours  the  whole  aspect  of  the  case  changed  from  despair  to  hopeful- 
ness. The  Avoman  was  at  the  point  of  death,  it  was  apparently  not 
worth  disturbing  her  by  treatment,  and  yet  a  few  hours  afterwards  she 
was  comfortable,  and  every  alarming  symptom  had  gone."  Such  re- 
covery as  this  is  only  seen  in  these  cases  of  pure  sapraemia. 

In  the  milder  cases  recovery,  when  it  occurs,  is  usually  rapid  and 
complete ;  but  in  the  more  severe  cases  convalescence  may  be  accom- 
panied by  great  anaemia  due  to  the  destruction  of  the  red  corpuscles 
and  haemoglobin. 


SEPTICEMIA   AND  PYyEMIA  595 


Morbid  Anatomy.  —  The  appearances  found  on  post-mortem  examina- 
tion of  these  cases  are  very  similiar  to  those  occurring  in  animals  in 
which  the  disease  has  been  artificially  produced.  They  are  somewhat 
indefinite,  and  present  nothing  absolutely  characteristic.  Rigor  mortis 
comes  on  early  and  soon  passes  off,  being  in  most  cases  but  slightly 
marked.  Decomposition  rapidly  sets  in,  and  even  in  cold  weather 
putrefaction  of  the  body  prevents  proper  examination ;  the  organs, 
eight  or  ten  hours  after  death,  are  diffluent  or  distended  with  foetid 
gases.  The  blood  remains  fluid  for  some  time,  and  gravitates,  causing 
marked  hypostatic  congestion.  Coagulation  occurs  but  slowly,  and  the 
clot  formed  is  soft. 

The  lining  membrane  of  the  vessels  and  endocardium  is  blood  stained, 
and  there  may  be  extravasations  of  dark  blood  beneath  the  skin,  pleura, 
pericardium,  in  the  brain,  etc.  Occasionally  the  pleura,  pericardium,  or 
other  serous  cavities  contain  a  little  blood  stained  fluid.  The  liver  and 
kidneys  are  usually  swollen ;  occasionally  small  haemorrhages  are  seen  in 
them,  and  microscopically  the  glandular  cells  are  swollen  and  cloudy, 
or  coarsely  granular.  The  spleen  is  almost  invariably  much  swollen, 
deeply  congested,  and  occasionally  almost  diffluent.  Various  microbes 
which  have  been  found  in  the  tissues  are  almost  certainly  of  post- 
mortem occurrence,  and  in  a  few  hours  they  swarm  in  the  body. 

Diagnosis  presents  no  difficulty  in  a  ordinary  case  where  we  have  the 
sudden  onset  of  febrile  symptoms  in  connection  with  an  obvious  cause. 
It  may  not  at  first  be  possible  to  say  positively  which  form  of  septic 
disease  is  present,  but  the  effect  of  treatment  and  the  progress  of  the  case 
will  decide  the  question  in  a  few  hours.  In  doubtful  cases  of  sapraemia 
and  septicaemia  the  test  of  treatment  must  be  relied  on  to  exclude  the 
former,  the  fact  of  importance  being  to  determine  if  septicaemia  be  present. 

It  must  also  be  remembered  that  certain  symptoms  of  "  collapse  " 
or  "  shock,"  on  or  about  the  third  day  after  operation,  are  commonly 
due  to  sapraemia.  It  is  probable  that  large  numbers  of  deaths  after 
ovariotomy  and  other  operations  on  the  abdomen  which  have  been 
ascribed  to  shock  and  exhaustion  are  really  due  to  sapraemia. 

As  to  prognosis  but  little  need  be  added.  In  simple  cases  of  sap- 
raemia the  prospect  of  recovery  is  always  hopeful  if  treatment  be  imme- 
diately adopted,  however  bad  the  patient  may  appear  at  the  time.  In 
the  old  and  debilitated,  however,  the  prognosis  must  be  regarded  as 
much  more  serious.  Also  the  risk  of  other  septic  troubles  arising  in 
connection  with  the  same  cause  must  be  borne  in  mind,  and  this  cannot 
be  dismissed  entirely  until  granulation  is  established. 

Finally  it  may  be  said  that  recovery,  when  it  occurs,  is  not  only 
rapid  but  complete. 

Treatment  is  mainly  sui-gical,  and  needs  but  a  brief  allusion.  The 
two  main  points  to  be  aimed  at  have  already  been  indicated,  namely,  to 
remove  the  source  of  the  trouble  as  thoroughly  as  possible,  and  at  tlie 
same  time  to  injure  the  tissues  as  little  as  ])ossible.  The  first  point  is 
attained  by  opening  up  the  part   freely,  removing  any  decomposing 


596  SYSTEM   OF  MEDICINE 

material  found,  and  then  flushing  all  the  surfaces  of  the  wound  thor- 
oughly with  a  mild  antiseptic  lotion.  Thus  if  the  cause  of  the  trouble 
be  blood-clot  or  pieces  of  placenta  or  membranes  retained  and  decom- 
posing in  the  uterus,  the  cervix  must  be  dilated  as  far  as  necessary, 
the  offending  substances  removed  by  flushing,  or  by  the  fingers,  or  by 
curetting  as  gently  as  possible,  and  then  the  whole  uterine  cavity  thor- 
oughly irrigated.  If  the  cause  be  a  wound  of  one  of  the  large  serous 
cavities  this  must  be  freely  laid  open,  cleansed  in  a  similar  way,  and 
means  taken  to  ensure  efficient  drainage. 

The  second  point  is  to  handle  the  tissues  as  gently  as  possible,  and 
to  avoid  the  use  of  strong  antiseptic  solutions  for  flushing  purposes. 
These  solutions  as  applied  only  act  mechanically  by  washing  away 
decomposing  material,  and  cannot  destroy  all  the  organisms  present. 
On  the  other  hand  they  act  deleteriously  on  tissues  already  weakened 
by  contact  with  the  poisonous  products,  so  that  the  wounds  allow  organ- 
isms to  enter,  to  act  on  the  parts  more  easily,  and  perhaps  even  cause 
their  death  —  thus  providing  a  fresh  nidus  for  the  putrefactive  bacteria. 
Such  fluids  as  sterilised  water,  boracic  acid,  or  perchloride  of  mercury 
(1-GOOO  or  1  in  10,000)  solutions  are  to  be  preferred.  The  best  tem- 
perature at  which  to  use  them  is  probably  about  100°-10o°  F.,  as  this 
does  not  damage  the  tissues,  and  it  acts  as  a  general  stimulant. 

Afterwards  the  wound  must  be  treated  on  general  surgical  principles. 
At  the  same  time  the  condition  of  the  patient  must  be  carefully  attended 
to.  The  cause  being  removed,  rapid  recovery  will  ensue  if  the  effects 
of  the  poison  already  absorbed  can  be  arrested.  The  collapse  of  severe 
cases  must  be  treated  by  large  quantities  of  stimulants  frequently  admin- 
istered. Brandy  must  be  given  by  mouth,  or  per  rectum  if  vomiting 
persist ;  strychnine  seems  to  be  of  special  value.  Carbonate  of  ammonia 
in  two  or  three  grain  doses  may  be  given  hourly,  or  sal  volatile  in  half- 
drachm  doses.  In  very  severe  cases  hypodermic  injections  of  ether 
must  be  resorted  to,  and  repeated  as  necessary ;  in  a  word,  every  effort 
must  be  made  to  keep  the  patient  alive  for  a  few  hours  until  the  poison 
in  his  blood  is  excreted. 

In  milder  cases  but  little  medical  treatment  is  required  beyond 
attending  generally  to  the  excretory  functions.  A  diet  consisting 
chiefly  of  milk  with  as  much  fluid  as  the  patient  cares  to  drink  may 
be  ordered,  a  large  quantity  of  fluid  serving  to  dilute  the  poison  and 
hasten  its  excretion.  If  vomiting  persist  it  may  be  allayed  by  a  simple 
effervescing  mixture,  or  by  small  doses  of  hydrocyanic  acid  and  bismuth. 
As  convalescence  is  established,  a  liberal  diet  with  general  tonics  —  iron, 
quinine,  or  strychnine  —  or  perhaps  change  of  air  will  be  beneficial. 

B.  Septicaemia 

The  pathology  of  this  disease  is  much  more  difficult  than  that  of 
sapraemia,  and  indeed  it  has  not  as  yet  been  definitely  worked  out : 
I  do  not  know  of  any  complete  solution  of  it.     From  my  description 


SEPTICEMIA   AND  PYEMIA  597 

of  the  experiments  on  animals,  it  would  seem  to  be  very  simple, 
namely,  that  in  sapraemia  we  have  poisoning  with  the  chemical  Tjroducts, 
in  septicaemia  we  have  a  blood  disease  (the  organisms  growing  in  the 
blood),  and  in  pyaemia  we  have  in  addition  to  blood  disease  the  forma- 
tion of  secondary  abscesses ;  but  when  we  come  to  the  pathology  of 
these  diseases  as  they  occur  in  man,  we  find  that  it  is  not  so  simple  as 
would  appear  from  the  investigations  in  animals.  As  a  matter  of  fact, 
in  cases  grouped  under  the  name  septicaemia,  we  have  not,  as  a  rule,  to 
do  with  a  disease  resembling  the  so-called  septicaemia  of  the  lower 
animals,  in  which  the  organisms  are  growing  freely  and  in  large 
numbers  in  the  blood.  True,  on  examining  the  blood  taken  from 
septicaemic  patients,  pyogenic  cocci  can  usually  be  found ;  but  they  are 
generally  in  small  numbers,  are  demonstrated  with  difficulty,  and  do 
not,  as  regards  their  numbers  or  distribution,  in  any  way  resemble  the 
septicaemia  of  mice  or  rabbits:  one  is  thus  tempted  to  consider  septi- 
caemia after  all  as  a  chemical  poison  similar  to  sapraemia,  the  organisms 
producing  this  chemical  poison  not  being  in  the  circulating  blood.  In 
septicaemia,  however,  we  have  one  marked  difference  from  sapraemia. 
In  the  latter  case,  washing  out  the  decomposing  products  from  the 
wound,  or  removal  of  the  part  which  is  the  seat  of  decomposition,  at 
once  arrests  the  disease  ;  the  explanation  being,  as  before  said,  that  the 
organisms  producing  the  poisonous  materials  are  growing  outside  the 
body,  and  that  the  poisonous  materials  are  absorbed  from  the  surface  of 
the  wound;  on  the  other  hand,  it  is  evident  that  in  septicaemia  the 
manufactory  of  the  poisonous  products  is  not  necessarily  in  the  wound 
itself,  but  may  be  in  other  parts  of  the  body  —  in  other  words,  we  have 
to  do  here  with  an  infective  disease  caused  \>^  parasitic  micro-organisms 
which  are  able  to  live  in  the  body  itself. 

As  to  the  place  where  these  organisms  live  and  produce  their  prod- 
ucts, I  believe,  as  I  have  just  said,  that  but  a  slight  effect  is  produced 
by  the  small  numbers  of  organisms  found  in  the  circulating  blood.  The 
main  body  of  them  are  at  rest  in  the  system,  and  from  the  parts  where 
they  are  deposited  they  pour  their  poisons  into  the  blood. 

One  of  the  common  seats  of  these  organisms  is  the  tissues  of  the 
wound  itself  which,  in  an  advanced  case  of  septicaemia,  would  generally 
be  found  infiltrated  with  the  cocci.  Although  they  do  not  grow  freely 
in  the  circulating  blood,  they  get  into  it,  and  are  carried  by  it  and 
deposited  in  various  parts;  after  death  it  is  not  uncommon  to  find  in 
cases  of  septicaemia  numerous  capillaries  throughout  the  body  blocked 
with  collections  of  cocci  which  have  not  yet  led  to  abscesses.  In  these 
cases  I  believe  the  organisms  have  become  adherent  to  the  endothelium 
of  the  blood-vessels,  and  having  succeeded  in  overcoming  the  resistance 
of  these  cells  they  grow  there,  and  form  the  plug  which  is  found  after 
death. 

A  few  cases  where  the  symptoms  are  similar,  though  probably  more 
acute,  have  been  found  to  depend  on  the  growth  of  organisms  in  large 
numbers  in  the  blood  —  usually  bacilli ;  this  condition  corresponds  to 


598  SYSTEM   OF  MEDICINE 

that  found  in  the  lower  animals.  The  organisms  which  are  usually  as- 
sociated with  septicaemia  are,  however,  the  pyogenetic  organisms,  either 
the  staphylococci,  or  perhaps  more  commonly  streptococci.  On  post- 
mortem examination  careful  search  generally  shows  a  few  organisms  in 
the  blood,  and  they  may  be  cultivated  from  the  blood  of  some  of  the 
internal  organs  —  more  especially  of  the  kidneys,  where  they  are  some- 
times in  considerable  numbers.  In  cases  of  bacillary  septicaemia  it 
seems  that  the  plugs  are  not  uncommon  in  the  heart  muscle.  The 
organisms  are  always  found  in  considerable  numbers  in  the  wound,  in 
the  pus,  or  discharges,  in  the  membranous  deposit  which  is  sometimes 
seen  on  its  surface,  and  deep  in  the  neighbouring  tissues ;  sometimes  in 
the  lymphatics  and  the  neighbouring  lymphatic  glands. 

It  is  difficult  to  understand  how  organisms  like  these  pyogenetic  cocci 
can  at  one  time  cause  a  simple  abscess,  and  at  another  a  severe  and 
rapidly  fatal  general  disease ;  apparently  this  depends  on  the  variation 
and  virulence  of  the  organisms.  These  pyogenetic  cocci  increase  in 
virulence  when  injected  into  the  peritoneal  cavity,  and  we  find  that 
inoculation  from  septic  peritonitis  is  one  of  the  commonest  causes  of  the 
very  rapid  and  fatal  form  of  the  disease  in  man.  Apart  from  variation 
and  virulence,  the  initial  dose  of  the  organisms  which  enters  the  body 
has  a  great  deal  to  do  with  the  result,  while  predisposition  on  the  part 
of  the  body,  and  the  existence  of  Aveak  points  where  the  organisms  can 
settle  and  develop  are  also  of  great  importance.  It  seems  probable  that 
under  the  term  septicaemia  several  different  septic  diseases  are  grouped ; 
but  the  possibility  of  making  out  the  state  of  the  case  is  becoming  more 
and  more  difficult,  owing  to  the  spread  of  the  principles  of  antiseptic 
surgery,  and  the  consequent  increasing  rarity  of  the  cases  —  at  any  rate 
in  the  hands  of  those  who  would  be  able  to  investigate  their  pathology. 

The  disease  may  arise  from  a  simple  prick  or  puncture  inflicted 
during  a  dissection  or  post-mortem  examination.  In  these  cases  the 
small  size  of  the  wound  forbids  all  idea  of  poisoning  by  chemical  prod- 
ucts alone,  and  the  disease  which  establishes  itself  is  usually  extremely 
rapid  in  its  course,  and  accompanied  by  great  fatality.  Most  commonly 
the  disease  follows  wounds  which  have  not  been  treated  aseptically,  and 
where,  consequently,  the  pyogenetic  organisms  are  present.  Why  it 
should  arise  in  one  individual  with  a  septic  wound  and  not  in  another 
is,  as  has  already  been  said,  not  at  all  clear. 

Apart  from  the  virulence  of  the  organisms  and  the  condition  of  the 
patient,  local  conditions  no  doubt  play  a  very  important  part,  such  as 
much  bruising  in  the  wounds,  esj)ecially  of  the  muscular  tissues,  in 
which  the  organisms  can  therefore  readily  settle ;  the  muscles,  more- 
over, are  very  plentifully  provided  with  lymphatic  vessels.  Perhaps  the 
most  important  local  cause  is  the  retention  of  the  decomposing  fluids 
in  the  wound  leading  to  that  amount  of  pressure  which  would  help  the 
entrance  of  the  organisms  into  the  blood  or  lymph  stream. 

In  former  times  the  contagious  nature  of  the  disease  was  well  shown 
by  the  severe  outbreaks  which  occurred  from  time  to  time  in  the  surgical 


SEPTICEMIA   AND  PYMMIA  599 

wards  of  hospitals.  The  disease  once  introduced  spread  from  patient  to 
patient  with  great  readiness ;  most  probably  being  communicated  by  the 
surgeons  or  nurses,  especially  in  the  use  of  the  same  instruments  for 
dressing  successive  cases  without  proper  disinfection.  More  dreaded 
still  was  it  in  some  of  the  large  maternity  hospitals,  where  there  are 
records  of  many  outbreaks,  especially  at  the  beginning  of  the  century. 
In  some  cases  half  or  two-thirds  of  the  women  delivered  contracted  the 
disease,  and  practically  all  of  these  died. 

The  post-mortem  changes  which  are  found  in  septicaemia  (apart  from 
the  presence  of  deposits  of  organisms  in  various  tissues  or  organs)  are 
almost  identical  with  those  found  in  saprsemia.  Rigor  mortis  is  as  little 
marked ;  putrefaction  proceeds  with  the  same  extreme  rapidity ;  there 
are  the  same  blood  changes,  blood  staining,  serous  effusions,  etc.  The 
spleen,  however,  is  rarely  quite  so  large,  and  congestion  of  the  lungs  and 
bronchitis  are  more  or  less  constantly  present. 

Symptoms. — In  discussing  the  syihptoms,  general  and  local,  the 
severer  and  more  typical  form  of  the  disease  will  first  be  treated,  and 
subsequently  reference  made  to  the  milder  varieties.    . 

General  Symptoms.  — The  disease  commences  abruptly,  often  as  early 
as  a  few  hours  after  inoculation,  usually  within  twenty-four  hours. 
Accompanying  the  changes  in  the  wound  the  temperature  is  observed 
to  be  rapidly  rising ;  rigors  occur  in  more  than  half  the  cases,  and  are 
usually  repeated  and  severe.  The  temperature  usually  remains  high 
throughout  (103°-105°  F.),  with  slight  remissions.  In  the  severer  cases 
the  patient's  life  is  rapidly  endangered ;  death  may  occur  as  early  as  the 
second  or  third  day.  The  pulse  is  always  very  rapid,  sometimes  par- 
ticularly feeble  and  irregular;  the  heart  sounds  weak.  The  respiration 
is  rapid,  there  may  be  dyspnoea  and  cyanosis,  accompanied  by  all  the 
signs  of  catarrhal  bronchitis.  There  is  always  complete  anorexia,  some- 
times accompanied  by  vomiting,  more  rarely  by  diarrhoea. 

The  cerebral  symptoms  also  vary  much.  There  is  usually  headache 
more  or  less  severe ;  in  some  cases  delirium  sets  in  early  and  is  followed 
by  coma, — more  usually,  perhaps,  the  mind  remains  clear  to  the  end. 
If  the  case  last  longer  the  patient  passes  into  a  typhoid  state.  The  skin 
usually  assumes  an  icteric  tint  and  purpuric  spots  may  occur.  The  urine, 
besides  the  usual  febrile  characters,  frequently  contains  albumin,  and 
micrococci  (in  cases  due  to  them)  can  usually  be  detected  in  it  when 
freshly  drawn  off  from  the  bladder.  The  gastro-intestinal  symptoms 
become  severe,  and  the  patient  dies  from  exhaustion  usually  within  a 
week. 

Although  the  differences  in  the  symptoms  noted  above  may  possibly 
depend  to  some  extent  on  corresponding  differences  in  the  causative 
agent,  yet  with  our  present  state  of  knowledge  it  is  impossible  to  say 
how  far  this  is  the  case.  No  trustworthy  observations  on  this  point 
liave  yet  been  made. 

The  symptoms  of  the  milder  varieties  of  this  disorder  need  only 
be  alluded  to:   they  are  those  which  ordinarily  occur  in  connection 


6oo  SYSTEM   OF  MEDICINE 

with  suppuration  and  septic  wounds.  There  is  always  fever,  but  the 
temperature  rarely  reaches  104°  F.,  and  rigors  are  unusual.  The 
patient  feels  ill,  suffers  from  headache  and  thirst,  the  tongue  is  furred, 
and  there  is  anorexia.  Vomiting  may  occur,  and  constipation  is  the 
rule.  In  these  cases  also  micrococci,  if  carefully  searched  for,  may  be 
found  both  in  the  blood  and  in  the  urine.  As  the  state  of  the  wound 
improves  the  fever  subsides  and  the  patient  becomes  convalescent. 

Local  Signs.  — The  changes  at  the  site  of  inoculation  or  in  the  wound 
also  vary  greatly.  In  severe  cases  from  a  post-mortem  prick  the  finger 
in  a  few  hours  becomes  greatly  swollen  and  intensely  painful ;  thin  red 
lines  of  inflamed  lymphatic  vessels  may  be  seen  spreading  up  the  arm, 
and  the  axillary  lymphatic  glands  become  affected.  Very  shortly  the 
whole  arm  may  become  swollen,  oedematous  and  painful.  In  rare  cases 
the  disease  is  apparently  arrested  in  the  glands,  and  suppuration  occurs 
there,  and  also  along  the  course  of  the  lymphatics.  In  these  cases,  the 
abscesses  being  freely  opened,  f ecovery  may  ensue ;  but  more  often  the 
infection  rapidly  passes  beyond  them.  Sometimes  a  form  of  gangrene 
spreads  rapidly  from  the  site  of  infection.  In  other  cases  no  sup- 
puration occurs,  but  the  wound  becomes  covered  with  a  yellowish 
white  adherent  membrane.  In  this  membrane  and  in  the  serous  flaky 
discharge  bacteria  can  often  be  demonstrated.  In  other  cases,  again,  no 
marked  changes  occur  at  the  site  of  inoculation.  In  the  milder  cases 
the  wound  is  usually  in  a  more  or  less  unhealthy  state,  suppurating  and 
painful,  with  swollen  reddened  margins. 

It  is  probable  that  some  forms  of  hectic  fever  may  be  due  to  staphy- 
lococci growing  in  the  granulations  and  the  tissues  bordering  on  the 
wound,  and  pouring  their  products  into  the  blood  stream.  As  these 
organisms  are  thus  growing  in  the  living  tissues,  according  to  our  defini- 
tions as  above,  some  forms  of  hectic  fever  must  be  considered  as  "  chronic 
septicaemia." 

The  diagnosis  may  be  made  with  ease  and  certainty  if  the  case  arise 
in  connection  with  a  small  wound  (an  obvious  source  of  infection),  or 
if  the  wound  present  some  characteristic  state  as  above  described.  In 
other  cases  extreme  difficulty  may  arise. 

The  distinction  from  sapraemia  has  already  been  pointed  out ;  from 
pyaemia  it  can  usually  be  made  by  its  acuter  onset,  more  rapid  progress, 
more  sustained  temperature,  and,  later,  by  the  absence  of  secondary 
abscesses.  The  possibility  of  a  severe  or  malignant  type  of  specific  fever, 
such  as  small-pox,  may  also  be  borne  in  mind.  The  presence  of  strepto- 
cocci in  the  blood  and  urine  may  be  of  help  in  some  doubtful  cases. 
The  possibility  of  overlooking  the  severer  underlying  condition,  and  re- 
garding the  case  as  one  of  simple  severe  bronchitis  with  cardiac  failure, 
must  be  guarded  against.  The  milder  cases  with  suppurating  or  septic 
wounds  present  no  difficulty. 

Prognosis  in  the  severer  forms,  if  an  absolute  diagnosis  can  be  made, 
is  almost  hopeless.  In  extremely  rare  cases,  as  has  been  mentioned,  the 
disease  may  be  arrested  in  the  lymphatics,  and  the  patient  ultimately 


SEPTICEMIA   AND  PYEMIA  601 


recover  after  a  prolonged  .and  severe  illness,  which  often  leaves  him  with 
an  impaired  constitution.  Although  persons  in  apparently  robust  health 
may  be  less  liable  to  fall  into  the  disease,  yet  when  once  established  it  is 
as  fatal  in  them  as  in  those  of  weaker  constitutions. 

Treatment.  —  On  first  seeing  a  case,  the  wound,  if  a  small  one,  should 
be  excised,  and  the  parts  freely  cauterised  with  pure  carbolic  acid  or 
the  actual  cautery.  In  cases  of  larger  wounds  thorough  cleansing,  fol- 
lowed by  application  of  pure  carbolic,  may  be  carried  out ;  or,  if  they  be 
situated  on  an  extremity,  the  question  of  immediate  amputation  must  be 
considered.  These  measures,  however,  rarely  do  any  good,  the  disease 
running  its  course  unchecked. 

The  most  that  can  be  done  is  to  support  the  patient's  strength  in 
every  way,  by  administering  in  small,  frequent  quantities  such  nutriment 
as  he  can  absorb,  by  giving  stimulants  —  brandy  and  carbonate  of 
ammonia  —  freely,  and  by  combating  in  a  suitable  way  some  of  the 
severer  symptoms.  Thus  the  temperature  may  be  controlled  by  tepid 
sponging,  vomiting  by  bismuth  or  alkalies,  and  narcotics  may  be  given 
where  there  is  pain.  Of  other  drugs  quinine  is,  perhaps,  of  as  much 
use  as  any. 

Pyemia 

When  we  consider  the  great  interest  in  this  disease,  and  the  terrible 
mortality  that  it  caused  among  surgical  patients  up  to  a  recent  period,  it 
is  very  remarkable  to  find  so  few  references  to  it  in  older  works,  and 
to  note  the  little  interest  which  it  apparently  excited  among  surgeons. 
Massa  in  1559  and  Ambrose  Pare  in  1561  pointed  to  the  occurrence  of 
abscesses  in  the  lungs  as  the  result  of  head  injuries;  but  no  precise 
theory  to  account  for  this  was  f orinulated  until  Boerhaave  published  his 
researches  in  1720.  Boerhaave  affirmed  that  the  complications  of  septic 
wounds  were  due  to  the  admixture  of  the  pus  of  the  wound  with  the 
blood ;  and  in  spite  of  many  adverse  theories  and  criticisms  this  view 
received  general  support  and  maintained  its  ground  until  our  own  day. 
John  Hunter,  while  apparently  adhering  to  the  view  that  pyaemia  was 
due  to  the  admixture  of  pus  and  blood,  demonstrated  the  existence  of 
suppurative  phlebitis,  and  believed  that  the  walls  of  the  veins  secreted  the 
pus.  The  presence  of  suppurative  phlebitis  in  almost  all  cases  was  also 
demonstrated  by  others,  of  whom  we  may  mention  Dance  in  1828.  In 
1834  Gunther,  and  also  Castelnau  and  Ducrest,  injected  considerable 
quantities  of  pus  into  the  veins  of  dogs  and  cats,  and  succeeded  in  nearly 
every  instance  in  producing  metastatic  abscesses.  Virchow,  in  1846  and 
later,  pointed  out  that  the  material  in  the  inflamed  veins  is  not  pus, 
but  softened  and  altered  blood-clot ;  and  that  it  is  cut  off  from  the  cir- 
culation by  more  recent  blood-clot  not  yet  broken  down ;  and  he  held 
that  the  alleged  mixture  of  blood  and  pus  is  really  a  leucocytosis.  He 
strongly  opposed  the  idea  that  pus  enters  the  circulation  from  the  veins 
or  from  the  lympliatic  vessels  ;  in  the  latter  case  he  pointed  out  that  the 
glands  must  stop  the  corpuscles.    In  1826  Cruveilhier  drew  attention  to 


6o2  SYSTEM  OF  MEDICINE 

the  constant  association  of  suppurative  phlebitis  with  metastatic  abscesses. 
He  injected  globules  of  mercury  into  the  circulation  of  the  lower  animals, 
and  noticed  that  abscesses  formed  where  the  globules  lodged  in  the  vessels ; 
and  he  believed  that  pus  from  the  veins  lodges  and  acts  in  a  similar  manner. 
In  1842  D' Arcet  stated  that  purulent  infection  consists  of  two  parts  which 
are  quite  distinct  from  each  other,  but  always  occur  together,  namely, 
poisoning  by  putrid  products  and  a  blockage  of  the  vessels  by  emboli ; 
the  first  leads  to  fever  and  general  symptoms,  and  the  second  to  the 
metastatic  abscesses.  This  theory  has  been  more  or  less  accepted  by 
Virchow  and  others.  Virchow  further  separated  septicaemia  (which  term 
he  also  applied  to  cases  of  septic  poisoning)  from  pyaemia,  and  showed 
that  the  two  might  occur  separately.  Most  of  the  experiments  in  support 
of  this  view  were  performed  with  putrid  pus :  the  well-filtered  solution, 
when  injected  into  the  veins,  produced  only  septictemia;  the  unfiltered 
solution  containing  solid  particles  led  to  pyaemia. 

AVhen  the  importance  of  bacteriology  in  connection  with  surgery 
was  recognised  these  views  were  carried  a  stage  further,  and  the  causal 
agents  were  shown  to  be  organisms  growing  in  the  decomposing  pus.  In 
1867  Sir  Joseph  Lister  first  published  the  results  which  he  had  obtained 
by  adopting  the  germ  theory  as  the  explanation  of  the  occurrence  of 
suppuration  in  septic  diseases ;  and,  acting  thereon,  the  brilliant  success 
of  the  antiseptic  treatment  soon  fully  confirmed  his  views,  and,  in 
spite  of  criticism,  it  has  constantly  gained  greater  and  greater  accept- 
ance, till  now  it  is  fully  recognised  and  firmly  established.  The  view 
now  generally  held  of  the  pathology  of  pyaemia  is  that  the  general 
symptoms  are  due  to  poisoning  Avith  the  products  of  certain  pyogenetic 
bacteria,  and  the  abscesses  for  the  most  part  to  plugging  of  the  blood- 
vessels with  masses  of  these  bacteria,  or  with  emboli  infected  with  them. 

Pathology.  —  Many  investigations  have  been  made  to  determine  the 
organisms  which  are  associated  with  pyaemia,  and  it  has  been  found  that 
the  organism  usually  present  is  the  streptococcus  pyogenes ;  though  in 
some  few  instances,  more  especially  in  the  less  severe  forms,  pyogenetic 
staphylococci  have  been  the  only  ones  present.  As  I  have  said,  the  fever 
and  general  symptoms  of  pyaemia  may  be  explained  as  those  of  septi- 
caemia ;  that  is  to  say,  they  are  due  to  poisonous  products  poured  into 
the  blood  stream  by  pyogenetic  cocci  growing  in  the  living  tissues  of  the 
body.  The  formation  of  the  secondary  abscesses  is,  however,  not  alto- 
gether quite  easy  to  explain  at  first  sight,  for  many  observers  have  found 
pyogenetic  cocci  circulating  in  the  blood  of  patients  with  septic  wounds 
in  whom  no  secondary  abscesses  were  established.  Ribbert  and  others 
have  found  that  the  injection  of  moderate  quantities  of  staphylococcus 
pyogenes  aureus  into  the  circulation  of  rabbits  is  followed,  as  a  rule,  only 
by  abscesses  in  the  kidneys,  the  other  organs  apparently  remaining  un- 
affected ;  hence  other  conditions  beside  the  mere  presence  of  pyogenetic 
organisms  circulating  in  the  blood  stream  are  found  necessary  for  the 
production  of  the  complete  picture  of  pyaemia. 

The  almost  constant  presence  in  these  cases  of  suppurative  phlebitis 


SEPTICAEMIA    AND  PY.-EMIA  603 


has  already  been  mentioned ;  and  there  seems  no  doubt  that  the  second- 
ary abscesses  —  at  any  rate  in  the  hmgs  —  are  explicable  on  the  view 
that  portions  of  the  softened  and  infected  thrombus  become  detached 
and  form  emboli  in  these  organs.  The  sequence  of  events  would  then 
be  as  follows :  —  (1)  Phlebitis  .occurs  in  direct  connection  with  the 
wound;  (2)  a  thrombus  impregnated  with  micrococci  is  formed  in  the 
vein;  (3)  the  thrombus  softens,  disintegrates,  and  portions  of  it  are 
carried  into  the  circulation  as  emboli ;  (4)  these  lodge  in  the  first  set 
of  capillaries  and  form  infarctions,  and  then  abscesses. 

In  support  of  this  view  are  the  following  experiments  :  —  Eibbert,  in 
experiments  on  rabbits  with  staphylococcus  pyogenes  aureus  found  that 
he  could  produce  abscesses  in  the  heart  and  in  various  organs  if  the 
cocci  were  injected  into  the  blood  stream  attached  to  particles  too  gross 
to  pass  through  the  capillaries  of  these  organs.  He  used  a  cultivation 
of  the  pyo'genetic  cocci  on  potatoes,  and  took  care  in  removing  the  cul- 
tivation to  scrape  off  also  the  superficial  layer  of  the  potato  itself.  If 
this  mixture  of  potato  granules  and  organisms  Avas  rubbed  up  with 
water,  so  as  to  form  a  fine  emulsion,  and  then  injected  into  the  circula- 
tion, the  result  was  the  production  of  deposits  of  organisms  in  various 
parts  of  the  body,  leading  to  the  formation  of  abscesses.  Bonome  found 
that  by  mixing  cultivations  of  pyogenetic  organisms  Avith  finely  pow- 
dered elder  pith,  and  injecting  the  mixture  into  the  jugular  vein,  he 
obtaiued  similar  appearances;  but  if  the  fragments  of  elder  pith  alone 
were  employed  no  abscesses  resulted. 

Various  other  experiments  might  be  quoted,  but  these  and  the  path- 
ological facts  are  sufficient  to  show  that  the  ordinary  pyogenetic  cocci  are 
able  to  cause  secondary  abscesses  in  the  lungs  if  they  enter  the  gen- 
eral circulation  attached  to  gross  particles,  and  to  establish  the  import- 
ance of  thrombosis  and  embolism  as  factors  in  the  production  of  pyaemia. 
The  point  of  difficulty,  however,  is  to  account  for  the  abscesses  in  organs 
other  than  the  lungs  in  cases  where  the  systemic  veins  are  affected ;  or 
than  the  liver  in  cases  Avhere  the  portal  area  is  the  seat  of  the  primary 
disease.  It  seems  hardly  probable  that  fragments  of  blood-clot  would  be 
able  to  pass  through  the  pulmonary  capillaries  and  stick  in  the  vessels  of 
the  kidney  and  other  organs,  and  some  other  condition  must  be  found 
to  account  for  the  presence  of  these  farther  abscesses. 

It  has  already  been  mentioned,  in  speaking  of  the  experiments  on 
animals,  that  Koch  found  micrococci  by  means  of  which  he  could  produce 
pyaemia;  and  that  the  way  in  which  the  deposits  of  organisms  Avere 
brought  about  was  by  their  groAvth  in  the  blood,  forming  masses  of 
organisms,  and  more  especially  entangling  blood  corpuscles.  It  is  very 
probable  that  something  similar  takes  place  in  man,  and  that  the  strepto- 
cocci growing  only  in  small  numbers  in  the  blood  tend  to  form  balls, 
which  may  be  increased  by  the  aggregation  of  blood  corpuscles,  and 
ultimately  attain  a  size  which  cannot  pass  through  the  capillaries.  It  is 
possible,  also,  that  in  the  lungs  afresh  suppurative  phlebitis  may  occur 
in  the  neighbourhood  of  the  secondary  abscesses,  and  thus  lead  to  the 


6o4  SYSTEM   OF  MEDICINE 

passage  of  emboli  into  the  arterial  circulation.  While,  however,  some  of 
the  tertiary  abscesses,  as  we  may  call  them,  may  be  brought  about  in  this 
way,  the  view  hardly  suffices  fully  to  explain  the  pathology,  because 
it  is  found  that  these  abscesses  are  more  numerous  in  certain  organs, 
more  especially  in  the  kidneys ;  whereas  if  plugs  of  cocci  were  floating 
about  in  the  blood  there  seems  no  reason  why  they  should  be  deposited 
more  in  one  organ  than  in  another.  There  appears,  therefore,  to  be  some 
selective  power  on  the  part  of  the  organs,  and  such  an  admission  clearly 
invalidates  a  pure  embolic  theory.  It  seems  probable  that  most  of  these 
tertiary  abscesses  occur  in  this  way  —  that  the  organisms  floating  in  the 
blood,  in  groups  not  sufficiently  large  to  form  emboli,  find  conditions 
in  certain  organs  more  favourable  to  their  deposit  and  growth  than 
in  others,  and  establish  themselves  in  the  endothelium  of  the  blood- 
vessels, grow,  and  form  plugs,  and  subsequently  abscesses.  Or  again,  it 
may  be  that  they  find  a  weak  spot,  caused  by  an  injury  or  otherwise,  in 
which  they  can  settle ;  or  again,  there  seems  evidence  in  support  of  the 
view  I  put  forward  some  years  ago,  which  has  since  received  a  certain 
amount  of  confirmation,  that  apart  from  the  rupture  of  blood-vessels 
and  communication  with  the  ducts  of  secreting  organs  there  may  be 
an  actual  secretion  of  the  organisms.  For  example,  in  the  case  of  the 
kidney,  the  organisms  may  pass  from  the  blood  with  the  water  and  get 
into  the  urinary  tubules  without  any  lesion  of  the  wall  of  the  blood- 
vessel or  tubule;  and  having  reached  the  tubules  they  may  then  find 
conditions,  such  as  rest  in  a  suitable  soil,  which  enable  them  to  develop, 
and  there  developing,  may  form  masses  and  subsequently  abscesses.  I 
found  distinct  evidence  of  this  some  years  ago  in  experiments  on  the 
lower  animals  with  a  certain  coccus  obtained  from  wounds,  wherein, 
after  injection  into  the  blood  stream,  the  kidneys  were  the  only  organs 
which  showed  signs  of  disease,  and  the  organisms  in  the  kidneys  were 
present  in  the  urinary  tubules.  This  is  the  most  probable  explanation 
of  the  occasional  occurrence  of  the  abscesses  in  the  parotid  and  other 
glands  sometimes  seen  in  pyaemia. 

The  suppurations  in  joints  and  serous  membranes  which  occur  in 
pyaemia  are  also  probably  brought  about  by  a  settlement  of  the  organisms 
in  the  endothelial  cells  of  the  capillaries  in  these  membranes,  which  grow 
there,  and  then  pass  into  the  joint  or  cavity  and  set  up  the  infection. 

From  what  has  been  said  it  seems,  therefore,  that  the  embolic  theory  of 
pyaemia  must  be  extended,  and  that  the  occurrence  of  abscesses  in  various 
organs  and  in  the  joints  must  be  farther  explained  by  supposing  either 
fresh  formation  of  emboli  in  the  circulating  blood,  or  deposit  of  organisms 
in  the  endothelium  of  the  smaller  vessels  and  their  growth  there ;  or 
exit  of  organisms  from  the  blood-vessels  into  the  tissues  in  connection 
with  injuries  ;  or  excretion  of  organisms  and  their  growth  in  the  tubules 
of  the  glands,  or  a  combination  of  these.  Various  other  factors  no  doubt 
come  into  play  in  the  production  of  pyaemia,  such  as  the  dose  of  organ- 
isms, the  degrees  of  their  virulence,  the  general  depression  of  the  vitality 
of  the  body,  and  so  on ;  but  the  above  are  the  essential  points. 


SEPTICEMIA   AND  PYEMIA  605 

We  must  now  briefly  trace  the  changes  which  take  place  in  the  tissues 
on  tlie  impaction  of  a  septic  embolus,  or  on  the  development  of  a  mass 
of  organisms  in  a  small  vessel  or  tubule,  which  changes  result  in  the 
formation  of  an  acute  abscess.  If  we  make  a  section  through  a  com- 
mencing pyaemic  abscess,  and  stain  it  appropriately,  we  shall  find  that 
in  the  centre,  obviously  in  the  lumen  of  a  vessel,  there  is  a  small  deeply 
stained  mass  which,  under  a  high  power  of  the  microscope,  is  seen  to 
consist  of  enormous  numbers  of  cocci.  Surrounding  this  is  an  unstained 
clear  area  in  which  the  structure  of  the  tissue  is  no  longer  readily  dis- 
cernible ;  this  is  an  area  which  has  undergone  coagulation  necrosis  [^vide 
articles  on  "  Inflammation  "  and  "  Retrogressive  Nutrition  "]  as  the  result 
of  the  action  on  it  of  the  concentrated  poisonous  products  poured  out 
from  the  central  mass  of  cocci.  Outside  this  zone,  where  the  poison  is 
weaker,  the  tissues  of  the  part  are  seen  to  be  undergoing  inflammatory 
changes ;  at  a  later  period  the  micrococci  burst  through  the  wall  of  the 
vessel,  and  pass  into  the  dead  tissue,  and  even  for  a  certain  distance  into 
the  inflamed  and  living  tissues ;  while  from  the  outer  part  a  large  amount 
of  fluid  plasma  and  a  large  number  of  leucocytes  are  poured  into  this  same 
dead  area.  Among  the  properties  of  these  organisms  is  their  power  of 
peptonising  albumin,  and  by  virtue  of  this  power  the  necrosed  tissues  are 
dissolved,  while  the  effused  plasma  does  not  coagulate ;  thus  a  central  fluid 
mass  is  formed,  in  which  are  floating  large  numbers  of  dead  leucocytes 
and  micrococci,  and  surrounding  this  mass  we  have  a  dense  layer  of  newly- 
formed  granulation  tissue  in  which  the  pyogenetic  cocci  are  present. 

In  man  pyaemia  may  originate  in  conrLCction  with  any  inflammation 
in  which  the  pyogenetic  cocci  are  present ;  thus  it  may  follow  injuries 
and  surgical  operations  where  suppuration  is  allowed  to  take  place,  either 
from  the  use  of  imperfect  precautions  to  ensure  asepsis,  or  from  condi- 
tions of  the  case  preventing  absolute  asepsis.  In  former  times  this  disease 
was  the  great  dread  of  surgeons,  and  the  cause  of  terrible  mortality  after 
all  operations ;  but  more  especially  did  it  follow  injuries  to  veins,  bones 
or  joints.  It  was  most  often  seen  in  hospitals,  and  especially  in  war,  where 
the  hygienic  conditions  were  bad,  and  many  wounded  were  crowded 
together.  It  is  interesting  to  note  that  so  late  as  the  first  decade  of  anti- 
septic surgery  (1869-1878)  there  were  no  less  than  903  cases  of  fatal 
septic  disease,  chiefly  pyaemia,  in  eight  of  the  large  London  hospitals. 

Acute  sup20urative  osteomyelitis,  or  periostitis,  is  a  not  unfrequent 
cause  of  pyaemia,  the  great  tension  under  which  the  pus  is  formed  prob- 
ably forcing  the  septic  emboli  from  the  veins  into  the  circulation.  It  is 
not  so  common  after  abscesses,  boils  and  carbuncles ;  but,  in  the  forms 
of  suppuration,  such  as  spreading  cellulitis,  due  to  streptococcus  pyo- 
genes, and  in  acute  and  chronic  middle  ear  suppurations,  pyaemia  is  not 
uncommon.  It  may  also  follow  ulcers  of  the  skin  or  of  the  intestinal 
tract ;  and  in  the  latter  cases  tlie  depressed  general  condition  of  the 
jjatient  may  promote  the  occurrence  of  the  disease. 

As  to  age,  statistics  point  to  pyaemia  being  more  common  between  the 
years  of  '60  and  40 ;  but  this  is  probably  due  to  accidental  causes :  no  age 


6o6  SYSTEM   OF  MEDICINE 

is  exempt.  Its  frequency  has  also  been  found  to  vary  with  the  seasons, 
being  more  common  in  damp  and  cold  weather ;  probably  because  of  the 
increased  neglect  of  hygienic  precautions  prevailing  at  such  periods. 

Symptoms.  —  The  ordinary  form  of  pyaemia  will  be  first  considered, 
and  later  the  distinctive  features  of  the  other  varieties.  The  disease 
usually  commences  within  the  first  week  of  an  injury  or  operation.  The 
wound  generally  becomes  unhealthy,  any  granulations  which  have  formed 
disappear,  the  previously  sealed  inter-muscular  planes  open  up,  and  the 
discharge  becomes  thin,  watery  or  sanious  pus,  often  so  scanty  that  the 
wound  may  appear  dry.  Phlebitis  of  the  veins  leading  from  the  affected 
part  may  \>b  made  out,  forming  at  first  tense  cords,  accompanied  later 
by  surrounding  thickening  and  tenderness  ;  and,  if  superficial,  by  oedema 
and  redness  of  the  skin.  In  other  cases,  as  in  thrombosis  of  the  lateral 
sinus,  severe  pain  and  tenderness  along  the  course  of  the  vessel  may  be 
the  main  local  indication  of  phlebitis ;  or  again  we  may  have  to  draw 
an  inference  from  oedema  of  the  area  drained  by  the  vein.  In  rare  cases 
the  wound  may  appear  healthy  and  even  heal,  and  thrombosis,  even  if 
present,  may  be  overlooked. 

The  general  symptoms  are  usually  ushered  in  by  a  severe  rigor  and  a 
rapid  rise  of  temperature  to  104°  or  105°.  For  a  few  days  before  this 
there  will  probably  have  been  some  general  malaise  and  loss  of  appetite, 
accompanied  by  more  or  less  fever.  The  rigor  is  followed  by  profuse 
sweating,  and  the  temperature  rapidly  falls  to  102°  or  101°,  or  even 
lower.  The  rigors  are  usually  repeated  throughout  the  course  of  the 
disease;  rarely  are  they  absent  for  more  than  24  hours  at  a  time, 
although  they  occur  quite  irregularly,  and  two  or  more  may  occur  in  the 
course  of  a  few  hours,  or  even  in  connection  with  a  single  rise  of  tempera- 
ture. The  temperature  is  always  high  during  the  rigors  — 104°  F.- 
105°  F. ;  even  IIU"  F.  has  been  certainly  registered ;  in  the  intervals  of 
the  rigors  it  may  be  100°  F.-101°  F.,  normal  or  even  subnorinal.  The 
rigors  are  always  followed  by  most  profuse  and  exhausting  sweats, 
and;  together  with  the  course  of  the  temperature,  are  fairly  characteris- 
tic ;  they  may,  however,  occur  with  such  daily  regularity  that  the  chart 
resembles  that  of  a  case  of  quotidian  ague,  or  again  the  temperature 
may  be  more  continuously  high  and  rigors  absent.  Profuse  sweating 
is  in  any  case  an  almost  constant  symptom. 

Usually  there  is  anorexia  and  sometimes  vomiting;  but  occasionally 
the  appetite  remains  good  until  near  the  end,  and  the  digestive  func- 
tions may  be  but  slightly  affected  in  the  earlier  stages  of  the  less  severe 
cases.  This  may  be  accounted  for  by  the  periods  of  apyrexia  or  com- 
parative apyrexia,  Avliich  give  the  patient  time  to  recover  from  the  effects 
of  the  fever.  In  other  cases  there  may  be  severe  and  frequent  vomit- 
ings, or,  more  rarely,  persistent  diarrhoea.  The  tongue  is  usually  furred, 
but  cleans  in  the  afebrile  intervals ;  later,  it  becomes  brown  and  dry, 
and  the  teeth  and  lips  are  covered  with  sordes.  The  breath  is  often  said 
to  have  a  sweet  smell.  Excessive  thirst  is  common,  and  the  patient 
will  consume  a  large  amount  of  fluid. 


SEPTICAEMIA    AND   PYEMIA  607 

From  the  beginning  the  pulse  is  very  rapid  and  soon  becomes  soft ; 
later,  it  becomes  very  feeble,  running,  irregular  or  uncountable.  The 
first  sound  of  the  heart  is  usually  weakened,  and  may  become  almost 
inaudible.  Various  cardiac  murmurs  may  also  be  heard ;  they  are  usually 
functional  in  origin,  but  in  these  cases  the  possibility  of  ulcerative 
endocarditis  must  always  be  borne  in  mind.  Examination  of  the  blood 
shows  that  the  white  corpuscles  are  increased  in  number,  relatively  and 
absolutely ;  and  in  some  cases  pyogenetic  cocci  have  been  seen  in  the 
blood,  or  obtained  from  it  by  cultivation.  The  respirations  are  increased 
in  frequency ;  sometimes  there  is  marked  dyspnoea  and  cyanosis,  but 
this  usually  occurs  only  in  connection  with  some  bronchial  or  pulmonary 
affection,  of  which,  however,  it  may  be  almost  the  only  clinical  manifes- 
tation. The  urine  usually  contains  a  small  amount  of  albumin,  but  acute 
nephritis  is  very  rare.  The  amount  passed  is  usually  about  normal  as 
a  large  amount  of  fluid  is  taken  in  the  diet.  The  urea  and  urates  are 
increased,  and  there  is  a  diminution  in  the  amount  of  inorganic  salts. 
If  blood  and  pus  be  present  they  point  rather  to  a  renal  abscess.  The 
patient  rapidly  loses  muscular  power,  the  muscles  become  flabby  and 
waste  rapidly,  and  all  movements  are  very  tremulous. 

For  a  long  time  the  patient's  mental  faculties  are  retained,  or  he  may 
perhaps  be  delirious  during  the  fever,  and  completely  conscious  during 
the  intervals.  Towards  the  end  of  the  disease  low  muttering  delirium 
is  common,  and  the  patient  usually  sinks  into  a  comatose  state.  In  other 
cases  marked  cerebral  symptoms  are  present.  Wild,  noisy  delirium  and 
prolonged  periods  of  unconsciousness  are  seen,  and  very  severe  headache 
is  not  uncommon.  These  symptoms  are  usually  the  result  of  the  fever : 
cerebral  abscess  or  meningitis  cannot  be  recognised  in  the  absence  of 
direct  localising  symptoms. 

The  skin  is  often  slightly  tinged  with  yellow,  but  rarely  much  jaun- 
diced, except  in  some  cases  of  liver  abscess.  Occasionally  an  erythem- 
atous rash  is  seen  much  resembling  scarlet  fever  in  general  appearance, 
but  differing  from  it  in  its  distribution ;  it  chiefly  occurs  on  the  parts 
around  the  axillae  and  groins,  and  spreading  down  the  limbs,  is  rarely 
pronounced  on  the  chest :  more  rarely  still  a  pustular  rash  occurs.  In 
the  later  stages  of  the  disease  petechiae  are  not  uncommon,  or  extensive 
cutaneous  hgemorrhages  may  occur.  Death  usually  ensues  about  the  end 
of  the  first  or  during  the  second  week ;  very  few  cases  live  more  than  three 
weeks.  The  patient  may  die  of  exhaustion,  with  all  the  symptoms  of  the 
typhoid  state,  and  coma  usually  precedes  death.  Or  the  patient  may  die 
from  the  direct  effects  of  a  secondary  lesion,  such  as  cerebral  abscess  or 
meningitis,  extensive  pulmonary  disease,  heart  affection,  etc.  In  rare 
cases  death  occurs  suddenly  from  impaction  of  a  large  embolus  in  the 
pulmonary  artery. 

jTZti?  locjd  symptovis,  consisting  of  secondary  abscesses  in  various  organs 
and  other  ])arts  of  the  body,  and  suppuration  of  the  serous  membranes, 
must  now  be  considered.  These  usually  appear  about  the  sixth  to  the 
tenLh  day  of  the  disease ;  and,  in  the  ordinary  form  of  pyaemia,  the  em- 


6o8  SYSTEM   OF  MEDICINE 

boli  originate  in  the  systemic  veins,  and  consequently  are  most  usually 
arrested  in  tlie  lungs.  The  lungs  rarely  escape  secondary  deposits  in 
cases  of  pysemia  arising  from  disease  of  bones,  such  as  osteomyelitis  or 
periostitis  from  compound  fractures,  amputations,  or  other  wounds  in- 
volving bones  ;  and  in  these  cases  the  lungs  only  may  be  affected.  In 
other  cases,  however,  it  is  more  usual  to  find  abscesses  in  other  parts 
with  or  without  abscess  of  the  lung ;  these  arise  either  from  the  emboli 
being  sufiiciently  minute  to  enable  them  to  pass  through  the  compar- 
atively wide  pulmonary  capillaries,  or  from  emboli  formed  in  some  of 
the  other  ways  above  discussed. 

Many  abscesses  may  form  in  the  lungs  and  yet  give  rise  to  no  very 
definite  symptoms.  The  dyspnoea  is  increased  and  there  are  general 
signs  of  bronchitis.  If  an  abscess  form  near  the  surface  of  the  lung  it 
will  set  up  a  localised  i^leurisy  ;  then  we  have  the  characteristic  pleuritic 
pain,  cough,  etc.,  and  on  aus'jultation  the  friction  sound.  Soon  fluid  is 
poured  out  into  the  pleura,  at  first  commonly  serous,  but  later  becoming 
purulent ;  or  the  lung  abscess  may  burst  into  the  pleura.  In  either  case 
a  localised  empyema  is  formed  with  or  without  pneumothorax,  and  may 
be  recognised  by  the  usual  signs.  Occasionally  an  abscess  near  the 
surface  of  the  lung  is  sufficiently  large  to  cause  dulness  on  percussion 
and  the  other  signs  of  consolidation. 

Pleurisy  may  also  occur  apart  from  pulmonary  abscess  ;  and  this  has 
been  more  commonly  noted  in  cases  of  pygemia  arising  in  connection  with 
middle  ear  disease.  The  spleen,  kidneys  and  brain  are  the  other  organs 
most  commonly  attacked  in  this  form  of  the  disease.  In  the  spleen 
some  pain  and  enlargement  accompanied  by  great  tenderness  may  be 
detected,  and  the  abscesses  bursting  into  the  general  peritoneal  cavity 
may  cause  acute  general  peritonitis.  Multiple  abscesses  in  the  kidneys 
usually  give  rise  to  some  pain  and  tenderness  with  albuminuria ;  occasion- 
ally all  symptoms  are  absent ;  or  again  there  may  be  acute  nephritis  with 
pus  and  blood  in  the  urine.  The  last  symptoms  are  the  only  trustworthy 
ones  on  which  to  base  a  definite  diagnosis,  and  they  are  but  rarely  seen. 
Abscesses  in  the  brain  and  purulent  meningitis  can  only  be  diagnosed 
definitely  when  some  definite  localising  symptom  is  present;  general 
symptoms,  such  as  headache,  vomiting,  optic  neuritis,  coma  and  the  rest, 
may  occur  apart  from  particular  cerebral  lesions.  Abscesses  in  the  liver 
also  occur,  especially  it  seems  after  head  injuries.  They  arise  in  con- 
nection with  the  branches  of  the  hepatic  artery,  and  thus  differ  from 
those  of  portal  pyaemia.  The  symptoms  will  be  discussed  later  under 
this  heading. 

The  eyes  may  also  be  affected  in  a  very  important  manner :  optic 
neuritis  may  occur  with  hsemorrhages  scattered  in  the  retina ;  the  arteria 
centralis  retinae  may  be  plugged  by  an  embolus;  this  causes  sudden 
blindness  of  the  affected  eye,  followed  by  suppuration  of  the  eyeball  — 
panophthalmitis.  The  latter  result  will  also  follow  if  an  embolus  lodge 
in  the  ciliary  region  or  iris. 

Suppuration  in  the  joints  is  one  of  the  commonest  lesions  of  pyasmia, 


SEPTICEMIA   AND  P  YE  AHA  609 


and  may  occur  in  any  joint.  There  is  usually  intense  pain  at  the  onset, 
rapidly  followed  by  purulent  effusion,  and  then  the  jjain  often  subsides 
more  or  less  completely.  The  joint  shows  all  the  signs  of  acute  suppui-Br 
tive  arthritis,  but  if  the  affection  be  treated  early  by  free  evacuation  of 
the  pu.s,  it  is  remarkable  how  little  permanent  damage  may  follow. 

Suppuration  in  the  peritoneal  cavity  also  not  uncommonly  occurs; 
and  may  be  j^rimary,  or  secondary  to  an  abscess  of  one  of  the  viscera 
which  may  burst  into  it.  It  is  very  common  in  puerperal  cases,  in  some 
probably  due  to  direct  extension.  It  is  usually  general,  but  may  be  localised 
at  the  outset.  Pain  at  first  is  severe  and  accompanied  by  all  the  symptoms 
of  acute  peritonitis ;  later,  however,  pain  and  tenderness  are  often  both 
absent;  excessive  tympanites  from  paralysis  of  the  intestines  is  present; 
and,  the  purulent  effusion  being  distributed  throughout  the  abdomen,  but 
nowhere  in  large  quantity,  dulness  or  fluctuation  may  never  be  obtainable. 
In  this  absence  of  signs  the  affection  is  commonly  overlooked. 

Purulent  effusion  in  the  pericardium  may  also  occur,  sometimes  pre- 
ceded by  signs  of  pericarditis,  friction  sounds,  etc.,  but  often  coming  on 
very  insidiously. 

In  the  cellular  tissue  of  the  body  large  abscesses  may  form  and  burrow 
extensively.  There  is  usually  severe  pain  at  the  outset,  but  afterwards 
this  may  subside  ;  the  swelling  is  often  very  diffuse,  and  tenderness  may 
not  be  very  marked.  Transient  patches  of  oedema  and  redness  of  the 
skin  and  subcutaneous  tissues,  subsiding  without  suppuration,  are  also 
described  (Erichsen).  Abscesses  in  the  muscles  are  very  rare.  In  the 
heart  they  are  also  rare.  The  symptoms  are  indefinite,  but  the  cardiac 
action  is  greatly  impaired,  and  death  is  liable  to  occur  from  rupture  of 
the  heart  wall.  In  rare  cases  abscesses  are  seen  in  the  parotid  gland, 
thyroid  gland  and  testicles.    Their  possible  pathology  has  been  discussed. 

Morbid  Anatomy.  —  After  what  has  already  been  said  this  may  be 
dealt  with  very  briefly.  The  general  blood  and  tissue  changes  are  exactly 
similar  to  those  already  described  in  septicaemia,  but  are  usually  some- 
what less  marked.  They  are  the  effect  of  the  fever  and  general  blood 
poisoning. 

The  wound  will  be  found  as  already  described ;  and  if  careful  search 
be  made,  a  thrombosed  vein  will  often  be  found  leading  from  it.  Such 
veins  are  filled  with  soft  adherent  clot,  in  some  places  breaking  down,  in 
others  replaced  by  pus,  which  is  always  shut  off  by  clot  from  the  general 
circulation.  Around  the  vein  there  is  a  certain  amount  of  periphlebitis, 
or  even  a  periphlebitic  abscess.  Cases  have  also  been  seen  (six  cases, 
Path.  Soc.  Reports)  in  which  thrombosis  followed  by  embolism  has  oc- 
curred in  a  vein  remote  from  the  seat  of  infection. 

In  the  lungs  signs  of  bronchitis  and  broncho-pneumonia  are  almost 
constantly  found.  Haemorrhagic  infarctions  are  rarely  seen,  but  scattered 
throughout  are  abscesses  varying  in  size  from  a  pea  upwards.  In  the 
kidneys  and  spleen  also  the  abscesses  are  commonly  multiple.  In  the 
brain  it  is  not  uncommon  to  find  a  large  area  of  acute  softening,  the  re- 
sult of  an  embolus,  with  only  a  drop  or  so  of  pus  in  its  centre.    Pyogenic 

VOL.    I  2   R 


6io  SYSTEM  OF  MEDICINE 

organisms  of  one  or  more  varieties  can  be  demonstrated  in  large  numbers 
in  the  original  site  of  infection,  in  tire  emboli  and  thrombosed  veins,  and 
in  the  secondary  abscesses ;  bnt  rarely  in  the  blood. 

Suppurative  Pylephlebitis  or  Portal  Pyaemia.  —  This  form  of  pysemia 
is  extremely  rare.  The  commoner  causes  of  it  are  suppurative  appen- 
dicitis, ulceration  of  the  intestine,  especially  dysentery,  malignant  ul- 
ceration of  stomach  or  intestines,  chronic  gastric  ulcer,  and  ulcerative 
diseases  of  the  rectum.  Suppuration  of  the  gall-bladder,  ulceration  from 
gall-stones,  or  suppurating  hydatid  cysts,  may  also  cause  it.  Cases  of  a 
foreign  body  which  has  been  swallowed  and  has  penetrated  to  a  branch 
of  the  portal  vein  are  on  record ;  and  we  have  already  mentioned  cases 
in  the  newly  born  following  phlebitis  of  the  umbilical  vein. 

The  result  of  the  suppurative  phlebitis  of  the  portal  system  is  the  pro- 
duction of  pyaemia  similar  in  all  its  general  symptoms  and  pathology  to 
that  already  described,  but  differing  from  it  in  that  the  chief  secondary 
deposits  occur  in  the  liver.  Numerous  abscesses  are  always  seen  through- 
out the  liver,  obviously  arising  in  connection  with  branches  of  the  portal 
vein.  The  liver  is  uniformly  enlarged  —  sometimes  very  large  —  the 
capsule  may  be  normal  or  covered  with  patches  of  peritonitis,  and  the 
abscesses  may  show  on  the  surface.  The  clotting  may  occur  throughout 
the  portal  vein,  and  even  spread  through  into  the  hepatic  vein.  These 
abscesses  must  be  distinguished  from  those  arising  from  gall-stones  and 
the  like,  where  the  infection  spreads  up  directly  by  means  of  the  bile 
ducts  ;  from  abscesses  in  ordinary  pyaemia,  which  arise  in  connection  with 
the  hepatic  artery,  and  are  usually  fewer  in  number ;  and  also  from  the 
large  tropical  abscesses.  In  none  of  these  is  portal  thrombosis  present, 
and  the  mode  of  origin  is  usually  obvious. 

Only  the  special  symptoms  due  to  the  implication  of  the  liver  will 
here  be  referred  to.  The  disease  is  always  of  a  severe  type,  and  runs  a 
rapidly  fatal  course.  There  is  intense  pain  in  the  right  hypochondriura, 
and  the  liver  rapidly  enlarges.  It  is  very  tender  on  palpation,  with  an 
ill-defined,  soft  margin.  Signs  of  gastro-intestinal  irritation,  especially 
vomiting,  are  common.  Two  characteristic  symptoms  are  ascites  and 
marked  jaundice,  but  they  are  by  no  means  constant.  Ascites  occurs  when 
a  considerable  extent  of  the  portal  vein  is  blocked,  but  it  may  also  be  due 
to  peritonitis.  Jaundice  occurs  when  a  large  bile  duct  is  pressed  on  or 
involved  in  an  abscess,  but  there  is  always  some  bile  passed  in  the  faeces. 

The  diagnosis  may  be  completed  by  placing  the  patient  under  an 
anaesthetic,  and  thoroughly  using  a  large  exploring  needle  or  trocar,  but 
even  then  an  abscess  may  be  missed. 

General  peritonitis  may  be  caused  by  rupture  of  an  abscess  into  the 
peritoneal  cavity.     The  spleen  is  always  much  enlarged. 

So-called  Chronic  Pycemia  or  MaUiple  Abscesses.  —  This  disease  arising 
under  similar  conditions  to  true  pyaemia,  and  leading  to  the  formation  of 
secondary  abscesses,  has  long  been  confounded  with  pyaemia.  It  differs, 
however,  essentially  from  true  pyaemia  in  that  embolism  apparently  plays 
no  part  in  it. '   Pyogenic  organisms  reach  the  blood  stream  by  a  wound, 


SEPTICMMIA   AND  PYyEMIA  6ii 

or  the  like,  and,  owing  to  the  depressed  vitality  of  the  patient,  continue 
to  live  there,  but  produce  only  slight  disturbance.  Then  if  some  spot  be 
weakened  by  the  result  of  a  slight  injury,  the  organisms  fix  on  that  spot, 
develop  in  it,  and  produce  an  abscess.  The  injury  producing  the  abscess  is 
usually  slight,  such  as  a  strain,  too  long  or  too  great  pressure  on  a  part, 
and  so  forth.  The  abscesses  are  consequently  few  in  number,  often  only 
one  or  two,  and  are  situated  in  the  subcutaneous  tissues  or  in  the  joints. 
The  disease  may  last  for  months,  the  general  symptoms  not  being  severe ; 
elevation  of  temperature,  pain,  etc.,  occur  at  the  commencement  of  each 
fresh  abscess,  but  subside  in  the  intervals. 

A  case  is  recorded  in  the  Pathological  Society's  Transaci?"o?is,  in  which 
a  compound  fracture  of  the  lower  jaw  was  followed  by  suppuration  occur- 
ring at  the  site  of  other  fractures  sustained  at  the  same  time.  The 
fracture  of  the  femur  was  noticed  suppurating  nearly  a  month  after  the 
injury,  and  ten  days  later  the  fractures  of  the  humerus  and  rib  were 
affected.  Numerous  experiments  on  animals  have  shown  that  the  simple 
injection  of  small  numbers  of  pyogenic  cocci  into  the  blood  stream  will  be 
followed  by  no  ill  effects,  but  that  if  simultaneously  an  injury  be  inflicted 
on  any  part  of  the  body  a  local  abscess  will  result. 

Diagnosis  of  Pyemia.  —  Difficulties  mainly  arise  in  cases  where  the 
source  of  infection  is  unusual  or  obscure ;  it  must  also  be  borne  in  mind 
that  a  patient  with  a  suppurating  wound  may  contract  a  fever,  such  as 
typhoid.  In  all  suspected  cases  such  sources  of  infection  as  osteomyelitis, 
chronic  middle  ear  suppuration,  ulcerative  endocarditis,  suppuration  in 
the  nose  or  in  connection  with  carious  teeth,  ulceration  of  the  mouth, 
throat,  or  alimentary  tract,  rectal  diseases,  gonorrhoea,  and  so  forth, 
must  be  very  carefully  inquired  into. 

Of  the  diseases  more  or  less  resembling  pyaemia  typhoid  fever  is  the 
most  important;  indeed,  pyaemia  has  been  called  wound-typhoid.  In  both 
we  find  a  similar  temperature,  and  in  both  an  enlarged  spleen ;  similar 
abdominal  symptoms  may  also  be  present ;  in  both  the  typhoid  state 
supervenes,  and  there  may  be  an  absence  of  other  definite  symptoms.  To 
distinguish  typhoid  we  must  inquire  into  a  possible  source  of  infection  ; 
the  rose-coloured  rash  and  peculiar  stools  are  decisive ;  haemorrhage  from 
the  bowel  is  extremely  suggestive;  the  abdominal  symptoms  may  be 
prominent,  and  the  fever  is  usually  more  regular.  Moreover,  in  very 
rare  cases  pyaemic  infection  may  arise  in  connection  with  the  typhoid 
ulcer.  On  the  other  hand  pyaemia  is  indicated  by  the  discovery  of  a 
probable  source  of  infection,  by  the  irregular  course  of  the  temperature,  by 
the  recurrent  rigors  and  profuse  sweating,  by  petechiae  in  the  skin,  by 
optic  neuritis  and  retinal  haemorrhages,  and,  lastly  and  conclusively, 
by  the  formation  of  multiple  abscesses. 

Typhus  fever,  now  extremely  rare,  also  closely  simulates  pyaemia. 
The  abrupt  onset,  high  fever,  and  cerebral  symptoms,  are  common  to 
both.  The  diagnosis  V>etvveen  them  must  rest  on  the  mulberi'y  rash  of 
typlius,  or  on  the  secondary  abscesses  in  pyfcmia.  In  acute  tuberculosis 
the  temperature  may  be  similar,  and  there  may  be  no  decisive  symptoms. 


6i2  SYSTEM   OF  MEDICINE 

We  must  look  for  otlier  signs  of  a  tubercular  disease  and  a  tubercular 
history.  Later,  the  slower  onset  of  the  disease,  its  protracted  course, 
signs  of  tubercle  in  the  choroid,  and  the  absence  of  local  signs  of  abscess, 
show  the  true  nature  of  the  disease. 

Pyaemia  may  closely  simulate  malaria  in  the  course  of  the  fever  and 
sweatings.  The  history  of  exposure  to  malarial  influences,  or  previous 
attacks  of  it,  the  absence  of  local  abscesses,  and  above  all  the  effect  of 
quinine,  will  decide  the  question.  Acute  rheumatism  and  pyaemia  have 
in  common  a  similar  course  of  temperature,  profuse  sweats,  inflammation 
of  serous  membranes  and  joints,  and  perhaps  endocarditis.  In  acute 
rheumatism  the  sweat  has  a  very  peculiar  sour  odour ;  the  inflammation 
of  the  joints  often  subsides  suddenly  and  attacks  other  joints,  and  there 
is  no  jaundice  or  sign  of  embolism. 

With  regard  to  ulcerative  endocarditis  it  must  be  remembered  that 
the  murmur  varies  much  and  may  be  absent,  and  that  the  disease  is 
most  common  after  pneumonia. 

The  differences  between  the  rash  of  scarlet  fever  and  a  skin  affection 
sometimes  seen  in  pyaemia  have  already  been  pointed  out,  and  these 
diseases  have  few  other  symptoms  in  common. 

The  diagnosis  from  septicseihia  is  not  important,  and  rests  entirely 
on  the  presence  of  secondary  abscesses. 

Pyaemia  may  have  to  be  distinguished  from  meningitis  when  head 
symptoms  are  very  prominent,  or  from  uraemia  in  cases  of  acute  nephritis. 

In  the  prognosis  of  pyaemia  the  varieties  of  the  disease  must  be 
separately  noticed.  Cases  of  ulcerative  endocarditis  and  suppiirative 
pylephlebitis  are  invariably  fatal. 

In  ordinary  surgical  pyaemia  the  prognosis  is  very  grave  and  recovery 
extremely  rare.  The  majority  of  the  patients  die  in  the  first  week,  and 
very  few  survive  more  than  two  weeks.  The  worst  cases  are  those 
associated  with  high  continuous  fever,  extreme  vital  depression,  and  the 
early  formation  of  visceral  abscesses.  In  the  cases  which  recover,  as  a 
rule  only  external  abscesses  have  occurred ;  and  even  then  an  impaired 
constitution,  stiff  joints  and  tendons  usually  remain.  In  cases  of 
chronic  pyaemia,  on  the  other  hand,  recovery  is  not  infrequent,  but  after 
months  of  suffering  and  with  the  deformities  above  mentioned. 

Treatment.  —  The  preventive  treatment  may  first  be  considered.  This 
is  purely  surgical,  and  consists  in  the  thorough  adoption  of  the  antiseptic 
methods  wherever  possible.  In  other  cases  every  precaution,  and  es- 
pecially free  drainage,  must  be  adopted  to  keep  the  wound  as  healthy 
as  possible.  At  the  same  time  the  patient's  general  health  must  be 
carefully  attended  to,  a  good  supply  of  fresh  air  provided,  and  over- 
crowding especially  of  patients  suffering  from  suppurating  wounds,  must 
be  avoided.  Even  where  thrombosis  of  a  vein  has  occurred  in  connec- 
tion with  suppuration  the  pyaemia  may  be  cut  short  by  freely  opening 
up,  purifying,  and  draining  the  source  of  infection,  and  at  the  same 
time  cutting  off  from  the  circulation  and  cleansing,  or,  much  better, 
excising  the  whole  of  the  thrombosed  vein. 


ERYSIPELAS  613 


The  disease  once  established  nothing  but  symptomatic  treatment  can 
be  attempted.  The  fever,  if  very  high  or  continuous,  may  be  controlled 
by  antipyretics,  or  better  still  by  such  means  as  tepid  sponging.  Quinine 
in  five  grain  doses  two  or  three  times  a  day  may  also  be  tried.  Cardiac 
failure  must  be  mainly  combated  by  stimulants,  of  which  brandy  or 
whisky  are  the  best,  and  these  may  be  given  in  large  quantities.  If 
vomiting  be  present  champagne  may  be  tried.  Severe  vomiting  may  be 
allayed  with  bismuth  or  small  doses  of  hydrocyanic  acid.  Morphia  is 
required  in  many  cases  to  relieve  pain.  The  patient's  general  health 
must  be  supported  by  abundance  of  such  light  nourishment  as  he  can 
digest ;  and  an  unlimited  quantity  of  fluid,  such  as  barley  water, 
"  imperial  drink,"  milk,  and  soda-water  may  be  allowed.  Special  care 
must  be  taken  in  the  nursing  to  avoid  bed-sores.  Secondary  abscesses 
must  be  promptly  opened  and  drained. 

W.  Watson  Cheyne. 


ERYSIPELAS 


Definition.  —  A  contagious  disease  characterised  by  a  peculiar  spread- 
ing inflammation  of  the  skin,  or  more  rarel}^  of  a  mucous  membrane, 
due  to  a  specific  micro-organism,  and  associated  with  general  febrile 
symptoms. 

The  contagious  nature  of  the  disease  was  not  recognised  until  about 
1850,  and  apparently  first  in  England.  Later  Velpeau  pointed  out 
this  fact  in  France,  and  showed,  as  Trousseau  had  previously  done, 
the  frequency  of  its  origin  in  connection  Avith  a  wound  or  abrasion. 
In  Germany  Wernher  in  1862  adopted  these  views,  and  Volkmann  in 
1869.  This  contagious  nature  has  now  been  conclusively  proved,  and 
that  the  disease  originates  almost  invariably  in  connection  with  slight 
wounds  or  abrasions  is  generally  admitted ;  but  there  is  even  yet  much 
dispute  as  to  the  exact  limits  of  the  name.  The  older  authors  applied  it 
to  a  large  number  of  distinct  skin  affections  (such  as  eczema,  etc.),  and 
also  to  diffuse  phlegmonous  inflammations  of  internal  organs  and  serous 
membranes.  The  skin  affection  known  as  erysipelas  is  now  sharply 
distinguished,  and  the  name  is  not  applied  to  internal  inflammations  ; 
though  some  authors,  following  Nunneley  (1841),  still  describe  as  ery- 
sipelas spreading  diffuse  forms  of  inflammation  afl'ecting  the  subcuta- 
neous tissues  with  or  without  associated  skin  affection,  and  even  such 
diseases  as  whitlow. 

It  has  also  been  held  that  erysipelas  can  give  rise  by  contagion  to 
pyaemia,  puerperal  fever,  and  other  septic  diseases,  and  vice  versa. 
There  is,  however,  no  sufficient  evidence  in  favour  of  these  views,  and 
the  statistics  of  a  reyjort  to  the  I^athological  Society  of  London  tend  to 
disjjrove  any  connection  between  them. 


6i4 


SYSTEM   OF  MEDICINE 


It  seems  more  in  accordance  with  the  present  state  of  our  knowledge 
to  regard  inflammation  of  the  subcutaneous  cellular  tissue  as  a  distinct 
(although  a  closely  allied)  affection  due  to  a  separate  cause ;  and  when  the 
two  affections  occur  simultaneously  and  run  concurrently,  to  regard  the 
disease  as  due  to  a  mixed  infection.  This  subject  must  be  further  con- 
sidered when  the  specificity  of  the  causative  micro-organism  is  discussed. 
A  distinction  has  also  been  drawn  between  surgical  erysipelas,  or  that 
complicating  wounds,  and  medical  erysipelas,  which  latter  mainly  attacks 
the  face  and  is  supposed  to  arise  idiopathically.  Usually,  however,  it 
arises  in  connection  with  some  slight  injury  of  surface,  and  there  is  no 
essential  difference  in  the  two  diseases.  Although  typically  a  skin  affec- 
tion and  limited  to  the  cutis  vera,  the  disease  may  attack  mucous  mem- 
branes, either  spreading  to  them  by  direct  extension  from  the  skin,  or, 
originating  on  a  mucoxis  membrane  such  as  that  of  the  throat,  it  may 
spread  to  the  skin,  or  possibly  even  remain  limited  to  the  mucous  surfaces. 

Etiology.  —  The  causes  of  this  affection  maybe  either  general  or  local, 
some  perhaps  act  both  generally  and  locally.  The  disease  is  widely  spread, 
and  usually  occurs  in  an  endemic  form ;  rarely  distinct  epidemics  of  it 
have  been  noted.  Women  are  more  liable  to  it  than  men,  and  people 
between  the  ages  of  35  and  55  are  chiefly  attacked.  Season  seems  to 
exert  a  decided  influence  on  its  prevalence,  the  disease  being  most  common 
in  spring  and  autumn,  much  less  so  in  summer  and  winter.  February 
and  November  are  the  months  in  which  the  disease  is  more  especially 
prevalent,  —  months,  that  is,  usually  associated  with  considerable  changes 
of  temperature,  but  on  the  whole  cold  and  damp.  This  may  be  in  part 
accounted  for  by  the  overcrowding  in  unhealthy,  ill-ventilated  rooms, 
and  the  want  of  proper  exercise,  which  commonly  occur  at  such  seasons. 

Erysipelas  formerly  was  not  uncommon  in  the  surgical  wards  of 
hospitals,  and  especially  in  those  which  were  ill  ventilated  or  defective  in 
sanitary  arrangements.  In  these  wards,  if  once  introduced,  the  disease 
was  extremely  dif&cult  to  eradicate,  and  nearly  every  patient  with  a 
wound  would  be  attacked,  the  contagion  being  probably  conveyed  by  the 
hands  of  the  dressers,  etc.  Where  the  hygienic  arrangements  are  good, 
and  efficient  means  are  taken  to  prevent  direct  conveyance  of  the  con- 
tagion by  the  hands  or  instruments,  the  disease  shows  but  little  tendency 
to  spread ;  the  poison  is  never  widely  diffused  through  the  air.  It  clings 
closely,  however,  to  furniture,  bedding,  clothes  and  the  like,  and  may 
be  conveyed  by  a  third  person.  The  disease  is  not  uncommon  in  patients 
debilitated  by  recent  acute  diseases  such  as  typhoid  fever;  and  in  gen- 
eral it  is  more  common  among  the  poor  and  weakly,  whether  from  im- 
proper food,  bad  hygiene,  or  the  exhaustive  effects  of  chronic  disease, 
especially  perhaps  of  albuminuria  and  diabetes. 

Certain  persons  show  a  marked  disposition  to  the  disease,  and  suffer 
from  many  attacks  of  it  throughout  their  lives :  the  attacks  sometimes 
show  a  kind  of  regularity,  returning  every  spring  or  sometimes  even  more 
often,  and  this  disposition  has  been  said  to  be  hereditary.  It  may  be  in 
part  a  general  disposition,  but  many  cases  may  possibly  be  explained  by 


ERYSIPELAS  615 


the  constant  presence  of  a  chronic  disease  producing  a  weak  spot  or  slight 
abrasion  from  which  tlie  disease  originates;  in  favour  of  this  view  it  is 
found  that  the  same  spot  is  attacked  time  after  time.  Thus  such  persons 
may  be  found  to  suffer  from  an  irritating  discharge  from  the  nose  or  ears 
which  excoriates  tlie  surrounding  skin.  It  is  probable  that  one  attack 
confers  immunity  for  a  very  short  time  ;  it  has  been  found  impossible  to 
inoculate  successfully  a  patient  who  had  had  an  attack  five  weeks  pre- 
viously ;  a  second  attack,  however,  may  occur  after  three  or  four  months. 

The  most  important  predisposing  condition  is  a  wound,  which  may  be 
of  any  size  ;  the  smallest  abrasion,  by  removing  the  epidermis,  seems  suf- 
ficient to  allow  the  organisms  to  gain  a  foothold.  This  advantage  may 
be  given  not  only  by  trauma,  but  by  irritating  discharges  from  ozsena, 
otorrhoea,  or  evea  a  common  cold ;  or  by  chronic  eczema,  lupus,  and  the 
like.  It  has  frequently  been  asserted  that  a  small  wound,  such  as  one  of 
these,  is  invariably  the  starting-point  of  the  disease,  and  that,  as  Volk- 
mann  says,  erysipelas  is  a  true  traumatic  infective  disease.  This  view 
is  most  probably  correct,  for  if  very  careful  search  be  made,  some  wound 
or  abrasion  will  be  found  in  the  large  majority  of  cases ;  for  the  others 
it  must  be  remembered  that  the  wound  may  have  healed  during  the 
incubation  period  of  the  disease,  and  that  if  the  disease  be  not  seen  at  its 
commencement,  the  swelling,  etc.,  that  occurs  will  soon  mask  it.  The 
fact  that  the  disease  on  the  face  generally  starts  at  the  margins  of  skin 
and  mucous  membranes,  or  near  the  external  auditory  meatus,  where 
excoriations  are  so  common  and  so  easily  overlooked,  lends  much  support 
to  this  view.  In  searching  for  wounds  it  may  be  remembered  also,  as 
Fehleisen  has  shown,  that  the  disease  may  first  appear  at  some  little 
distance  (3  cm.)  from  the  point  of  inoculation. 

The  immediate  cause  has  been  most  conclusively  shown  by  Fehleisen 
to  be  a  streptococcus  very  closely  allied  to,  if  not  identical  with  the 
streptococcus  pyogenes.  Micrococci  of  various  kinds  had  been  previously 
recognised  in  the  blood  and  lymphatic  vessels  of  the  skin  of  the  affected 
part,  chiefly  at  and  just  beyOnd  the  spreading  margin  of  the  disease,  by 
such  observers  as  Lukomsky,  Von  Recklinghausen,  Koch  and  Billroth. 
They  also  described  the  cocci  as  occurring  in  the  subcutaneous  tissues  and 
in  the  internal  organs ;  indeed,  there  is  a  great  probability  that  most  of 
their  observations  were  made  on  cases  of  erysipelas  complicated  with 
cellulitis  or  pyaemia.  Fehleisen  was  the  first  to  describe  accurately  and 
to  isolate  a  specific  streptococcus,  to  cultivate  it  in  pure  cultivations 
outside  the  body,  and  to  demonstrate  its  direct  causal  relationship  with 
the  disease. 

On  examining  6•ec^^■ons  of  skin  taken  through  the  margin  of  the  spread- 
ing redness,  he  observed  numerous  micrococci  growing  in  chains  in  the 
lymphatic  vessels  and  spaces  of  the  corium,  not  in  the  blood-vessels  as 
other  observers  had  stated ;  these  he  found  to  be  most  numerous  at  and 
just  beyond  the  spreading  margin  of  the  disease,  but  in  parts  where  the 
redness  is  passing  or  has  passed  off,  the  lymphatic  vessels  and  spaces 
become  infiltrated  with  leucocytes  and  the  cocci  rapidly  die  out.     A  few 


6i6  SYSTEM    OF  MEDICINE 

cocci  were  also  seen  in  the  neighbouring  subcutaneous  tissues ;  the  ap- 
pearances were  the  same  in  all  of  thirteen  cases  examined.  Pure  cul- 
tivations, were  obtained  on  various  nutrient  media,  —  blood  serum,  jellies, 
and  on  potatoes.  Fehleisen  asserts  that  their  growth  in  these  media  is 
characteristic,  but  most  observers  have  failed  to  detect  any  difference 
between  this  growth  and  that  of  streptococcus  pyogenes. 

Experiments  were  made  by  inocidatiug  the  ears  of  rabbits  with  pure 
cultivations.  A  definite  disease  followed,  characterised,  as  in  man,  by  a 
sharp  spreading  margin  of  redness  without  suppuration.  On  making 
sections  of  the  spreading  margin  the  cocci  were  found  in  the  lymphatic 
vessels  and  spaces  presenting  the  same  appearances  as  in  man.  Other 
organisms  may,  however,  produce  similar  results  in  rabbits.  But,  further, 
Fehleisen,  by  inoculating  persons  the  subjects  of  incurable  tumour  with 
pure  cultivations  of  the  cocci,  has  absolutely  proved  that  these  organisms 
are  the  cause  of  erysipelas  in  man.  Of  seven  individuals  so  inoculated, 
six  presented  the  disease  in  every  way  typical ;  the  seventh  case  failed 
even  after  repeated  inoculation,  but  he  had  suffered  tAVO  or  three  months 
previously  from  an  attack  of  erysipelas,  and  Avas  probably  immune.  It 
Avas  shoAvu  in  some  of  the  other  six  cases  that  immunity  Avas  conferred 
for  at  least  a  short  time,  as  repeated  inoculations  failed  to  reproduce  the 
disease.  The  method  he  employed  Avas  to  make  superficial  scarifications 
over  the  part,  and  then  to  rub  in  the  pure  culture.  The  incubation 
period  in  these  cases  varied  from  fifteen  to  sixty -one  hours,  and  it  is  also 
noted  that  the  disease  did  not  always  start  exactly  at  the  punctures,  a 
fact  Avliich  has  also  been  noted  in  cases  occurring  spontaneously. 

It  had  long  been  noted  that  various  malignant  diseases  —  especially 
sarcoma  and  such  chronic  skin  diseases  as  lupus  and  chronic  eczema  — 
were  markedly  improved  or  even  cured  by  an  attack  of  erysipelas ;  and 
many  observers  had  endeavoured  Avith  more  or  less  success  to  set  up  in 
such  cases  a  curative  erysipelas.  It  was  for  this  reason  that  Fehleisen's 
experiments,  Avhich  at  first  sight  might  appear  unjustifiable,  Avere  under- 
taken ;  considerable  benefit  occurred  in  most  of  the  cases,  althoiigh  prob- 
ably none  Avere  cured.  This  treatment,  almost  abandoned  because  of 
its  danger,  has  lately  been  revived  in  an  improved  form  for  the  cure  of 
some  forms  of  malignant  disease,  the  toxins  of  erysipelas  obtained  by 
sterilising  a  pure  cultivation  of  the  cocci  being  employed  as  a  hypodermic 
injection. 

An  important  question  has  been  raised  by  a  number  of  obserA^ers,  who 
have  asserted,  and  many  still  assert,  that  the  streptococcus  of  erysipelas  is 
identical  Avith  the  streptococcus  pyogenes,  and  that  the  different  results 
depend  on  differences  in  other  conditions,  such  as  variation  in  the  viru- 
lence, dose,  seat  of  inoculation,  susceptibility  of  the  host,  and  so  forth. 
Fehleisen  asserted  that  in  cultiA^ations  under  similar  conditions  there  AA^ere 
marked  differences  in  the  modes  of  growth  of  the  two  forms,  and  also 
that  the  inoculations  in  rabbits  gave  rise  to  similar  but  distinctive  proc- 
esses. Other  observers,  however,  have  totally  failed  to  confirm  these 
results.     There  is  no  doubt  that  the  two  organisms  are  very  closely 


ERYSIPELAS  617 


allied  species,  but  that  they  are  absolutely  identical  seems  difficult  to 
reconcile  with  clinical  experience  in  man.  On  the  one  hand,  there  is  no 
sufficient  evidence  to  show  that  the  erysipelas  cocci  can  cause  suppuration 
in  man  —  this  result  has  never  followed  experimental  inoculation  with 
pure  cultivations  —  and,  on  the  other  hand,  inoculation  into  the  skin  of 
streptococcus  pyogenes  has  produced  suppuration,  but  not  erysipelas. 
Thus,  in  opening  abscesses  which  not  infrequently  contain  streptococci, 
the  skin  is  necessarily  inoculated ;  and  in  one  delinite  case  (Rosenbach) 
a  dense  inflammatory  induration  appeared  round  the  incision,  but  ery- 
sipelas has  never  been  shown  to  result  in  such  cases.  The  balance  of 
evidence,  therefore,  seems  to  be  in  favour  of  the  specific  nature  of  the 
erysipelas  coccus,  but  the  point  is  still  under  discussion. 

Some  further  experiments  illustrating  the  mode  in  which  the  disease 
is  spread  may  be  alluded  to.  It  has  been  found  extremely  difficult 
to  transmit  the  disease  directly  from  patient  to  patient,  and  pre- 
pared plates  exposed  to  the  air  of  wards  containing  cases  of  erysipelas 
have  very  rarely  yielded  cultures  of  the  organism.  They  have  been 
most  successful  when  the  patients  were  freely  desquamating,  when  the 
scales  thrown  off  have  been  shown  by  cultivation  to  contain  living 
organisms.  Thus  it  is  probable  that  these  scales  are  the  most  usual 
means  of  carrying  the  disease. 

Pathology.  —  The  minute  anatomy  of  the  local  lesion  has  already  been 
described,  and  as  it  will  be  further  discussed  under  the  symptomatology, 
but  little  need  be  said  in  this  place.  The  redness  of  the  skin  disappears 
after  death,  but  some  of  the  swelling  remains ;  blebs  and  effusion  into 
the  lax  subcutaneous  tissue  are  also  seen.  These  blebs  usually  contain 
serum  more  or  less  turbid ;  they  rarely  contain  organisms.  The  loose 
tissues  of  the  eyelids,  larynx,  etc.,  may  also  be  seen  distended  with 
serum,  and  the  tension  of  the  effusion  may  have  been  so  great  as  to 
cause  gangrene  of  these  parts. 

In  patients  dying  of  erysipelas,  besides  those  dying  of  laryngeal 
stenosis,  the  characteristic  appearances  of  the  more  fatal  complications 
will  also  usually  be  found.  Thus  in  many  cases  diffuse  cellulitis  will  be 
seen,  and  often  a  resulting  pycemia.  Disease  of  the  kidneys  must  also  be 
looked  for.  In  such  cases  organisms  are  commonly  found  in  the  internal 
organs,  but  this  is  probably  not  so  in  simple  cases  of  erysipelas.  Pneu- 
monia or  broncJiitis  may  also  be  found,  more  rarely  meningitis ;  the  latter 
has  been  said  to  arise  from  the  inflammation  passing  directly  inwards 
from  the  scalp  to  the  meninges,  or  from  the  face  along  the  trunks  of  the 
fifth  nerve,  but  it  is  more  probably  a  pyaemic  symptom.  If  a  person  die 
of  simple  imcomplicated  erysipelas,  the  internal  organs  simply  show  the 
usual  signs  of  a  septic  disease  or  those  common  to  the  typhoid  state, 
namely,  swollen  congested  spleen,  enlarged  liver,  and  kidneys  with 
cioudy  degeneration  of  the  glandular  epithelium,  etc. 

Symptoms.  — The  incubation  period  of  erysipelas  has  been  variously 
estimated  at  from  three  to  seven  days.  We  liave  already  seen  that  it  is 
fifteen  to  sixty-one  hours  when  the  disease  is  experimentally  jjroduced. 


6i8  SYSTEM   OF  MEDICINE 

The  general  symptoms  commence  somewhat  abruptly,  siumltaneously 
with,  or  just  before  or  after  the  appearance  of  the  local  lesion.  The 
temperature  rises  rapidly  ;  there  is  often  a  more  or  less  severe  rigor,  the 
patient  feels  ill,  is  languid,  and  often  has  intense  headache,  anorexia  or 
even  vomiting.  Tlie  fever  and  constitutional  disturbance  are  usually  in 
direct  proportion  to  the  extent  of  the  local  lesion.  Herpes  labialis  is 
not  uncommonly  seen,  and,  apart  from  cases  of  erysipelas  of  the  fauces, 
there  is  soreness  of  the  throat  accompanied  by  general  congestion.  The 
fever,  with  varying  remissions,  usually  remains  high  while  the  skin 
affection  is  spreading,  and  often  terminates  suddenly  with  the  cessation 
of  the  spread.  The  skin  is  hot  and  dry,  but  sweating  occurs  during  the 
remissions  of  the  temperature.  Other  febrile  symptoms,  such  as  rapid 
pulse,  frequent  respirations,  febrile  condition  of  urine,  are  also  present, 
usually  in  direct  proportion  to  the  degree  of  the  fever.  In  some  cases 
after  apparent  cessation  of  the  symptoms  a  recrudescence  of  the  disease 
takes  place,  a  fresh  rise  of  temperature,  etc.,  accompanying  a  fresh  local 
outbreak.  In  the  chronic  cases  of  toandering  erysipelas  the  temperature 
takes  a  very  irregular  course ;  it  may  become  normal  while  the  disease 
is  still  spreading,  but  usually  a  fresh  spread  is  accompanied  by  marked 
but  brief  constitutional  disturbances. 

In  the  milder  uncomplicated  cases  the  general  disturbance  may  be 
and  usually  is  very  slight ;  in  other  cases,  more  especially  in  debilitated 
constitutions,  the  gravest  symptoms  may  supervene.  The  severity  of 
the  fever  and  its  duration  may  bring  on  the  typhoid  state,  and  the 
patient  sink  of  exhaustion.  In  other  cases  severe  gastro-intestinal  dis- 
turbances may  be  present — complete  anorexia,  obstinate  vomiting  ac- 
companied by  constipation  or  profuse  diarrhoea  —  and  these  symptoms 
persist  and  exhaust  the  patient.  Of  albuminuria  I  shall  speak  later. 
In  other  cases,  again,  and  especially  in  drimkards,  nervous  symptoms, 
such  as  intense  headache  and  great  restlessness  accompanied  by  violent 
delirium,  may  be  very  prominent  from  the  commencement.  The  delir- 
ium may  pass  into  the  low  muttering  type  as  the  patient  sinks  into  stu- 
por, coma,  and  death.  In  most  of  the  severer  cases  the  spleen  may  be 
made  out  somewhat  enlarged,  and  the  skin  is  more  or  less  jaundiced. 

Locally,  the  disease  as  it  attacks  the  face  and  head  will  be  alone  de- 
scribed. A  sharply-defined  patch  of  redness  appears  on  the  cheeks  —  or 
more  usually  at  the  junction  of  the  mucous  membrane  of  the  nose  and 
skin  —  at  the  margins  of  the  lips,  near  the  external  auditory  meatus, 
or  near  the  margin  of  the  hairy  scalp.  The  affected  portion  of  skin 
becomes  red,  hot,  swollen  and  shiny,  and  is  accompanied  by  a  feeling  of 
tension  or  burning  pain ;  the  patch  spreads  by  direct  continuity  to  sur- 
rounding parts.  Extension  usually  occurs  unequally  in  different  direc- 
tions, and  the  disease  is  very  apt  to  be  arrested  by  a  fold  in  the  skin  or 
at  the  margin  of  the  scalp.  Where  it  is  spreading  there  is  always  a 
sharply-defined,  raised  red  line,  separating  the  healthy  from  the  affected 
tissues,  which  may  be  both  seen  and  felt.  Behind  this  line  the  redness 
and  swelling  gradually  shade  off  until  the  parts  become  normal  agaim 


ERYSIPELAS  619 


The  disease  lasts  in  a  particular  spot  about  four  or  five  days,  so  that  it 
may  still  be  spreading  in  another  place  while  the  part  first  attacked  has 
become  normal.  Where  the  disease  spreads  over  loose  tissues  much 
serous  effusion  oozes  into  them ;  thus  the  eyelids  become  enormously 
swollen,  and  the  eyes  are  closed,  the  ears  are  greatly  thickened,  the 
wrinkles  of  the  face  obliterated,  and  the  features  quite  unrecognisable. 
Blebs  more  or  less  large  may  also  appear  on  the  skin  in  the  severer 
cases  and  add  to  the  deformity.  They  contain  serum,  often  turbid,  or 
a  sticky  gelatinous  fluid,  and  soon  burst  and  dry  up,  leaving  adherent 
crusts.  Very  rarely  local  gangrene  may  occur  from  the  intense  viru- 
lence of  the  inflammation  and  the  tension  of  the  effusion  in  such  tis- 
sues as  the  eyelids,  ears,  etc.  In  such  cases  the  eye  may  be  destroyed. 
The  glands  in  the  neck  are  always  enlarged  and  tender. 

Definite  abscesses  occurring  in  the  skin  or  subcutaneous  cellular  tissue 
are  most  probably  the  result  of  a  mixed  infection,  and  this  is  not  un- 
likely to  be  the  case  when  they  occur,  as  is  not  very  uncommon,  in  the 
eyelids. 

When  the  disease  spreads  to  the  scalp  there  is  usually  increased  head- 
ache accompanied  by  much  local  tenderness  and  oedema,  but  without 
redness.  The  disease  may  spread  from  the  face  to  the  neck  and  body. 
In  some  cases  it  assumes  a  chronic  form,  spreading  from  place  to  place 
until  nearly  the  whole  body  has  been  attacked,  and  one  part  may  even 
be  affected  twice.  These  cases  are  more  common  in  children ;  the  consti- 
tutional disturbance  varies,  but,  as  a  rule,  is  mild,  aiid  recovery  may  take 
place  after  many  weeks ;  in  infants,  however,  recovery  may  be  incom- 
plete, and  death  occur  later  from  marasmus.  In  these  cases  also  the 
spreading  margin  of  the  disease  is  no  longer  distinct,  but  diffuse  patches 
appear,  often  not  in  continuity. 

Where  the  disease  spreads  over  a  joint,  effusion  takes  place  into  its 
cavity.  This  is  serous,  perhaps  turbid,  but  probably  in  simple  erysipelas 
never  purulent.  Wherever  the  skin  has  been  attacked  considerable 
desquamation  follows,  and  this,  as  has  already  been  shown,  is  the  chief 
means  of  dissemination  of  the  disease. 

I  have  already  said  that  the  various  mucous  membranes  may  also  be 
attacked  by  erysipelas ;  the  frequency  with  which  this  occurs  varies  in 
different  epidemics.  The  disease  may  begin  on  the  skin  and  spread  by 
direct  continuity  to  the  mucous  membranes  of  the  nose,  mouth,  etc.,  or 
conversely  ;  or,  beginning  at  the  junction  of  skin  and  mucous  membrane, 
may  extend  simultaneously  in  both  directions.  There  is  also  good  reason 
to  believe  that  some  of  the  cases  described  as  acute  oedematous  laryngitis 
and  pharyngitis  are  really  examples  of  erysipelas  limited  to  that  region. 
The  disease  always  spreads  from  the  throat  to  the  skin,  or  vice  versa,  by 
direct  continuity ;  and  cases  have  been  described  which  illustrate  the  four 
paths  by  which  this  extension  may  take  place.  In  order  of  frequency 
they  may  be  enumerated  as  follows :  (1)  from  the  lips  by  the  mucous 
membraT)e  of  the  mouth,  tongue,  etc.;  (2)  Ijy  means  of  the  nostrils,  na^ 
sal  mucous  membrane,  etc.;  (3)  by  the  Eustachian  tube  and  auditory 


620  SYSTEM   OF  MEDICINE 


canal ;  (4)  from  the  eyes  by  the  lachrymal  canal  to  the  nose,  etc.  The 
mouth,  ear,  nose,  tongue,  palate,  pharynx,  larynx  and  trachea  may  all 
be  affected.  Coruil  records  eighteen  cases  in  which  the  throat  was 
attacked;  in  nine  of  these  the  affection  spread  inwards  from  the  skin, 
in  seven  it  originated  in  the  tliroat.  In  the  former  case  the  throat 
was  generally  attacked  on  the  third  to  the  fifth  day  of  the  disease.  In 
all  these  cases  the  general  symptoms  are  much  more  severe,  and  gastro- 
intestinal disturbances  are  common.  The  throat  is  extremely  painful, 
preventing  sleep,  and  causing  great  pain  and  difficulty  in  swallowing. 
When  the  larynx  is  attacked  there  is  the  further  danger  of  suffocation 
from  laryngeal  stenosis;  or  the  disease  may  spread  down  the  trachea, 
and  broncho-pneumonia  may  be  set  up. 

The  local  appearances  on  the  palate  and  fauces  are  most  characteristic. 
The  whole  part  is  uniformly  dark,  shiny,  red,  and  feels  dry  and  burning 
hot.  Much  oedematous  swelling  also  occurs,  especially  affecting  the 
uvula ;  the  tonsils  share  in  the  process,  but  are  not  nearly  so  enlarged  as 
in  quinsies,  and  sometimes  the  sharp  spreading  margin  of  the  disease 
may  be  distinctly  seen.  Bullae,  small  or  large,  are  frequently  seen ;  at 
first  they  are  well  formed  and  contain  turbid  serum,  but  in  a  few  hours 
they  burst,  leaving  yellowish  white,  membranous-looking  patches  which 
persist  some  days.  After  the  disease  has  subsided  dilated  veins  are 
observed  on  the  part. 

AVhen  the  nose  is  attacked  the  swelling  of  the  mucous  membrane 
entirely  occludes  it.  In  the  mouth  erysipelas  gives  rise  to  marked 
purplish  red  swelling  and  profuse  ptyalism.  In  all  these  cases  the 
glands  at  the  angles  of  the  jaw  are  markedly  swollen  and  tender, 
causing  great  pain  and  difficulty  in  mastication. 

When  the  larynx  is  attacked  there  is  deep  red  congestion  and  swelling 
of  the  whole  mucous  membrane,  and  great  oedema,  especially  affecting 
the  epiglottis,  aryepiglottic  folds,  and  arytenoids.  This  oedema  always 
comes  on  very  suddenly,  and  may  rapidly  destroy  the  patient's  life  un- 
less urgent  means  of  treatment  be  adopted.  In  rare  cases  the  inflam- 
mation goes  on  to  gangrene :  this  usually  attacks  the  oedematous  parts, 
or  arises  in  the  membranous  patches  above  described.  All  the  symptoms 
are  then  aggravated,  there  is  intense  prostration,  the  breath  is  extremely 
foetid,  and  septic  forms  of  bronchitis  and  pneumonia  may  set  in. 

Two  other  forms  of  the  disease  may  be  briefly  mentioned.  In  infants 
the  disease  may  start  in  connection  with  the  navel,  and,  though  commonly 
fatal  from  the  feeble  resisting  power  of  the  patient,  it  presents  no  other 
peculiarity.  Also  in  infants  or  young  children  the  disease  is  not  un- 
commonly seen  to  start  from  the  vulva.  Intense  swelling  and  oedema 
of  these  parts  occurs,  with  pain  and  great  difficulty  in  micturition ;  not 
very  uncommonly  it  results  in  gangrene. 

Complications  and  Sequelae.  — The  most  serious  local  complication  of 
erysipelas  is  diffuse  cellulitis ;  this  it  is  which  gives  rise  to  local  suppura- 
tion, to  pleurisy,  pericarditis,  meningitis,  and  the  other  pyaemic  symptoms 
usually  descril3ed  as  complications  of  erysipelas.    Apart  from  septic  in- 


ERYSIPELAS  621 


fection,  pneumonia  and  bronchitis  are  occasionally  seen,  especially  if 
the  throat  be  affected. 

Albuminuria  is  very  commonly  present  as  a  symptom  of  erysipelas, 
and  acute  nephritis  is  not  very  rare.  In  drunkards  delirium  tremens 
may  arise.  Still  more  rarely  by  implication  of  the  conjunctiva,  the  nu- 
trition of  the  cornea  may  suffer,  leading  to  sloughing  and  destruction  of 
the  eye ;  if  the  disease  spread  along  the  ear  and  Eustachian  tube  acute 
suppuration  of  the  middle  ear  with  all  its  evils  necessarily  ensues. 

Among  sequelse  may  be  noted  increased  liability  to  the  disease  after 
a  brief  period  of  immunity ;  and  repeated  attacks  not  uncommonly  leave 
a  greatly  thickened,  unsightly  condition  of  the  skin.  When  the  scalp  is 
attacked  there  is  visually  a  falling  off  of  the  hair,  which,  however,  soon 
grows  again,  unless  the  attacks  be  repeated.  Chronic  skin  diseases  — 
eczema,  lupus,  etc.  —  are  often  much  reduced  or  even  cured  by  an  attack 
of  erysipelas  ;  in  many  cases  after  single  attacks  it  has  been  noticed  that 
the  skin  is  finer  and  softer,  and  the  complexion  much  improved. 

The  diagnosis  of  erysipelas  of  the  skin  is  usually  quite  easy;  the 
abrupt  raised  margin  of  redness,  spreading  by  direct  extension,  and 
accompanied  by  constitutional  disturbance,  is  characteristic. 

Diffuse  cellulitis  is  accompanied  by  more  brawny  swelling,  and  the 
superjacent  redness  of  the  skin  is  more  diffuse.  The  redness  accompany- 
ing lymphangitis  is  also  more  diffused,  and,  at  least  in  parts,  the  thin  red 
lines  of  the  larger  inflamed  vessels  may  be  made  out. 

Erythema  of  the  skin  occurs  in  bright  red  diffuse  patches,  and  spreads 
by  the  formation  of  fresh  distinct  patches.  It  chiefly  resembles  the 
migratory  form  of  erysipelas,  but  is  not  accompanied  by  pain  or  any 
constitutional  disturbance. 

Acute  eczema  spreads  by  the  formation  of  tiny,  pin-point  lesions, 
usually  minute  vesicles;  it  has  a  weeping  surface,  and  never  anywhere  a 
distinct  raised  margin.  Other  skin  affections  —  such  as  herpes,  pemphi- 
gus and  urticaria — need  scarcely  be  mentioned. 

In  the  throat,  also,  erysipelas  presents  characteristic  points  apart  from 
its  general  association  with  skin  affection.  The  pharynx  is  more  acutely 
painful,  the  constitutional  disturbance  greater,  the  local  signs  of  swelling 
and  oedema  more  marked,  and  the  parts  of  a  deeper  red  than  in  simple 
acute  pharyngitis.  The  tonsils  are  not  nearly  so  large  or  inflamed  as  in 
quinsy.  Herpes  of  the  palate  is  not  associated  with  so  much  general 
congestion  or  swelling,  and  the  constitutional  disturbance  is  slight. 
When  the  larynx  is  attacked  reliance  must  chiefly  be  placed  on  the  ac- 
companying severe  bodily  prostration  to  distinguish  it  from  other  forms 
of  acute  oedema.  Scarlet  fever  may  simulate  both  the  throat  and  skin 
affection ;  but  the  scarlet  rash  never  appears  first  on  the  face  and  is  more 
diffuse  and  punctiform  both  on  the  skin  and  throat.  The  pultaceous 
throat  sometimes  met  with  in  scarlet  fever  may,  however,  be  indistin- 
guishable from  that  following  the  formation  of  vesicles  in  erysipelas; 
the  diagnosis  must  then  be  made  by  the  concomitant  symptoms. 

The  prognosis  of  erysipelas,  as  it  occurs  in  healthy  adults,  is  veiy 


622  SYSTEM  OF  MEDICINE 

favourable ;  but  some  epidemics  are  much  more  severe  than  others.  Mild 
cases  last  two  or  three  days ;  the  severer  ones  live  to  ten  days :  the 
migrating  form  may  last  for  weeks,  and  in  any  case  after  apparent  ces- 
sation relapses  may  occur. 

Erysipelas  attacking  surgical  or  puerperal  patients  is  apparently 
much  more  fatal  than  the  kind  above  described ;  but  the  mortalit}^  for- 
merly occurring  in  such  cases  was  probably  due  in  part  to  the  lowering 
treatment  (bleeding,  a.nd  so  forth)  too  often  adopted  in  patients  already 
depressed;  and  in  part  to  other  complications  of  the  wound.  The 
disease  is  more  fatal  in  the  aged ;  and  in  infants  it  tends  to  assume  the 
spreading  form  which  not  unfrequently  leads  to  marasmus  and  death. 

In  patients  suffering  from  chronic  renal  disease  the  prognosis  is 
extremely  bad ;  it  is  also  grave  in  the  subjects  of  chronic  alcoholism 
or  of  any  wasting  disease  such  as  diabetes,  phthisis,  malignant  disease, 
chronic  suppuration,  and  the  like. 

Cases  in  Avhich  the  throat  is  attacked  are  more  dangerous  than  those 
in  which  the  skin  is  affected  alone  ;  and  those  cases  in  which  the  disease 
spreads  inwards  from  the  skin  are  said  to  be  much  more  dangerous  than 
those  in  Avhich  the  extension  takes  places  in  the  opposite  direction. 
When  the  larynx  is  involved  the  case  becomes  extremely  grave,  apart 
from  the  special  danger  of  suffocation.  Gangrene  of  the  throat  is  almost 
necessarily  fatal. 

In  most  cases  the  severity  of  the  general  disturbance,  the  pulse,  tem- 
perature, gastric  and  mental  symptoms  will  give  trustworthy  data  on 
which  to  base  a  prognosis. 

Treatment.  —  The  disease  being  contagious  the  patient  must  be 
isolated  as  soon  as  possible ;  especially  must  he  be  kept  away  from  all 
communication  with  patients  suffering  from  wounds,  and  from  puerperal 
cases.  The  attendants  on  the  sick  must  also  be  very  careful  of  any  cuts, 
cracks  or  abrasions  on  their  hands,  and  these  attendants  must  not  at  the 
same  time  look  after  other  patients,  especially  not  those  suffering  from 
wounds.  If  these  precautions  be  rigidly  carried  out,  and  other  cases 
treated  aseptically,  there  is  little  harm  in  the  patient  remaining  in  the 
same  ward  with  them.  On  recovery  the  patient's  bed,  clothes,  and  other 
articles  must  be  thoroughly  purified,  and  the  walls  and  furniture  around 
well  washed.  During  convalescence,  when  desquamation  is  in  prog- 
ress, increased  care  must  be  taken ;  if  the  patient's  skin  be  affected  it 
should  be  well  greased  with  vaseline  or  olive  oil,  or,  if  the  area  be  small, 
with  carbolic  oil  (1-40),  and  the  part  sponged  with  a  weak  solution  of 
permanganate  of  potash  many  times  a  day  until  the  process  has  come 
to  an  end. 

In  the  ordinary  milder  cases  seen  in  adults  no  active  medicinal  treat- 
ment is  required.  A  light,  nutritious  diet,  with  possibly  a  little  stimu- 
lant, is  prescribed ;  the  action  of  the  bowels  should  be  attended  to  in 
conjunction  Avith  some  of  the  local  means  of  treatment  about  to  be 
described,  and  the  disease  Avill  get  well  of  itself. 

In  severer  cases  more  active  treatment  is  required,  and,  the  disease 


ER  YSIPELAS  623 


being  essentially  adynamic,  no  lowering  methods  must  be  adopted.  The 
diet  must  be  chiefly  fluid,  milk,  eggs  and  the  like,  with  a  liberal  allow- 
ance of  stimulants.  If  vomiting  be  present  it  may  be  met  by  effervescing 
mixtures  or  bismuth,  and  the  regular  action  of  the  bowels  must  be  ensured. 
The  worst  cases  require  a  very  large  amount  of  stimulants ;  and  carbonate 
of  ammonia  and  strychnine  may  be  prescribed  in  addition.  Should  the 
temperature  remain  persistently  high,  or  hyperpyrexia  be  present,  the 
effect  of  large  doses  of  quinine  may  be  tried ;  but  as  a  rule  tepid  sponging 
or  the  cold  bath  will  prove  a  more  efficient  method  of  treatment.  Other 
antipyretics  are  less  to  be  trusted,  and  have  too  great  a  tendency  to  depress 
the  patient.  For  great  restlessness,  want  of  sleep  or  delirium,  spong- 
ing may  be  employed,  or  an  ice-bag  applied  to  the  head.  If  these  fail 
morphia  is  probably  the  best  drug  to  use,  or  bromides  with  chloral  may 
be  given. 

In  addition  to  the  above  symptomatic  treatment  two  drugs  may  be 
mentioned,  which  at  different  times  have  been  considered  to  act  almost 
as  specifics.  Of  these  the  best  known  is  perchloride  of  iron,  which  is 
given  in  very  large  doses  (^l  40-60  of  the  tincture)  every  four  hours. 
This  drug  is  certainly  well  tolerated  in  these  cases,  and  by  maintaining 
the  patient's  strength  probably  does  good  in  many.  The  other  drug  is 
camphor,  recommended  by  Striimpel,  but  is  of  more  doubtful  value. 
Camphor  is  given  in  three  grain  doses  every  tAvo  or  three  hours,  and  at 
the  same  time  the  patient  is  encouraged  to  drink  large  quantities  of  hot 
tea,  so  that  he  soon  perspires  freely.  Quinine  was  also  at  one  time  con- 
sidered a  specific. 

Numerous  methods  of  local  treatment  have  been  recommended  at 
various  times,  the  very  number  showing  their  general  inefficiency.  It  is 
probable  that  the  simplest  are  the  best ;  such  are  dusting  the  affected 
part  with  powdered  boracic  acid,  zinc  oxide,  or  a  mixture  of  these  with 
starch,  and  covering  the  part  with  a  thin  layer  of  cotton  wool.  This  in 
part  relieves  the  painful  local  sensations,  is  cleanly,  and  does  no  harm. 
For  the  face,  it  is  a  good  plan  to  cut  a  mask  of  lint  with  holes  for  the 
mouth,  nose,  and  eyes,  and  to  keep  this  moist  with  evaporating  lead 
lotion.  This  is  very  soothing,  but  must  never  be  applied  to  any  part 
where  there  is  the  least  tendency  to  gangrene.  Where  the  pain  is  great 
tinct.  opii  (2f  oz.  to  the  pint)  may  be  added  to  the  lotion.  These  two 
methods  are  better  than  simply  dusting  the  part  thickly  with  flour,  or 
applying  plain  water  dressings.  The  dry  powders  are  also  much  better 
than  the  various  pastes  Avhich  are  sometimes  recommended,  and  better 
than  the  ointments,  at  least  at  this  stage.  Painting  the  affected  part 
with  collodion  usually  does  harm.  If  there  be  very  great  tension  in  the 
affected  part,  or  gangrene  threaten,  free  incisions  must  be  made  into  it 
at  once,  and  antiseptic  fomentations  applied. 

Formerly  it  was  much  the  fashion  to  apply  nitrate  of  silver  over  the 
healthy  skin — just  beyond  the  spreading  margin  of  the  erysipelatous 
redness  —  care  being  taken  not  to  destroy  the  whole  thickness  of  the  skin ; 
it  was  asserted  that  in  a  considerable  number  of  cases  the  erysipelas  came 


624  SYSTEM  OF  MEDTCTNE 

to  a  standstill  wlieii  it  reached  the  line  so  made.  Unfortunately,  however, 
it  very  often  crosses  at  some  part  or  other  and  spreads  on  as  before.  In 
place  of  nitrate  of  silver  some  surgeons  use  iodine.  At  first  sight  the 
value  of  this  method  of  treatment  is  not  very  obvious,  and  many  have 
asserted  that  in  the  cases  where  the  disease  was  arrested  at  this  line  they 
had  to  do  with  mere  coincidence.  From  recent  work  on  the  pathology  of 
the  disease,  however,  we  can  see  that  the  plan  was  not  so  foolish  as  may 
appear.  As  previously  mentioned,  the  erysipelas  cocci  spread  in  the 
lymphatic  vessels  of  the  skin,  and  it  has  been  found  that  while,  on  the 
one  hand,  Avhen  Ave  have  to  do  with  an  acute,  rapidly-spreading  erysipelas 
there  is  very  little  cellular  infiltration  in  the  part,  yet  on  the  other  hand, 
when  the  process  is  mild,  or  when  it  is  coming  to  a  standstill,  a  large 
number  of  cells  are  found  forming  a  barrier  against  its  further  progress. 
JSTow  the  application  of  nitrate  of  silver  to  the  skin  in  so  strong  a  solution 
as  to  cause  slight  ulceration  will  lead  to  a  rapid  exudation  of  leucocytes 
which  may  fill  up  and  block  the  lymphatic  vessels  of  the  part ;  and  thus 
when  the  cocci  in  their  spread  reach  that  line,  they  may  find  their  path 
barred  by  a  collection  of  leucocytes. 

Not  very  long  ago,  when  the  parasitic  nature  of  the  disease  was  first 
understood,  attempts  were  made  to  arrest  its  spread  by  the  injection  of 
weak  antiseptic  solutions  —  such  as  2  per  cent  carbolic  acid  solution,  Aveak 
perchloride  of  mercury  lotion,  etc.  —  into  the  healthy  skin  just  beyond 
the  spreading  margin.  This  method  proved  untrustworthy.  More 
recently,  however,  it  has  been  improved  by  Krause,  whose  method  of 
treatment  is  highly  spoken  of  by  those  who  have  experience  in  erysipelas. 
This  plan  is  to  make  numerous  scarifications  in  the  healthy  skin  beyond 
the  spreading  margin,  the  scarifications  crossing  one  another  and  com- 
pletely surrounding  the  disease,  as  did  the  old  nitrate  of  silver  line.  In 
order  to  carry  out  this  plan  efficiently  the  patient  must  be  placed  under 
an  anaesthetic.  AVhen  the  scarification  is  complete,  a  steam  spray-pro- 
ducer, containing  1  to  20  carbolic  acid,  is  made  to  play  on  the  part  for 
some  considerable  time  (an  hour  or  two) ;  it  is  subsequently  dressed  with 
carbolic  compresses.  I  cannot  speak  personally  of  this  method,  as  my 
experience  in  the  treatment  of  erysipelas  is  insufficient. 

When  the  mouth  is  affected  it  should  be  constantly  washed  out  with 
simple  gargles  of  boracic  acid,  Condy's  fluid,  or  sanitas ;  and  if  the  nose 
be  attacked  it  should  be  gently  syringed  with  similar  solutions.  Whfen 
the  throat  is  attacked  the  gravity  of  the  affection  must  be  borne  in  mind, 
and  in  spite  of  opposition  on  the  part  of  the  patient,  a  considerable 
amount  of  fluid  nourishment  and  stimulants  must  be  administered.  The 
pain  of  sAvallowing  may  be  considerably  mitigated  by  the  simple  plan 
recommended  by  ]\Ir.  Hovell :  an  attendant  standing  laehind  the  patient 
makes  firm  pressure  during  the  act  of  deglutition  over  the  ears  and 
part  of  the  neck  below  by  the  palms  of  the  hands,  the  fingers  being 
directed  upwards.  Locally  the  patient  may  be  directed  to  suck  ice  con- 
stantly, and  to  use  weak  antiseptic  gargles  frequently.  Sometimes,  on  the 
other  hand,  frequent  gargling  with  a  hot  saturated  solution  of  bicarbonate 


ERYSIPELAS  625 


of  sodium  will  give  most  relief,  and  atthe  same  time  hot  fomentations  may 
be  applied  around  the  angles  of  the  jaw.  If  these  measures  fail,  free 
scarification  of  the  palate,  and  especially  of  the  uvula,  will  always  afford 
relief.  When  the  larynx  is  attacked  the  special  danger  of  suffocation  is 
added,  and  treatment  must  be  mainly  directed  to  prevent  this.  All  food 
must  be  given  cold,  and  all  hot  or  steam  inhalations  scrupulously  avoided. 
Formerly  great  reliance  was  placed  on  leeches,  six  to  twelve  being  applied 
over  the  larynx,  and  they  certainly  give  temporary  relief.  But  their 
tendency  is  to  exhaust  the  resources  of  the  patient,  and  usually  they 
have  to  be  repeated.  Other  means  of  counter-irritation  are  useless. 
The  best  plan  of  all  is  to  keep  the  patient  constantly  sucking  ice ;  at  the 
same  time  he  should  keep  quite  quiet,  and  avoid  all  use  of  the  voice.  In 
some  cases  this  treatment  will  be  all  that  is  required.  Where,  however, 
in  spite  of  this  the  swelling  increases,  we  must  either  perform  tracheo- 
tomy or  freely  scarify  the  larynx.  The  effect  of  the  latter  may  be  first 
tried  in  adults,  where  the  patient  is  not  too  intolerant  of  the  necessary 
manipulations,  and  where  the  dyspnoea  is  not  so  extreme  as  to  render  the 
method  dangerous  from  the  reflex  spasm  it  excites.  The  method  recom- 
mended is  as  follows :  — cocaine  is  not  used,  its  application  wearies  the 
patient,  excites  spasm,  and  does  no  good  —  guided  by  the  laryngoscope  a 
long,  deep  incision  is  made  into  each  ary-epiglottic  fold,  most  efficiently 
by  an  open  knife  like  Heryng's,  rather  than  by  a  guarded  instrument 
like  Mackenzie's  scarifier ;  it  is  better  to  make  the  incisions  into  the 
outer  side  of  these  folds,  so  that  the  blood  may  have  less  tendency  to 
trickle  into  the  larynx,  and  thus  to  cause  much  discomfort  or  even 
serious  danger  to  the  patient.  The  bleeding  is  promoted  by  gargling 
with  hot  fluids,  and  afterwards  the  patient  continues  to  suck  ice. 

If  this  fail  to  relieve  the  dyspncea  tracheotomy  will  be  required,  and 
this  should  be  done  as  soon  as  its  necessity  is  foreseen,  so  as  to  give  the 
patient  his  best  chance  of  recovery.  Where  scarification  is  out  of  the 
question,  as  in  children  and  adults  who  cannot  tolerate  the  necessary 
manipulations,  tracheotomy  offers  the  sole  hope  of  relief ;  for  all  other 
methods  of  scarifying — by  the  finger  nail,  or  by  a  guarded  bistoury 
guided  by  the  finger  touch  —  are  to  be  strongly  condemned  as  unscien- 
tific and  dangerous. 

When  the  parts  around  the  vulva  or  anus  are  attacked  much  relief 
may  be  obtained  by  immersing  the  child's  body  in  a  warm  bath  to  which 
small  quantities  of  tincture  of  iodine  may  be  added.  The  child  is  swung 
in  a  sheet  and  properly  supported,  and  may  be  allowed  to  remain  in  the 
bath  twenty -four  to  forty-eight  hours  at  a  time. 

Finally,  in  addition  to  the  general  and  local  treatment  above  described, 
the  presence  of  complications  must  be  carefully  sought  or  watched  for, 
and  especially  must  the  state  of  the  kidneys  be  investigated,  and  appro- 
priate treatment  adopted  in  the  respective  cases. 

W.  Watson  Cheyne. 


VOL.    I 


626  SYSTEM   OF  MEDICINE 


REFERENCES 

1.  Bristowe.  Article  "  Pyaemia, "  Reynolds'  System  of  Medicine,  1862. — 2.  Burdon- 
Sanderson.    "  Septicsemia,"  etc.,  British  Medical  Journal,  1877,  vol.  ii.,  and  1891,  vol.  ii. 

—  3.  Bjnomk.  Fortschritte  d.  Med.  1886,  No.  1;  Deutsche  med.  Wochenschrlft,  1886. — 
4.  CH.iYNE,  W.  W.  Suppuration  and  Septic  Diseases,  1889  (which  contains  full  refer- 
ences down  to  1889). — 5.  Cornil.  "Erysipelas,"  Archives  de  medecine.  Paris,  1861 
and  1862.  — 6.  Duncan,  Matthews.  "  Sapraemia,"  Lancet,  1880,  vol.  ii.  —7.  Erichsen. 
Principles  and  Practice  of  Surgery.— d,.  Eiselsberg.  V.  Langenbeck's  J.rc/i<w,  vol. 
.XXXV.  —9.  Emmerich.  Fortschritte  der  Mzd.  vol.  v.  1887.  — 10.  Fehleisen.  Aetiologie 
der  Erysipels.  Berlin,  1883;  Micro-organisms  in  Disease,  New  Sydenham  Society,  1886. 
— 11.  Gaspard.  "  Me'nioire  physiologic  sur  les  maladies  puruleutes  et  putrides,"  Jour- 
nal de  Majendie,  1822.  —  12.  Hamilton.  Textbook  of  Pathology.  — 13.  Jeannel. 
L' infection  pwrulente  ou  pyrhemie.  Paris,  1880.  — 14.  Koch,  Robert.  Aetiologie  der 
Wundinfectionskrankheiten ;  and  Traumatic  Infective  Diseases,  New  Sydenham  Society. 

—  15.  Knoor.  "Identity  of  Streptococcus  Pyogenes  and  S.  Erysipel,"  Berl.  klin. 
Wochens.  xxx.  1893,  p.  699.  — 16,  Klein.  "  Behandlung  der  Erysipels,"  Berliner  klinische 
Wochenschrlft.  1891,  No.  39.  — 17.  Lockwood.  "Traumatic  Infection,"  Lancet,  1895, 
vol.  i.  — 18.  "Metschnikoff.  Arch.  f.  Path.  Anat.  cvii.  1887. —19.  Nunneley.  On 
Erysipelas.  Lond.  1811. — 20.  Ogston.  British  Medical  Journal,  1881.-21.  Osler. 
"  Goulstonian  Lectures,"  British  Medical  Journal,  1885,  vol.  i.  — 22.  Paget.  "Pyae- 
mia," Lancet,  18S6,  vol.  ii.  — 23.  Panum.  "  Zur  Lehre  von  der  putriden  oder  septischen 
Infectionen,"  Schmit's  Juhrbiicher,  1855.— 24.  Riubert.  Deutsche  m3d.  Wochen- 
schrlft, 1884,  1885. — 25.  Rosenbach.  Mikro-organism°n  bei  d.  Wundinfectionskrank- 
heit-''n  des  Menschen.  Wiesbaden,  1884;  MlcTO-organisms  in  D;s°a.s3,  New  Sydenham 
Society. — 26.  Sternberg.  Manual  of  Bacteriology. — 27.  Transactions  of  the  Patho- 
logical Society  of  Lond)n,  vol.  xxx.  1879.— 28.  Vacher  and  Braidwood.  "Report 
to  the  Scientific  Grants  Committee,"  British  Medical  Journal,  1882,  vol.  i. — 29. 
Vaughan  and  Nouy.  Ptomaines  and  Leucomaines,  1894.  —  30.  Virchow.  Gesammelte 
Abhand'ungen  zur  luiss^nschaftlichen  Medicln,  1862.  —  31.  Wilks.  "Arterial  Pyae- 
mia," British  Medical  Journal,  1882,  vol.  i.  —  32.  Ziegler.  Textbook  of  Pathology, 
(translated  by  D.  Macalister). 

w.  w.  c. 


INFECTIVE  ENDOCARDITIS 

Syiston-tms.  —  Ulcerative  Endocarditis,  Malignant  Endocarditis,  Arte- 
rial Pyaemia,  Mycosis  Endocardii. 

For  some  time  two  forms  of  acute  endocarditis  have  been  distin- 
guished—  the  simple,  benign  or  verrucose,  and  the  malignant  or  ulcera- 
tive endocarditis.  There  now  is  abundant  evidence  that  in  both  forms 
of  acute  endocarditis  micro-organisms  are  formed  ;  and  though  in  some 
cases  the  same  organisms  have  been  found  in  the  two  forms,  yet  as  the 
malignant  type  very  frequently  implants  itself  on  the  chronic  form  of 
benign  endocarditis,  and  produces  a  new  and  often  fatal  train  of  symp- 
toms, it  is  desirable  that  the  two  affections,  so  different  in  their  charac- 
ter and  principle  features,  should  be  considered  separately. 

Various  names  have  been  suggested  for  the  malignant  type,  none  of 
which,  hov/ever,  is  quite  unobjectionable :  ulcerative  and  malignant  endo- 
carditis are  those  now  most  frequently  used.  Against  the  name  ulcerative 
endocarditis  it  may  be  urged  that  occasionally  no  distinct  ulcerations  are 
found ;  whilst  on  the  other  hand  the  ulceration  which  may  result  from 


INFECTIVE  ENDOCARDITIS  627 

degenerative  changes  in  clironic  endocarditis  or  in  the  arterio-scl erotic 
form — the  so-called  atheromatous  ulceration — is  not  associated  with 
the  symptoms  of  malignant  endocarditis.  Against  the  name  malignant 
endocarditis  it  may  be  urged  that  some  cases  recover ;  and  again,  that 
even  the  verrucose  form  may  sometimes  run  a  rapid  and  fatal  course  (29). 

Infectious  or  infective  endocarditis  (E.  infectieuse,  E.  infectante,  E. 
vegetante  of  French  authors)  is  perhaps  the  least  objectionable  name, 
but  as  yet  it  has  not  been  generally  adopted  by  English  writers. 

As  there  is  now  clear  proof  that  the  cause  of  malignant  endocarditis 
is  a  microbe,  and  as  in  many  cases  the  organisms  occurring  in  septic  and 
pyaemic  diseases  have  been  found  in  it,  we  think  that  the  proper  place  for 
infective  endocarditis  is  amongst  the  septic  diseases  ;  in  deference,  how- 
ever, to  habit  and  convenience  we  propose  to  consider  now  only  the 
etiology  and  general  pathology  of  this  form  of  endocarditis :  the  symptom- 
atology, morbid  anatomy,  diagnosis  and  treatment  will  be  dealt  with  in 
one  of  the  articles  on  diseases  of  the  heart. 

History  and  Etiology  of  the  Disease.  —  Bouillaud  (1824-1832)  is  said 
to  have  been  the  first  to  indicate  a  form  of  acute  endocarditis  which  occa- 
sionally began  with  pyaemic  symptoms ;  but  he  did  not  recognise  the  rela- 
tion of  the  endocardial  lesions  to  the  general  symptoms  :  Stenhouse  Kirkes 
was  the  first  to  comprehend  the  malignant  form  of  endocarditis  ;  he  looked 
upon  the  general  or  typhoid  symptoms  as  due  to  an  altered  condition  of 
the  blood  produced  by  the  granular  masses  detached  from  the  diseased 
valves.  Virchow  not  only  pointed  out  the  embolic  nature  of  the  blocks 
found  in  the  small  arteries  in  cases  of-  valvular  lesions  of  the  heart, 
but,  in  a  case  of  puerperal  perimetritis,  with  peritonitis  and  diphtheritic 
deposits  in  the  large  intestines,  he  also  described  coagula  with  granular 
masses,  like  diphtheritic  deposits  on  the  mitral  valve ;  and  he  looked 
upon  the  process  as  possibly  due  to  a  parasitic  cause. 

The  pysemic  character  of  malignant  endocarditis  was  also  early  noted 
by  Dr.  Wilks  who  afterwards  suggested  the  name  of  arterial  pyaemia  for 
this  affection  (52) ;  he  was  followed  by  J.  W.  Ogle,  Murchison,  Moxon, 
Bristowe,  and  other  English  writers.  Bamberger  and  Friedreich  laid 
stress  on  the  similarity  of  the  symptoms  in  some  forms  of  endocarditis 
and  in  pyaemia ;  and  of  the  early  French  observers  we  may  note  Char- 
cot and  Vulpian  and  Lancereaux,  who  described  the  clinical  characters 
of  malignant  endocarditis.  Not  a  few  observers,  such  as  Hayem  and 
Dugues,  and  Desplats,  looked  upon  the  valvular  lesions  and  the  le- 
sions in  the  other  organs  as  local  manifestations  of  a  general  infectious 
disease. 

Winge  was  the  first  to  describe  microbes  (which  he  spoke  of  as  chains 
of  small  rods  or  round  granules  like  chains  of  leptothrix)  both  on  the 
valves  and  in  the  secondary  infarcts  in  a  case  of  infective  endocarditis ; 
and,  as  the  patient  had  suffered  from  suppuration  of  a  toe,  he  thought 
the  microbes,  which  ho  regarded  as  the  cause  of  the  disease,  were  derived 
from  this  source :  he  accordingly  proposed  for  the  disease  the  name 
mycosis  endocardii. 


628  SYSTEM   OF  MEDICINE 

Heiberg  found  microbes  similar  in  character  to  those  seen  by  Winge 
in  a  case  of  infective  endocarditis  in  a  puerperal  case.  He  inserted 
particles  from  the  affected  valves  into  the  peritoneal  cavity  of  a  rabbit, 
but  with  negative  results. 

Nevertheless  Heiberg's  observations  formed  the  starting-point  of  a 
series  of  similar  publications  all  of  which  made  for  the  existence  of 
microbes  in  the  diseased  valves :  some  of  the  cases,  like  that  of  R.  Meier, 
were  primary  infective  endocarditis  ;  in  others  (Wedel  (50)),  the  primary 
source  was  septic  endometritis,  whilst  in  others  again  (27),  the  primary 
disease  was  pneumonia  with  empyaema. 

Birch-Hirschfeld  not  only  found  numerous  micrococci,  in  zoogloea 
masses  and  in  chains,  in  the  diseased  valves  and  in  the  metastatic  in- 
farcts, but  he  also  succeeded  in  producing  panophthalmitis  in  three  rab- 
bits by  inoculation  with  fragments  from  the  valve  deposit.  Klebs  made 
some  important  contributions  to  this  subject:  from  an  examination  of 
twenty-seven  cases  of  endocarditis  he  came  to  the  conclusion  that  all 
forms  of  this  malady  are  of  mycotic  nature ;  the  verrucose  form  being 
due  to  cocci  (monaclines),  the  other  (which  he  calls  the  septic  endocar- 
ditis) to  a  somewhat  different  organism  (a  capsulated  coccus).  Koester, 
by  a  series  of  observations,  confirmed  the  opinion  of  Klebs  that  every 
endocarditis,  Avhether  malignant  or  benign,  is  caused  by  microbes  ;  find- 
ing, moreover,  that  many  of  the  vessels  of  the  affected  valves  were  filled 
with  thrombi  consisting  of  cocci,  he  came  to  the  conclusion  that  the 
endocarditis  was  produced  by  these  microbic  emboli  which  rupture  the 
walls  of  the  vessel  and  reach  the  free  surface  of  the  valve.  About  this 
time  Cayley,  who  suggested  the  name  infecting  endocarditis  (6),  and 
Purcer  published  malignant  cases  of  endocarditis  in  which  they  de- 
scribed the  presence  of  microbes.  Litten  confirmed  the  observations  of 
Klebs  and  Koester.  In  thg  meantime  the  clinical  features  of  infective 
endocarditis,  and  its  relation  to  the  simple  or  rheumatic  endocarditis, 
were  made  the  subject  of  further  study  by  many  pathologists  and 
clinicians,  some  of  whom  will  be  referred  to  in  the  clinical  section ;  at 
present  I  will  mention  only  the  papers  by  Groodhart  (17)  and  Osier  (37). 

With  the  progress  of  bacteriology,  our  knowledge  of  the  organisms 
found  in  this  disease  has  become  more  definite ;  pure  cultures  of  them 
have  been  obtained,  and  their  behaviour  when  injected  into  animals  defi- 
nitely followed.  A  series  of  important  observations  were  published 
between  the  years  1885  and  1888,  amongst  others  by  the  following  ob- 
servers:— Wyssokowisch,  Cornil  and  Babes  (9),  Eibbert,  Senger,  Bram- 
well,  Netter  (35),  Prudden,  E.  Frankel  and  Saenger,  Stern  and  Hirschler, 
Weichselbaum,  Dreschfeld,  0.  E-osenbach.  Of  the  papers  treating  on 
the  etiology  of  this  disease  published  since  1888  I  may  cite  those  of 
F.  Taylor,  Gilbert  and  Lion,  G.  Lion,  Roux  and  Josseraut,  and  Dessy. 

If  we  summarise  the  results  of  these  and  some  other  observations  we 
arrive  at  the  following  data :  — 

1.  That  in  nearly  all  the  cases  of  infective  endocarditis,  whether 
ulcerative  or  not,  microbes  were  found. 


INFECTIVE  ENDOCARDITIS  629 

2.  That  in  most  cases  only  one  organism  was  found,  but  in  a  few 
(Weichselbaum,  Stern,  Hirschler,  Frankel,  etc.)  more  than  one. 

3.  That  the  organism  found  was  not  the  same  in  all.  In  many  cases 
an  organism  was  found  which  occurs  in  other  infectious  diseases,  whilst 
in  some  an  organism  occurred  not  hitherto  found  in  other  diseases. 

The  organisms  belonging  to  the  first  group  were :  the  streptococcus 
pyogenes  (including  the  streptococcus  of  erysipelas)  ;  the  staphylococcus 
pyogenes  aureus,  the  staphylococcus  pyogenes  albus ;  the  pneumococcus 
of  Frankel  and  the  pneumobacillus  of  Friedlander;  the  typhoid  bacillus 
(16) ;  the  bacillus  of  tuberculosis  (25,  8,  20)  ;  the  bacillus  of  diphtheria 
(21)  ;  the  gonococcus  (29). 

The  organisms- belonging  to  the  second  group  were  bacillus  endocardi- 
tis griseus  (Weichselbaum  and  Netter)  ;  micrococcus  endocarditis  rugatus 
(Weichselbaum)  ;  bacillus  endocarditis  capsulatus  (Weichselbaum)  ;  ba- 
cillus immobilis  et  foetidus  (Frankel  and  Sanger),  and  the  bacillus  of  Gil- 
bert and  Lion  (besides  a  few  others  with  less  definite  specific  characters). 

4.  In  most  cases  the  microbe  found  in  the  diseased  valves  was  also 
met  with  in  such  secondary  deposits  as  infarcts  and  metastatic  abscesses. 

5.  The  organisms  most  frequently  found  were  the  streptococcus  pyo- 
genes, the  staphylococcus  pyogenes  aureus,  and  the  pneumococcus.  The 
first  two  were  found  chiefly  in  cases  in  which  the  endocarditis  was  pri- 
mary, in  cases  of  puerperal  diseases,  of  pysemia  and  septicaemia  (wounds, 
abscesses,  osteo-myelitis,  etc.),  and  especially  in  those  cases  in  which 
the  infective  endocarditis  had  attacked  valves  already  affected  with 
chronic  rheumatic  endocarditis. 

The  pneumococcus  has  been  found  mostly  in  cases  where  croupous 
pneumonia  was  present,  and  in  some  of  meningitis  without  pneumonia. 
As  streptococci  and  staphylococci  have  also  been  found  in  the  diseased 
valves  when  the  primary  disease  was  enteric  fever,  diphtheria,  gonor- 
rhoea, and  so  forth,  it  is  evident  that  sometimes  the  endocarditis  is  due 
to  a  mixed  infection. 

6.  Experimental  investigations  on  animals  have  led  to  diverse  results. 
Particles  of  the  diseased  valves  inserted  into  the  subcutaneous  tissue, 
into  the  peritoneal  cavity,  or  into  the  anterior  chamber  of  the  eye,  have 
sometimes  produced  no  effect;  but  often  they  have  given  rise  to  local 
abscesses.  Injections  of  pure  cultivations  into  the  peritoneum  or  under 
the  skin  sometimes  produced  no  results ;  at  other  times  they  gave  rise 
to  marked  septic  symptoms  and  lesions. 

Endocarditic  lesions  have  been  produced  by  the  injection  into  animals 
(rabbits  and  dogs  have  most  frequently  been  used  for  this  purpose)  of 
pure  cultivations  of  the  organisms  found  on  the  diseased  valves  in 
cases  of  malignant  endocarditis.  Some  observers  —  Kibbert,  Ferret  and 
E-odet,  Bonome,  Dreschfeld,  Mannaberg,  Gilbert  and  Lion,  Houx  and 
Josseraut,  and  Vaillard  —  by  injecting  pure  cultivations  into  the  jugular 
vein  of  rabbits,  succeeded,  without  Y>i"eviously  injuring  the  valves,  in 
producing  inflammatory  changes  Vv^itli  or  without  ulcerations  in  the 
aortic  valves,  and  often  also  on  the  mitral  and  tricuspid  valves;  and  in 


630  SYSTEM   OF  MEDICINE 

the  valvular  deposits  masses  of  the  organisms  of  the  pure  culture  were 
found  both  on  the  surface,  in  the  deeper  layers  of  the  deposits,  and,  in  some 
few  cases  also,  inside  the  capillaries  and  small  arteries  of  the  inflamed 
valves.  Other  changes  found  in  the  animals  experimented  upon  were  :  — 
Enlargement  of  the  spleen,  metastatic  infarcts,  and  haemorrhage  into  the 
brain.  These  various  lesions,  though  evidently  the  result  of  the  mi- 
crobes, were,  however,  by  no  means  uniformly  found.  Gilbert  and  Lion, 
by  the  injection  of  a  peculiar  bacillus  found  in  a  case  of  infective  endo- 
carditis into  a  vein  of  the  ear  in  rabbits,  produced  marked  endocarditis 
with  many  secondary  changes  (softening  and  haemorrhages  in  the  central 
nervous  system). 

The  majority  of  experimenters,  however  (Rosenbach,  Ortli,  Frankel  and 
Saenger,  Weichselbaum,  etc.),  only  succeeded  in  producing  endocarditis 
by  injuring  the  aortic  valves  shortly  before  injecting  the  cultures  into  the 
jugular  vein.  The  aortic  valves  were  injured  by  introducing  a  sterilised 
stylet  through  the  carotid  into  the  left  ventricle,  a  method  first  made 
use  of  by  Rosenbach  (43).  vSecondary  or  metastatic  deposits  of  mici-obic 
origin  were  also  found  in  these  animals,  together  with  other  changes  such 
as  enlargement  of  the  spleen,  fibrinous  deposits  in  the  pleura,  etc. 

7.  The  examination  dm-ing  life  of  the  blood  of  persons  suffering 
from  infective  endocarditis  has  shown  in  a  few  cases,  especially  on  the 
application  of  certain  methods  which  will  be  given  in  the  clinical  sec- 
tion, the  presence  of  microbes  of  the  septic  kind. 

As  regards  the  nature  of  infective  endocarditis  the  conclusions  which 
we  may  draw  from  the  above  data  are :  — 

(i.)  Infective  endocarditis  is  a  disease  due  to  micro-organisms. 

(ii.)  This  disease  is  not  produced  by  one  specific  microbe  only ;  other 
organisms,  separately  or  together,  may  give  rise  to  it. 

(iii.)  The  organisms  which  most  frequently  are  the  cause  of  the 
disease  belong  to  the  septic  and  pyogenetic  type  (streptococci  and 
staphylococci. 

(iv.)  Of  other  organisms,  the  diplococcus  of  pneumonia  often  gives 
rise  to  infective  endocarditis;  the  specific  organisms  of  enteric  fever, 
gonorrhoea,  diphtheria,  tuberculosis  do  so  very  rarely :  infective  endo- 
carditis occurring  in  the  course  of  any  one  of  these  affections,  or  found 
in  valves  already  the  seat  of  chronic  endocarditis  or  atheroma,  is  due 
to  septic  organisms,  and  must  be  looked  upon  as  a  mixed  infection  com- 
plicating these  diseases. 

(v.)  The  organisms  more  readily  attack  valves  weakened  or  altered 
by  disease. 

(vi.)  Some  of  the  microbes  found  in  infective  endocarditis  are  also 
found  in  the  rheumatic  or  verrucose  endocarditis. 

Etiologically  we  may  distinguish  the  following  types  of  infective 
endocarditis :  — 

(a)  Primary  infective  endocarditis. 

(6)  Infective  endocarditis  as  a  complication  of  septic  disease  (pyae- 
mia, septicaemia,  puerperal  affections,  traumatism). 


•  INFECTIVE   ENDOCARDITIS  631 

(c)  Infective  endocarditis  as  a  complication  of  pneumonia  or  menin- 
gitis, and  due  to  the  diplococcus  pneumoniae. 

(d)  Infective  endocarditis  as  a  mixed  infection  due  to  septic  organ- 
isms secondary  to  acute  infectious  fevers,  or  secondary  to  rheumatic 
endocarditis  or  sclerotic  conditions  of  the  valves. 

Remote  Causes.  —  1.  A  debilitated  state  of  the  system.  Though 
infective  endocarditis  occasionally  attacks  persons  of  sound  constitution 
and  in  good  health,  it  is  more  often  noticed  in  debilitated  persons,  in 
drunkards,  in  persons  suffering  from  nervous  depression  and  the  like,  or 
suffering  from  such  chronic  exhaustive  diseases  as  cirrhosis  of  the  liver 
(45a). 

2.  The  presence  of  an  infectious  disease.  This  point  I  need  scarcely 
dwell  upon  again.  Besides  the  various  affections,  septic  and  non-septic, 
already  mentioned,  we  may  note  also  dysentery,  malaria,  small-pox,  scarlet 
fever,  epidemic  inHuenza  (Fiessinger)  as  diseases  which,  by  lessening  the 
resistance  of  the  body,  favour  the  entrance  and  growth  of  the  septic 
organisms.  Syphilis  does  not  appear  to  enter  into  the  causation,  and  the 
endocarditis  accompanying  it  is  more  of  a  sclerotic  and  fibrous  nature 
with  fibrous  deposits  in  the  myocardium. 

3.  During  pregnancy  and  the  puerperal  state  infective  endocarditis 
has  repeatedly  been  observed,  especially  in  the  presence  of  a  septic  or 
pyaemic  affection  of  the  uterus  or  its  appendages. 

4.  Acute  rheumatic  arthritis,  though  much  more  commonly  associ- 
ated with  rheumatic  or  verrucose  endocarditis,  occasionally  gives  rise  to 
malignant  endocarditis.  Dr.  Ogle  recorded  three  cases,  and  others  have 
been  mentioned  by  Osier,  Peter,  Burkart,  Fernet. 

5.  Chronic  valvular  affection  of  the  heart,  the  result  of  chronic 
endocarditis  or  produced  by  sclerotic  changes,  commonly  enters  into  the 
causation.  Of  sixty-nine  cases  of  infective  endocarditis,  Dr.  Coupland 
noticed  sixty-one  in  which  the  valves  had  been  previously  affected,  and 
Osier  states  that  in  three-fourths  of  his  cases  sclerotic  changes  persisted 
in  the  valves.  (To  avoid  repetition,  I  will  give  the  results  of  my  own 
analysis  when,  in  a  later  article,  I  consider  the  clinical  aspects  of  this 
form  of  endocarditis.) 

6.  Gallstones,  with  or  without  suppuration  in  the  biliary  passages, 
have  occasionally  been  known  to  give  rise  to  infective  endocarditis.  As 
yet  seven  cases  only  have  been  published,  but  I  may  mention  another 
which  occurred  in  a  patient  under  the  care  of  my  colleague  Dr.  Steell. 
Murchison  had  already  noticed  this  association  in  his  work  on  Diseases  of 
the  Liver.  Other  cases  have  been  described  by  Jaccoud,  by  Mathieu  and 
Malibran,  Ijy  Is  etter  and  Martha,  and  more  recently  by  Leva,  who  gives 
the  literature  on  this  subject.  ISTetter  and  Martha  (36)  found  a  small 
bacillus  in  the  biliary  abscesses,  and  also  in  the  endocarditic  deposits.  As 
the  bacterium  coli  commune  is  occasionally  found  in  calculous  affections 
of  the  biliary  apparatus,  the  connection  between  cholelithiasis  and  infec- 
tive endocarditis,  even  when  there  is  no  suppuration,  is  easily  understood. 

7.  That  chorea,  which  is  so  closely  connected  with  rheumatic  endo- 


632  SYSTEM  OF  MEDICINE 

carditis,  may  be  associated  with  infective  endocarditis,  is  shown  by  the 
following  case  which  came  \mder  my  care  about  two  years  ago.  A  boy, 
aged  11,  was  taken  into  the  Manchester  Infirmary  suffering  from  chorea ; 
there  was  no  history  of  rheumatism,  and,  on  admission,  there  were  no 
signs  of  endocarditis.  A  Aveek  after  admission  he  began  to  be  feverish, 
and  a  loud  mitral  systolic  bruit  appeared ;  a  fortnight  later  he  showed 
signs  of  a  cerebral  affection  (severe  headache,  delirium,  optic  neuritis, 
hemiparesis).  At  the  post-mortem  examination  infective  ulcerative  endo- 
carditis of  recent  date,  and  a  small  abscess  of  the  brain  with  suppurative 
meningitis,  were  found.  The  valves  showed  no  signs  of  chronic  disease. 
Barkley  (39)  gives  a  case  of  chorea,  terminating  fatally,  in  which 
endocarditis,  abscess  of  the  parotid,  and  broncho-pneumonia  were  found ; 
the  endocarditis  in  this  case  may  possibly  have  been  secondary  to  the 
pneumonia. 

8.  Traumatism,  apart  from  external  w^ounds  and  injuries,  may  give 
rise  to  infective  endocarditis  in  another  way,  namely,  by  an  injury 
causing  rupture  of  a  heart  valve.  Biggs  gives  a  case  in  which  the 
aortic  valves  Avere  ruptured  by  a  fall,  and  infective  endocarditis  super- 
vened. A  similar  and  very  interesting  case  came  under  my  notice.  A 
gentleman,  a  patient  of  Dr.  Stott  of  Haslingden,  had  been  under  obser- 
vation for  several  years  on  account  of  slight  albuminuria,  for  which  he 
periodically  consulted  Sir  William  Roberts.  He  met  with  a  severe  bodily 
strain,  and  shortly  afterwards,  not  feeling  well,  consulted  Sir  William 
Roberts  again,  who  then  for  the  first  time  detected  a  loud  aortic  diastolic 
bruit.  He  returned  to  Haslingden  and,  some  short  time  after  whilst 
out  shooting  in  the  month  of  September,  he  began  to  suffer  from  symp- 
toms of  malignant  endocarditis  (repeated  rigors,  which  recurred  almost 
daily,  intermittent  pyrexia  in  which  the  temperature  rose  to  105°  F., 
and  eventually  embolism  of  the  posterior  tibial  artery)  :  from  this  state 
after  a  time  he  recovered.  He  is  now  in  the  enjoyment  of  good  health, 
though  the  loud  diastolic  aortic  bruit  is  still  present. 

9.  Climatic  conditions  appear  to  me  to  have  some  influence  in  this 
matter.  I  have  noticed  that  cases  of  infective  endocarditis  occur  more 
frequently  during  the  autumn ;  and  in  several  cases  the  patient  before 
the  attack  had  spent  some  time  in  a  swampy  or  marshy  district.  De- 
caying vegetable  matter  may  have  something  to  do  with  the  outbreak 
of  the  disease  in  these  cases. 

10.  Infective  endocarditis  occurs  especially  between  the  ages  of  20 
and  40.  It  is  very  rare  in  older  people,  and,  according  to  Osier,  it  is 
also  very  rare  in  children  (3  to  4  out  of  209  collected  cases).  From  my 
own  observations  infective  endocarditis  in  children  would  appear  not 
to  be  so  rare  as  this  estimate  would  indicate.  Men  are  more  frequently 
affected  than  women. 

The  paths  of  entrance  of  the  microbes,  as  in  other  septic  diseases, 
vary  in  the  different  groups  of  cases.  We  may  notice  as  the  chief 
portals  :  — 

(a)    The  skin  and  subcutaneous  tissue.     Many  of  the  septic  cases, 


INFECTIVE  ENDOCARDITIS  633 

following  abrasion  or  ulceration  of  the  skin,  belong  to  this  group ;  and 
likewise  the  cases  of  infective  endocarditis  following  furuncles,  carbiin- 
cles,  gangrene,  erysipelas,  and  the  like.  Considering  how  slight  an  ab- 
rasion may_  sometimes  be  followed  by  septic  infection,  it  is  possible  that 
in  some  cases  of  the  so-called  "primary"  infective  endocarditis  the  germs 
may  have  entered  the  system  in  this  way, 

(&)  The  osseous  system,  as  in  osteomyelitis  and  otitis  media. 

(c)  The  mucous  membranes  of  the  digestive  tract.  Ulceration  of  the 
intestines  explains  the  occurrence  of  septic  endocarditis  after  enteric  fever 
and  dysentery.  In  several  of  the  recorded  cases,  besides  the  idceration  in 
the  intestines,  there  was  an  old  lesion  of  the  valves.  Gangrenous  stomati- 
tis and  ulcers  on  the  tongue  and  lip  are  occasionally  quoted  (Brissaud, 
Gilbert)  as  primary  channels  of  entrance.  Probably  the  tonsils,  which 
are  so  often  affected  in  rhuematic  endocarditis,  may  occasionally  serve  as 
the  means  of  entrance,  and  thus  again  some  of  the  so-called  "  primary 
cases  "  may  be  explained. 

(d)  Of  the  biliary  passages  we  have  already  spoken. 

(e)  The  genito-urinary  organs.  The  frequent  occurrence  of  infective 
endocarditis  in  puerperal  disease  and  after  abortions  has  been  noted ;  the 
channels  along  which  the  infection  travels  are  the  uterine  lymphatics  and 
veins.  In  men  the  mucoiis  membrane  of  the  urinary  tract  may  form  the 
starting-point,  as  in  gonorrhoea,  or  bladder  and  kidney  affections,  which 
bave  sometimes  been  followed  by  infective  endocarditis. 

(/)  Respiratory  tract.  We  know  that  many  infective  germs  may 
pass  into  the  blood  through  the  respiratory  passages,  often  after  having 
caused  such  changes  in  the  epithelium  as  facilitate  their  entrance  into  the 
blood.  But  it  may  also  be  admitted  that  germs  may  pass  through  the 
/.ungs,  and  find  their  way  into  the  circulation  without  any  previous 
^-"jury. 

The  frequent  association  of  infective  endocarditis  with  pneumonia 
aeed  scarcely  be  mentioned  again :  the  disease  has  also  been  noted  in 
bronchiectasis  by  Thiroloix.  The  microbes,  having  reached  the  blood,  find 
access  to  the  valves  (where  they  produce  more  or  less  extensive  lesions  to 
be  described  hereafter  under  the  pathological  anatomy  of  the  disease) 
either  on  their  free  surface  by  deposition  from  the  circulating  blood  —  a 
view  first  set  forth  by  Virchow  —  or  by  way  of  the  vessels  of  the  valves 
in  which  they  form  small  emboli,  and  thence  penetrate  into  the  tissue  and 
to  the  surface  —  a  view  already  attributed  to  Koster.  Most  observers  are 
inclined  to  adopt  Virchow's  opinion,  one  strongly  supported  by  experi- 
mental pathology  (seeing  that  infective  endocarditis  so  often  attacks 
valves  already  diseased),  and  by  argumentsbasedupon  the  paucity  of  blood- 
vessels and  capillaries  in  the  valves  even  when  inflamed.  On  studying 
the  distribution  of  the  micro-organisms  in  sections  of  the  diseased  valves, 
I  have  been  struck  by  the  gradual  diminution  in  their  number  from  the 
surface  of  the  valve  inwards ;  but  this  may  well  be  due  to  the  more  favour- 
able conditions  on  the  surface  of  the  valve  for  their  growth. 

Several  observers,  however  (Cornil  and  Babes,  Koster  and  others), 


634  SYSTEM   OF  MEDICLVE 


have  described  numerous  emboli,  consisting  almost  entirely  of  microbes 
in  the  vessels  of  the  inflamed  valves.  There  is  no  reason  why  we  should 
not  accept  both  views  of  the  processes. 

Chemical  Pathology.  —  On  this  subject,  which  is  sure  to  become  an 
important  one  in  all  bacteriological  diseases,  we  have  to  record  the 
observations  of  Sidney  Martin,  who,  in  connection  with  his  important 
researches  on  diphtheria,  studied  also  the  action  of  the  chemical  poisons 
in  malignant  endocarditis  and  in  anthrax.  A  chemical  examination  of  the 
blood  and  of  the  spleen  (by  his  method)  from  a  case  of  infective  endo- 
carditis, in  which  a  staphylococcus,  which  could  be  cultivated,  was  found 
in  the  diseasedvalves,  showed  the  presenceof  two  bodies — aproteid(proto- 
and  deutero-albumose)  and  a  non-proteid  product  of  strong  acid  reaction. 
The  albumoses  when  injected  into  animals  produced  fever,  and  retarded 
the  coagulation  of  the  blood ;  and  the  fever  increased  with  the  quantity 
injected :  the  albumoses  from  anthrax  were  more  toxic,  and  caused  greater 
loss  of  weight  in  the  animal.  The  post-mortem  examination  of  the  an- 
imals that  died,  or  were  killed,  showed  that  no  pathogenetic  organism 
was  present ;  when  a  large  single  dose  of  the  albumoses  was  injected  into 
the  animal  fatty  degeneration  of  the  heart  was  found  after  death. 

Julius  Dreschfeld. 

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KiRKES,  Stenhouse.  Edin.  Med.  and  Surg.  Journal,  vol.  xviii.  1853,  p.  Hi). — 23. 
Klebs.  Archiv  f.  experim.  Pathol,  vols.  iv.  and  ix.  p.  52.  —  24.  Koester.  Virchow's 
Archiv,  vol.  Ixxii.  p.  257.  —  25.  Kundrat.  Wiener  med.  Wochen.  1883.  —  26. 
Lancereaux.  Soc.  de  Biologic,  1862.  —  27.  Lehmann  and  Van  Deventer.  Wck- 
blad  von  det.  Ned^r lands ch  Tidjschr.  1875. — 28.  Leva.  Deufsch.  med.  Woch.  1892, 
p.  228.-29.  Leyden.  Deutsche  med.  Wochen.  189.3,  No.  21;  1894,  p.  913.-30. 
Lion,  G.  "Essai  sur  la  nature  des  endocardites  infectieuses,"  Thess  de  Paris,  1890. 
—  31.  Litten.  Zeitsch.  f.  klin.  Med.  vol.  ii.  p.  378.  —  32.  Mannabebg.  Soc.  des 
sciences  mid.  de  Lyon,  1891.  —  33.  Martin,  Sidney.  Local  Government  Renort  for 
1891-92,  p.  147.  — 34.  Meier,  R.  Virchow's  Archiv,  vol.  Ixii.  p.  145. — .35.  Netter. 
Arch,  de  Physiol,  norm,  et  path.  1880,  vol.  viii.  p.  107;  and  Arch,  ginir.  dz  mid. 
1887.  —  36.  Netter  and  Martha.  Arch,  de  Phys.  normal  et  path.  1886. — 37. 
OsLER.  "  Goulstonian  Lectures,"  Brit.  Med.  Jour.  1885,  vol.  i.  p.  467.  —  38.  Perret 
and  RoDET.  Arch.  Ital.  de  biol.  1887. — 39.  Petit  (quotes  Barkley).  "Endo- 
carditis,"   Traiti  de  mddicine,  vol.  v.  p.  148.  —  40.  Prudden.     The  Amer.  Jour,  of 


PUERPERAL   SEPTIC  DISEASE  635 

ilfed.  (Sci.  1887.  —  41.  Purcer.  Z)M&Zin  Jomj-.  o/ilfecZ.  Science,  1877,  p.  553.  —  42.  Ribbert. 
Fortsch.  der  Med.  1886,  No.  1.  —  43.  Rosbnbach,  O.  Arch.f.  exper.  Path.  vol.  ix. ; 
Deiitache  ined.  Wochensch.  1887,  Nos.  32,  33;  article  "  Herz  Krankheiter  "  in  Eulenberg's 
Real  encyclopxlia  ;  and  Breslauer  lirztllche  Zeitsch.  1881. — 44.  Roux  and  Josserau't. 
Soc.  des  sciences  med.  de  Lyon,  1891;  and  Arch,  de  iiUd.  exper.  No.  3,  1S92.  —  45. 
Senger.  Arch.f.  exp.  Path.  vol.  xx.  p.  389;  and  Deutsche  med.  Wochen.  1886,  No.  4. — 
45a.  Steell.  Med.  Chronicle,  1892.  —  46.  Stern  and  Hirschler.  Wien.  med.  Pi'esse, 
1887,  Nos.  27,  28.— 46a.  Taylor,  F.  Guy's  Hospital  Reports,  1891,  p.  169.  — 47.  Thiro- 
Loix.  Soc.  Anat.  Mar.  1891.  — 48.  Vaillard.  Soc.  med.  des  hopitaux,  Fev.  1890. — 49. 
ViRCHOw.  Gesammelte  Abhandlungen,  Frankfort,  1856,  p.  505;  and  Arch,  fdr  path. 
Anat.  u)id  Phys.  lS5i>. — 50.  Wedel.  "  Mycosis  Endocardii,"  Z>wserta<ion.  Berlin,  1873. 
—  51.  Weichselbaum.  Wiener,  m.ed.  Wochen.  1885,  No.  41;  Med.  Jahrh.  1886;  and 
Ziegler's  Beitriige  zur  path.  Anat.  1888,  vol.  iv.  p.  127.  —  52.  Wilks,  Dr.  Guy's  Hosp. 
Reports,  1870,  vol.  xv. — 53.  Winge.  Nordisk.  Med.  Arkiv,  vol.  ii.  1870. — 54.  Wysso- 
KowiscH.  (Jentralbl.f.  med.  Wissensch.  1885,  No.  33;  and  Virchow's  Archiv,  1886,  vol. 
ciii.  pp.  301,  333. 

J.  D. 


PUERPEEAL   SEPTIC    DISEASE  ^ 

History.  —  Before  the  comparatively  recent  recognition  of  the  influence 
of  infective  germs  in  the  causation  of  puerperal  septic  disease,  the  views 
entertained  of  the  nature  of  this  terrible  scourge  of  obstetric  practice  were 
most  chaotic  and  puzzling.  Of  course  the  frequency  of  the  disease  in 
practice  had  ensured  attention  to  the  subject  from  the  earliest  times,  and 
explanations  were  almost  endless ;  generally  some  prominent  symptom 
was  supposed  alone  to  indicate  the  origin  of  the  malady.  For  instance, 
Hippocrates,  Galen,  and  many  of  the  older  authors,  who  distinctly 
recognised  the  disease,  supposed  it  to  be  caused  by  suppression  of 
the  lochia,  —  an  opinion  which  was  maintained  by  many  later  obstetri- 
cians, such  as  Smellie,  Denman  and  others.  In  Prance  the  view  of 
Puzos  that  the  disease  was  due  to  milk  metastasis  was  generally  accepted. 
This  opinion  was  obviously  derived  from  a  mistaken  theory  of  the 
nature  of  the  peritoneal  exudations  so  frequently  observed  after  death. 
Similar  errors  prevailed  in  this  country,  where  the  disease  was  attrib- 
uted to  local  inflammation ;  thus  one  attributed  it  to  peritonitis,  another 
to  metroperitonitis,  to  metritis,  or  to  inflammation  of  the  veins  and 
lymphatics.  Other  authors  contended  that  puerperal  fever  was  an 
acute  specific  fever,  occurring  in  lying-in  women  only  ;  this  view  was 
stoutly  maintained  by  Fordyce  Barker  in  his  well-known  work  on  The 
Puerperal  Diseases. 

It  is  not  surprising  that  in  the  face  of  such  various  and  contradictory 
views  our  knowledge  of  this  fatal  malady  was  narrow  and  unsatisfactory. 
Various  observers,  however,  from  time  to  time  came  to  have  inklings 
of  the   true   nature   of   the   disease,  although  these   truths   are  now 

1  It  seemed  well  to  include  this  short  article  in  the  System  of  Medicine,  as  the  general 
physician  has  often  to  treat  cases  of  puerperal  septicseraia.  — Ed, 


636  SYSl'EM   OF  MEDICINE 

only  recognised  in  the  light  of  our  recent  knowledge.  The  analogy  of 
the  interior  of  the  uterus  after  delivery  to  the  stump  of  an  amputated 
limb  (lirst  pointed  out  by  Harvey,  and  subsequently  insisted  upon  by 
Van  Swieten,  Cruveilhier  and  others)  was  an  approach  at  least  to  a  rec- 
oguition  of  the  identity  in  this  respect  of  a  puerperal  and  a  surgical 
patient,  which  is  the  essential  fact  in  the  interpretation  of  septic  disease 
in  childbirth ;  but  the  still  more  important  lesions  of  continuity  about  the 
cervix,  vagina  and  vulva,  through  which  the  absorption  of  the  infectious 
materials  so  readily  occurs,  were  not  then  uoted.  Some,  however,  suggested 
that  the  disease  was  due  to  the  introduction  of  animal  poisons  into  the 
system  after  delivery,  and  a  subsequent  vitiation  of  the  blood ;  as,  for 
example,  Kirkland,  who  in  1774  wrote,  "  It  sometimes  happens  that  coag- 
ulated blood  lodges  in  the  uterus  after  delivery,  and  putrefying  from 
access  of  air,  forms  an  active  poison,  is  in  part  absorbed,  and  brings  on 
putrid  fever."    But  such  passing  surmises  attracted  little  attention. 

The  enormous  mortality  occurring  in  Lying-in  Institutions,  both  in 
this  country  and  abroad,  could  not  fail  to  startle  and  shock  those  who 
knew  the  facts.  When  we  look  back  on  what  occurred  it  seems  almost 
incredible.  It  will  probably  be  now  generally  admitted  that  it  is  safer 
for  a  lying-in  woman  to  be  delivered  in  a  well-conducted  Lying-in  Hos- 
pital than  in  the  most  luxurious  house,  of  which  the  hygiene  and  ar- 
rangements are  not  thoroughly  within  our  control.  Yet  not  very  long 
since  in  these  very  same  buildings  the  mortality  was  at  times  so  great 
that  every  woman  entering  them  held  her  life  in  her  hand,  and  ran  a 
risk  not  less  than  that  of  some  grave  surgical  operation.  This  is 
no  exaggerated  statement ;  the  history  of  obstetrics  is  full  of  accounts 
of  these  so-called  epidemics  of  puerperal  fever,  now  happily  unknown,  in 
which  the  disease  spread  from  one  case  to  another,  or  rather  was  conveyed 
from  one  case  to  another,  with  appalling  frequency.  Thus  in  the  years 
1760,  1768  and  1770,  it  prevailed  in  London  to  such  an  extent  that  in 
some  of  the  Lying-in  Institutions  nearly  all  the  patients  died.  Of  the 
Edinburgh  Infirmary  it  is  said  that  "  almost  every  woman,  as  soon  as 
she  was  delivered,  or  perhaps  about  twenty-four  hours  after,  was  seized 
with  it,  and  all  of  them  died."  In  the  large  Maternity  Hospitals  of  the 
Continent  the  mortality  was  equally  great,  and  outbreaks  of  puerperal 
disease  occurred  in  them  all,  even  clown  to  comparatively  recent  times, 
when  they  were  checked  by  the  general  introduction  of  antiseptic  pre- 
cautions.    The  history  of  medicine  records  no  such  triumph  as  this. 

The  starting-point  of  our  present  estimate  of  the  nature  of  puerperal 
septic  disease  was  the  well-known,  but  at  the  time  little  appreciated 
work  of  Semmelweiss  who,  in  1847,  was  the  first  to  show  clearly  that 
puerperal  septic  disease  was  directly  conveyed  to  the  patient  by  hands, 
sponges  and  the  like,  defiled  by  decomposing  animal  matter ;  and  was 
the  first  also  to  point  out  the  influence  of  cleanliness  and  antisepsis 
in  destroying  puerperal  contagion,  by  showing  that  students  who  washed 
their  hands  in  solutions  of  chloride  of  lime  after  handling  infective 
matter,  did  not  convey  the  disease  in  anything  like  the  same  measure  as 


PUERPERAL   SEPTIC  DISEASE  637 

those  who  neglected  such  precautions.  After  years  of  calumny  and 
neglect  his  epoch-making  observations  are  now  estimated  at  their  proper 
value.  The  practical  identity  of  surgical  and  puerperal  septicsemia  was 
very  clearly  pointed  out  by  Sir  James  Simpson  in  his  interesting  paper 
"  On  the  Analogy  between  Puerperal  and  Surgical  Fever,"  which  was  far 
in  advance  of  the  teaching  of  the  day.  It  is  interesting  to  note  how  he 
foreshadowed  the  enormous  gains  both  to  surgery  and  midwifery  which 
have  followed  the  general  adoj)tion  of  the  principles  of  antisepticism. 
"I  do  believe,"  he  says,  "  that  if  any  man  should  ever  have  the  good 
fortune  to  detect,  or  suggest  any  simple  and  practical  measures  to  avert 
and  prevent,  or  to  mitigate  and  cure  surgical  and  puerperal  fever,  he 
would,  in  doing  so,  confer  one  of  the  greatest  of  all  possible  benefits 
upon  the  advancement  of  surgery  and  midwifery,  and  be  the  means  of 
saving  numerous  lives  in  operative  and  obstetric  practice.  Nor  does  it 
seem  utterly  hopeless  to  expect  the  possible  detection  of  some  such 
measures  in  the  way  of  prevention,  at  least,  if  not  in  the  way  of  cure." 
Happily  the  man  lias  been  found,  with  the  results,  as  regards  the 
mortality  of  public  Lying-in  Institutions,  which  Simpson  predicted,  and 
all  the  world  knows. 

Unfortunately,  as  Dr.  Boxall  has  clearly  shown,  as  yet  there  is  no 
corresponding  improvement  in  the  general  puerperal  mortality  of  private 
practice.  It  takes  a  long  time  for  the  paramount  importance  of  the 
somewhat  irksome  details  of  antiseptic  midwifery  to  be  generally  ap- 
preciated. To  the  bulk  of  the  practitioners  educated  before  the  new 
doctrines  were  taught  in  the  schools,  such  notions  probably  appear  new- 
fangled and  useless,  and  the  uneducated  midwives  practising  all  over 
the  country  probably  never  even  heard  of  them.  In  a  decade  or  more, 
when  the  students  of  to-day  are  in  active  work,  there  is  good  reason 
for  hoping  that  the  general  decrease  in  the  mortality  and  morbidity 
of  childbirth  which  has  followed  the  introduction  of  strict  clean- 
liness and  asepsis  into  Lying-in  Hospitals  will  be  apparent  in  general 
practice  also. 

The  recent  development  of  bacteriology,  and  the  recognition  of  the 
existence  of  infective  germs  which  may  be  conveyed  to  the  lying-in 
woman  in  various  ways,  have  entirely  altered  the  views  formerly  held 
of  the  nature  of  the  puerperal  fevers,  whose  identity  Avith  the  septic 
diseases  following  surgical  operations  is  practically  conceded.  The  risk 
now  seems  to  be,  not  that  the  influence  of  bacteria  in  producing  puerperal 
diseases  should  be  insufficiently  recognised,  but  that  causes  of  puerperal 
disease  difficult  thus  to  explain,  but  of  which  there  is  strong  clinical 
evidence,  should  be  discredited  or  disbelieved  because  they  do  not  readily 
accord  with  the  new  views.  In  this  there  is  grave  danger,  since  it  may 
lead  us  to  overlook  sources  of  disease  which  might  otherwise  be  guarded 
against  or  removed. 

Etiology.  —  It  is  generally  conceded  that  puerperal  septic  disease  is 
strictly  analogous  to  surgical  wound  fever  [wide  art.    "  Septicaemia "j.    It 


638  SYSTEM   OF  MEDICINE 

may  be  well,  however,  to  indicate  very  briefly  the  present  state  of  our 
knowledge  of  some  special  questions  concerning  the  puerperal  form  of 
the  disease. 

First,  as  regards  bacteriology,  it  seems  to  be  pretty  clearly  proved 
that  as  yet  no  one  microbe  has  been  identified  as  a  specitic'cause  of  puer- 
peral fever.  In  the  majority  of  cases  of  puerperal  septic  disease,  how- 
ever divergent  in  symptoms,  the  infection  appears  to  be  caused  by  the 
streptococcus  pyogenes,  Avhich  is  found  in  great  quantities,  and  is  prob- 
ably introduced  from  without,  on  the  hands  of  the  medical  attendant 
or  nurse,  or  by  infected  sponges,  instruments  and  the  like.  Other  micro- 
organisms, such  as  staphylococci,  gonococci,  and  (as  has  been  shown  in 
one  case)  the  bacterium  coli  have,  however,  been  detected,  and  may  be 
effective  either  alone,  or  in  combination  with  streptococci,  in  causing 
febrile  processes  in  lying-in  women ;  and  it  seems  probable  that  other 
varieties  of  pathogenetic  micro-organisms  may  have  like  effects.  Diseases 
originating  in  this  way  correspond  to  those  which  were  formerly  described 
as  "  heterogenetic,"  the  sources  of  infection  being  external.  It  is  to 
be  ncrted  that  these  same  varieties  of  micro-organisms  are  found  in 
erysipelas,  certain  sore  throats,  and  surgical  wound  fever.  There  is, 
indeed,  an  important  class  of  puerperal  diseases,  originating  in  the 
decomposition  of  portions  of  organic  matters  in  the  genital  tract  (such 
as  blood-clots,  detached  portions  of  placentae,  membranes,  and  the  like), 
which  were  formerly  described  as  "  autogenetic  " ;  it  is  pretty  clear,  how- 
ever, that  this  term  is  not  strictly  applicable  to  cases  of  this  kind,  for 
had  not  these  retained  matters  themselves  become  infected  from  Avithout, 
no  septic  mischief  would  have  resulted.  It  has  been  supposed  that 
cases  of  this  kind  are  "  saprsemic,"  the  mischief  arising  from  the  absorp- 
tion of  poisonous  ptomaines  resulting  from  their  decomposition:  it  is, 
however,  recently  contended  that  saprsemia  of  this  kind  is  not  by  any 
means  so  common  as  has  been  supposed ;  pure  cultivations  of  strepto- 
cocci are  generally  to  be  made  in  these  cases,  and  they  are  probably  due 
to  infection  from  ordinary  pus  producing  organisms. 

Whether  strictly  "  autogenetic  "  poisoning  may  occur  in  puerperal 
women,  from  pathogenetic  organisms  existing  in  the  genital  tract  before 
delivery,  is  a  question  which  has  been  hotly  discussed.  It  is  supposed 
that  such  organisms,  having  no  effect  during  pregnancy,  may  become 
dangerous  when  absorbed  through  the  lesions  of  continuity  occurring 
during  labour.  A  large  number  of  observers  have  examined  the  vaginal 
and  uterine  secretions  in  women  after  delivery,  and  those  of  the  vagina 
during  pregnancy.  The  general  result  is  that  both  before  and  after 
delivery  micro-organisms,  generally  streptococci,  are  to  be  found  in  the 
vaginal  secretions,  which  do  not  exist  after  delivery  in  the  uterine  dis- 
charges unless  febrile  symptoms  be  present,  when  they  are  found  in 
abundance.  This  being  so,  auto-infection  is  theoretically  possible.  It  is 
probable,  however,  that  it  is  of  rare  occurrence,  since  Leopold  and  others, 
on  abandoning  the  use  of  antiseptic  douches  before  and  during  labour, 
found  that  the  number  of  febrile  cases  in  their  practice  was  lessened  con- 
siderably. 


PUERPERAL    SEPTIC  DISEASE  639 

That  strict  antisepsis  of  hands,  instruments  and  the  like  is  of 
primary  importance  in  midwifery  practice  has  been  clearly  proved  by 
the  remarkable  results  which  have  followed  its  introduction  into  Lying-in 
Institutions  in  all  parts  of  the  world.  No  satisfactory  explanation, 
however,  has  as  yet  been  offered  of  the  extreme  susceptibility  of 
puerperal  women  to  the  influence  of  pathogenetic  micro-organisms.  It 
is  cleai'ly  not  their  absorption  through  lesions  of  continuity  in  the  gen- 
ital tract  which  is  alone  at  fault;  such  lesions  continually  occur  in 
women  who  have  undergone  operations  about  the  vagina  and  uterus, 
when  micro-organisms  must  be  present  as  they  are  after  delivery,  and 
yet  nothing  analogous  to  puerjjeral  fever  occurs.  There  must,  therefore, 
be  something  besides  the  mere  presence  of  micro-organisms,  something 
which  is  special  to  the  lying-in  woman,  which  predisposes  to  this  type  of 
infection ;  what  is  it  which  causes  her  structures  to  afford  so  favourable 
a  soil  for  the  growth  and  development  of  such  micro-organisms  as  may 
have  gained  access  to  them  ?  In  the  ansv/er  to  this  question  the  explana- 
tion of  the  proclivity  of  lying-in  women  to  septic  disease  will  no  doubt 
be  found,  but  as  yet  no  very  satisfactory  answer  can  be  given.  The 
hydraemic  condition  of  the  blood  existing  during  pregnancy,  and  the  fact 
that  immediately  after  delivery  a  quantity  of  excrementitious  matter  is 
absorbed  into  the  circulation  during  the  process  of  involution,  suggest 
themselves  as  possible  factors  in  this  susceptibility ;  but  further  investiga- 
tions in  this  direction  are  still  much  needed. 

Of  late  years  there  has  been  a  tendency  on  the  part  of  obstetricians 
to  limit  the  causes  of  puerperal  infection  to  pathogenetic  matter  conveyed 
directly  on  the  hands,  instruments  and  the  like,  and  to  minimise  the 
influence  of  contagion  conveyed  in  any  other  way.  There  appears  to  be, 
however,  strong  clinical  evidence  that  infective  material  suspended  in  the 
atmosphere  may  reach  the  patient  by  some  other  means  than  by  direct 
conveyance.  Dr.  Amand  Roiith,  in  a  discussion  on  this  matter  at  the 
Obstetrical  Society,  referred  to  a  case  occurring  in  the  wife  of  a  butcher 
who  was  confined  over  the  shop.  I  have  myself  been  called  in  to  no 
less  than  three  such  cases  in  butchers'  wives.  In  some  of  these  the  odour 
of  meat  permeated  the  whole  hoiise.  Is  it  not  probable  that  infective 
germs,  similar  to  those  which  convey  the  contagion  in  the  case  of  students 
engaged  in  dissection,  were  widely  diffused,  and  that  no  lying-in  woman 
is  safe  in  such  an  atmosphere  ? 

A  number  of  cases  have  been  brought  forward  by  m}rself  to  prove  the 
origin  of  puerperal  disease  in  defective  sanitary  surroundings.  Similar 
cases  have  been  published  by  Gueniot  and  many  others;  and  it  appears 
beyond  doubt  that  here  is  a  fertile  source  of  a  dangerous  kind  of  illness 
in  lying-in  women,  which  has  never  yet  been  clinically  distinguished 
from  puerperal  septicaemia  due  to  manual  and  like  conveyance.  Is  it 
to  be  assumed,  as  some  seem  inclined  to  assume,  that  this  illness  is  some- 
thing entirely  different  from  septicaemia,  merely  because  they  do  not 
admit  that  pathogenetic  microbes  can  be  suspended  in  the  atmosphere 
as  well  as  attached  to  examining  lingers  ?     It  has  been  suggested  that 


640  SYSTEM   OF  MEDICINE 

as  the  air  of  sewers  has  been  proved  to  be  bacteriologically  pure,  these 
cases  may  be  explained  on  the  supposition  that  sewer  air  alone  does  not 
cause  septicaemia,  but  produces,  possibly  by  some  unrecognised  ptomaine 
contained  in  it,  a  condition  peculiarly  favourable  to  the  growth  and 
absorption  of  pathogenetic  germs  after  delivery.  This  hypothesis  would 
account  for  cases,  otherwise  difficult  to  explain,  in  which  women,  who 
have  been  exposed  for  a  length  of  time  to  sewer  emanations  without  ap- 
parent mischief,  show  signs  of  septic  disease  as  soon  as  labour  has  taken 
place. 

There  is  also  good  clinical  evidence  that  a  form  of  puerperal  disease, 
hitherto  not  distinguished  from  septicaemia,  may  arise  from  the  con- 
veyance of  the  poison  of  such  zymotic  diseases  as  scarlet  fever  or 
erysipelas,  in  which  the  characteristic  symptoms  of  these  diseases  re- 
spectively are  not  present.  It  is  impossible  in  a  paper  of  this  description 
to  bring  forward  this  evidence,  but  it  exists  in  abundance.  It  has  been 
supposed  that  Dr.  Boxall's  excellent  researches  disprove  this  position. 
AVhat  Dr.  Boxall  has  proved,  and  very  conclusively,  is  that  scarlet  fever, 
and  presumably  erysipelas  and  other  forms  of  zymotic  disease,  frequently 
breed  true  in  lying-in  women,  and  run  a  normal  course.  This,  so  far  as 
I  know,  no  one  has  ever  denied.  He  has  not,  however,  proved,  although 
the  inference  has  very  generally  been  drawn,  that  such  diseases  always 
breed  true.  There  is,  indeed,  strong  evidence  to  the  contrary ;  and  it 
seems  impolitic  and  illogical  to  shut  one's  eyes  to  recorded  facts,  and 
to  say  —  as  many  do  —  because  they  do  not  fit  in  with  certain  opinions 
on  the  causation  of  puerperal  septic  disease,  "  This  is  a  mere  coincidence, 
and  in  these  special  cases  the  infection  must  have  been  conveyed  from 
some  other  source."  It  is  not  very  easy  to  explain  why  the  poison  of 
zymotic  disease  should  in  one  lying-in  woman  produce  a  typical  case  of 
the  originating  disease,  and  in  another  an  illness  indistinguishable  from 
septicaemia.  It  may  be  that  in  the  latter  case  the  channel  of  entry  is 
through  lesions  of  continuity  in  the  genital  tract.  All  I  can  now  say  is, 
that  the  evidence  of  the  origin  of  certain  forms  of  puerperal  disease  in 
this  way  is  very  weighty,  and  as  yet  has  never  been  shaken. 

Pathology.  —  The  post-mortem  signs  in  cases  of  puerperal  septicaemia 
are  so  various  as  to  render  any  complete  description  impossible.  In  the 
most  intense  form  the  patient  may  succumb  before  definite  pathological 
changes,  such  at  least  as  are  evident  to  the  naked  eye,  have  had  time  to 
appear.  There  may  then  be  little  more  to  observe  than  a  thin  altered 
condition  of  the  blood,  and  traces  of  commencing  inflammation  in  the 
veins  and  lymphatics  of  the  uterus.  Microscopically  signs  of  diffuse 
mischief  may  be  found  in  almost  all  the  tissues,  as  shown  by  granular 
infiltration  and  disintegration  of  cell  elements. 

In  the  more  chronic  cases  extensive  pathological  changes  are  found 
in  many  organs.  The  genital  organs  themselves  are  largely  implicated. 
The  vagina  will  generally  be  found  inflamed  and  oedematous,  and  any 
lacerations  about  the  perinaeumor  cervix  swollen,  especially  at  their  edges, 


PUERPERAL   SEPTIC  DISEASE  641 

and  covered  with  a  dirty  yellowish  membrane.  This  membrane  is  chiefly 
formed  of  pus  cells  and  necrosed  tissues,  and,  in  the  event  of  recovery, 
is  thrown  off,  leaving  a  healthy  granulating  surface  beneath.  The  tissues 
of  the  uterus  show  signs  of  oedematous  infiltration,  and  become  soft  and 
swollen.  The  endometrium  is  covered  with  a  purulent  debris ;  or  it  may 
become  necrotic,  and  the  underlying  tissues  bared  or  partially  destroyed 
in  portions.  The  lymphatics  are  especially  enlarged,  and  their  dilated 
cavities  filled  with  a  yellowish  fluid  consisting  of  pus  and  masses  of 
cocci.  From  them  inflammation  spreads  into  the  para-metritic  connective 
tissues  all  round  the  uterus,  between  the  folds  of  the  broad  ligaments, 
and  even  into  the  iliac  f ossee ;  and  this  may  eventually  resolve  or  may 
terminate  in  abscess.  Salpingitis  and  ovaritis  are  generally  met  with, 
and  the  canals  of  the  tubes  may  also  be  filled  with  infected  pus. 

Some  form  of  peritonitis  is  almost  always  present.  This  may  be 
limited  to  the  neighbourhood  of  the  pelvis,  and  then  the  folds  of  the 
peritoneum  are  matted  together  with  exudation.  Diffuse  general  peri- 
tonitis is  of  very  common  occurrence,  the  pathogenetic  matters  being 
conveyed  through  the  inflamed  uteriue  lymphatics,  or  along  the  tubes  to 
the  peritoneum.  Then  follow  very  various  results  of  the  peritonitic 
affection.  The  cavity  of  the  peritoneum  is  filled  with  an  offensive  serous 
fluid,  the  surfaces  of  the  intestines  are  covered  with  a  fibrinous  exuda- 
tion, their  muscular  tissues  are  swollen  and  oedematous,  and  they  are 
often  enormously  distended  with  flatus. 

Other  serous  cavities  are  often  attacked,  probably  through  the 
lymphatics  which  have  been  found  full  of  bacteria  at  great  distances 
from  the  uterus ;  and  marked  inflammations  of  the  pleurae,  the  peri- 
cardium, and  even  of  the  larger  joints  are  common. 

Thrombi  in  the  veins  may  play  an  important  part  in  the  pathology 
of  the  disease,  as  they  may  become  infected  by  bacteria  conveyed  to 
them  in  the  blood.  In  the  course  of  the  changes  naturally  occurring  in 
these  blood-clots  they  soften,  and  minute  infective  emboli  detached  from 
them  may  be  carried  to  distant  parts  of  the  body,  and  there,  becoming 
impacted,  may  give  rise  to  multiple  abscesses,  pneumonia,  and  other 
complications  of  the  septic  process. 

Symptoms. — As  puerperal  and  surgical  septicaemia  are  diie  to  like 
causes,  so  are  the  resulting  symptoms  much  alike. 

The  first  symptom  to  be  observed  is  an  initial  rigor,  which  may  be 
so  slight  as  to  escape  notice ;  but  on  inquiry  it  will  generally  be  found 
that  the  patient  had  complained  of  chilliness,  which  attracted  little 
attention  at  the  time.  This  may  occur  as  soon  as  twenty-four  hours 
after  delivery,  more  commonly  on  the  third  or  fourth  day,  and  rarely, 
if  ever,  after  a  week.  Puerperal  illnesses  commencing  later  are  of  doubt- 
ful septic  origin,  as  in  cases  in  which  the  distinct  influence  of  sewer  gas 
emanations  are  traced ;  or,  it  may  be,  that  the  initial  symptoms  were 
so  slight  as  to  escape  observation,  until  some  secondary  complication, 
such  as  pelvic  inflammation  or  phlegmasia  dolens,  appeared.     During  a 

VOL.    I  2   T 


642 


SYSTEM  OF  MEDICINE 


protracted  septic  process  fresh  rigors  may  from  time  to  time  occur,  due 
to  the  absorption  of  more  poison,  as  in  cases  in  which  putrefying  organic 
materials  remain  undisinfected  in  the  passages ;  or  in  the  pysemic  type 
of  disease,  in  which  coagula  formed  in  the  veins  soften  and  break  down, 
and  infective  emboli,  becoming  thus  detached,  are  carried  to  and  arrested 
in  distant  parts  of  the  body. 


TIME      MEMEMEMEM 


NAME.  A. S. 
AGE  30 


CONFINED 
FEB5!27:rl879 


DIED 
MARCH.  10^"         105' 


39E3I1D9 


■■■■iiia^B 

■■WJHIIH 
*:M£vaBiBBa 

IIBCI 

"iir" 


rui-3L       x^      \I2&\      \  |g4\  II6X  "°\  I^IK.       \ 

DATE     27     2  8  MARl     2       3       4-567 


Chart  2. 

Following  the  initial  rigor,  fever,  indicated  by  elevated  temperature, 
is  always  present,  and  continues  until  death  or  convalescence.  There  is 
no  very  definite  period  of  the  pyrexia,  which  varies  according  to  the 
nature  of  the  case,  the  intensity  of  the  poison,  the  occurrence  of  second- 
ary complications,  and  the  like.  In  the  accompanying  Charts,  copied 
from  my  Treatise  on  Midwifery,  these  variations  are  well  shown. 
Sometimes  (as  in  Charts  7  and  8),  it  remains  uniformly  high  —  from  102° 
up  to  104°  or  105°  —  even  during  a  protracted  illness,  until  convalescence 
or  death ;  at  other  times  (as  in  Charts  5  and  6),  it  shows  marked  remis- 
sions and  exacerbations,  the  latter  probably  being  caused  by  fresh 
absorption  of  septic  materials.    With  fever  the  pulse  is  always  frequent, 


PUERPERAL   SEPTIC  DISEASE 


643 


ranging  in  bad  cases  from  120  to  140,  and  becoming  thin,  compressible, 
and  even  imperceptible. 

The  other  symptoms  of  septicaemia  vary  considerably  with  the  type 
of  disease  which  is  present. 

In  the  most  intense  cases  (such  as  were  formerly  so  often  seen  in 
Lying-in  Hospitals,  but  now  happily  rarely  met  with),  the  patient  may 


Tl  ME    M  E:  M   E 


lHBBBfflHBBBBBI3BEIBBBi3BBBBB3 


age:  25 
CONFINED 
MAY  11'^  .    187  9 

PUERPERAL 
SEPTICAEMIA 

RECOVERY 


AN  UKiTRAPPED 
PIPE.  COMMUNICATING 
WITH  SEWER.  WAS, 
FOUND   IN    BATH     p 
CLOSE  TO  THIS     u 
PATIENT'S    BED       ^ 


12     13     14     15      16 


Chart  3. 

be  overwhelmed  from  the  first  by  the  intensity  of  the  disease.  The 
temperature  ranges  from  104°  upwards,  with  little  or  no  remission  (as 
in  Chart  8)  the  x^ulse  is  rapid,  small,  compressible,  running  up  to  140, 
or  it  may  even  become  uncountable.  The  countenance  is  sallow  and 
anxious,  and  the  tongue  dry  and  furred;  the  intelligence  as  a  rule  is 
unimpaired,  although  tov/ards  the  end  there  may  be  low  muttering 
delirium. 

In  a  type  of  disease  which  is  not  so  intense,  but  analogous  in  char- 
acter, and  in  which  the  septic  poison  is  probably  absorbed  through  the 
lymphatics,  the  symptoms  are  of  the  sanui  kind,  but  not  so  severe.     The 


644 


SYSTEM  OF  MEDICINE 


illness  generally  commences,  within  three  days ;  in  Charts  2,  6,  and  8  it 
will  be  seen  to  have  begun  on  the  second  day.  The  fever  runs  high, 
even  to  105°,  and  it  may  continue  elevated  for  three  weeks  and  up- 
wards, as  in  Chart  7.  More  frequently  the  disease  ends  in  one  way  or 
another  within  a  fortnight.  The  pulse  is  rapid,  thin  and  compressible. 
The  tongue  may  be  clean,  or  even  dry  and  cracked,  but  this  generally 

occurs  when  too  much  stim- 


AGE     24 
L/>BOUR  NATURAL 

CONFINED 
MAY  221?   IB80 

A    PIECE  OF 

DECOMPOSED 

MEMBRANE    THE 

SIZE  OF    HAND 

WASHED  OUT 

OF  HER   UTERUS  p 

AT    FIRST      ^ 

INTRAUTERINtE      j; 

INJECTION  Z 

UJ 

RAPID  RECOVERY    X 


IIbIbEE 


5BaBBBi;SgSgBBa 

■■■■MMEll 

iHMBSQ&ilaBB 

■■■■B'jHHi^^g 


lasdaBBB 
jSBB||S|||^gg.. 


BBBaBBBBBSBBB 
iBBBBBBBBB&SBB 


iQHQHQH^Hl  ulant  has  been  given.  In 
such  cases  extreme  disten- 
sion of  the  abdomen  is  usu- 
ally a  marked  symptom,  not 
due  to  peritonitic  effusion, 
but  to  paralysis  of  the  intes- 
tinal muscles,  and  to  exces- 
sive flatulent  distension.  It 
is  not,  as  a  rule,  tender  on 
pressure,  and  generally,  even 
when  the  illness  is  intense, 
the  patient  makes  no  com- 
plaint of  suffering.  The 
bowels  may  be  constipated ; 
but  sometimes,  and  as  the 
disease  makes  unfavourable 
progress,  uncontrollable  di- 
arrhoea supervenes.  Vomit- 
ing of  dark,  grumous,  coffee- 
coloured  matter  is  sometimes 
present.  The  respiration  is 
often  hurried  and  panting, 
and  if  the  pleurae  or  pericar- 
dium become  affected,  char- 
acteristic friction  sounds 
may  be  heard.  The  skin  is 
at  first  dry  and  burning,  and 
frequent  mottled  red  septic 
rashes,  of  an  erythematous 
character,  may  be  seen  about 
the  chest  and  abdomen ;  later  in  the  disease  profuse  perspirations  are  of 
frequent  occurrence.  The  intelligence  as  a  rule  is  not  much  affected :  the 
patient  may  be  dull  and  heavy,  and  she  is  generally  unconscious  of  the  peril 
in  which  she  is  placed ;  but  her  faculties  may  otherwise  be  clear  to  the  end. 
At  other  times  delirium,  but  never  of  a  very  intense  type,  may  be  present. 
The  cases  in  which  the  venous  system  is  more  especially  affected 
are,  as  a  rule,  more  protracted  in  their  course,  and  more  marked  in  the 
remissions  which  may  occur ;  the  temperature  falling  nearly  to  normal, 
and  again  rising,  after  a  fresh  rigor,  from  the  causes  already  described. 
When  the  septic  process  leads  to  perimetritis  or  parametritis  the 


iSEHHIIlHi 

jiiiliaBSBMil 


DATE     22      23     24      25     26'     27     28 


Chakt  4. 


PUERPERAL   SEPTIC  DISEASE 


645 


symptoms  are  modified  accordingly.  Much  more  abdominal  pain  is  felt, 
and  there  are  always  characteristic  local  signs  depending  on  exudation 
in  and  about  the  pelvis,  involving  the  peritoneum  or  the  connective 
tissues.  This  may  be  absorbed  if  the  case  run  a  favourable  course,  or 
the  inflammation  may  run  on  to  suppuration,  and  end  in  pelvic  abscess. 
In  the  more  purely  pyaemic  cases  we  may  have  prolonged  elevation 
of  temperature  of  a  hectic  type,   with  morning  remissions,  and  the 


SQQQQHQQQSQGIDSDBDSDBSBISSDSBO 


age:    22 

CONFINED 
THURSDAY 
MAY  6"""    1880 


rORCEPS 

LOCHIA 
FROM  T-HE  FIRST 
OFFCNSIVE.         A 

small  •  piece  of 
membrane:  was 
probably    left 

IN     UTERO. 


84     106      84     116      96      120 


Chart  5. 


eventual  formation  of  multiple  abscesses  in  various  parts  of  the  body  ; 
or  suppuration  may  occur  in  the  larger  joints.  Occasionally  there  may 
be  general  peritonitis  instead  of  the  localised  form  of  the  disease :  then 
the  symptoms  are  much  more  intense ;  there  is  acute  pain  and  general 
tenderness,  and  the  abdomen  soon  becomes  greatly  distended  from  gaseous 
expansion  of  the  intestines.  Very  constant  and  distressing  vomiting  is 
usually  present,  and  such  a  case  will  generally  end  fatally  in  a  few  days. 
It  IS  needless  to  say  that  these  symptoms  may  all,  or  some  of  them, 
be  very  variously  mixed  in  particular  cases.     Hence  the  paramount 


646 


SYSTEM  OF  MEDICINE 


importance,  when  in  attendance  on  any  case  of  septicaemia,  of  carefully- 
watching  day  by  day  for  the  various  complications  that  may  occur. 

Treatment.  —  If  there  be  one  disease  more  than  another  in  which  the 
time-honoured  adage,  "Prevention  is  better  than  cure"  should  be  inces- 


SBn!!!!!!!innHHmi™iiHHHnHHHnHiniiiii  iiiiii 
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BgHHIIIIHIIIIillllllllllllllllllillllliillliSiillllllllllll 

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santly  borne  in  mind,  it  is  surely  puerperal  septicaemia.  To  enter  into 
the  details  of  preventive  treatment,  however,  would  involve  a  recapitu- 
lation of  the  whole  subject  of  practical  attendance  on  lying-in  women, 
especially  of  antiseptic  midwifery,  to  the  importance  of  which  all  students, 


PUERPERAL   SEPTIC  DISEASE 


647 


practitioners,  and  nurses  are  now,  it  is  to  be  hoped,  thoroughly  alive. 
Briefly,  absolute  cleanliness  of  hands  and  instruments ;  the  disuse  of 
sponges ;  the  thorough  washing  of  the  hands,  first  with  soap  and  water, 
then  with  antiseptic  lotions  (such  as  the  1  in  1000  solution  of  perchloride 
of  mercury) ;  the  judicious  use  of  antiseptic  douches  before  and  after 


BHini 


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nniiiiHiiiHiiiKiiiiiiiiiiii 


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mil  mniiiiinissiiiiiiiiimiiiiiimii  m 

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niuiii  mil  iiiiiiKssiiiimiiiiiiiiiiiiiiiiimi  iii 

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^iinisiiiiiiiiimiiiiiiiiiiiiiiuiiiiiii  nil 

VL  mi.  isziEEElEEaiissiiiiimiiimiiiiiiiiiiHiii  mi 

II  liiiimi  iiimiiiiiismiiiiiiiiiiiiiiiiiiim  mi 
::  iiiiimimimiiiiiiKmimiiimiiiiiiiiimmi 

mimiiimi  iiiiiiiiissiiimiiimiiiiiiiiiinniimi 
iimiiimi  iiiisgjiiiiiiiimimiimiiii  liiiiii  iii 

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delivery  and  durino:  convalescence;  the  avoidance  of  needlessly -repeated 
vaginal  examinations;  the  closure  with  aseptic  ligatures  of  all  attainable 
breaches  of  continuity  in  the  orenital  tract,  such  as  lacerations  of  the 
perin;p.uni  ;  attention  before  delivery  to  such  questions  of  hygiene  as 
drainaii'e.  the  avoidance  of  contagion,  and  the  like,  form  the  main  head- 
ings of  this  all-important  topic. 


648 


SYSTEM  OF  MEDICINE 


When  once  the  conflagration  has  begun,  it  may  now  and  again  be 
possible  to  extinguish  it  soon  by  removing  any  obvious  source  of  mis- 
chief, such  as  by  Avashing  away  decomposing  materials  in  the  genital 
tract,  the  removal  of  the  patient  to  a  fresh  and  unvitiated  atmosphere, 
and  so  on;  but  more  generally  our  aim  must  then  be  to  watch  the 
patient  until  the  septic  process  has  burnt  itself  out,  to  minimise  its 
ravages,  and  to  keep  her  alive  until  the  imminent  danger  is  over. 


CONFINELD 

MARCH    IV 


DIED 

APRIL  7 '.X  1879 


M  E hlE  M!E  MiE  M  E  M  E h|E  M  E  M  E  MlE  1 


^HBH 


Bi 


DATE      S9      30  I  31    lAP!:  1 1    2 


Chart  8. 


On  the  first  advent  of  threatening  symptoms  the  possible  pres- 
ence of  any  removable  cause  of  septic  infection  should  be  carefully 
investigated. 

It  will  be  well  to  make  a  thorough  local  examination  to  see  whether 
there  be  any  sloughing  surfaces  about  the  vulva,  or  a  lacerated  peri- 
nseum,  which,  if  lacerated,  should  be  disinfected  as  completely  as  possible 
by  scraping,  dusting  with  iodoform,  and  the  like.  One  or  two  irriga- 
tions of  the  uterine  cavity,  which  should  be  administered  by  the  practi- 
tioner himself,  may  cut  short  a  threatened  attack   by  washing  away 


PUERPERAL   SEPTIC  DISEASE  649 

infecting  organic  matters.  Tincture  of  iodine  dropped  into  warm  water 
nntil  it  is  of  a  dark  sherry  colour,  a  solution  of  creoline  in  water,  or  a 
1  in  2000  solution  of  perchloride  of  mercury,  are  amongst  those  which 
are  most  effective.  Subsequently  antiseptic  vaginal  douches  should  be 
given  night  and  morning.  The  value  of  such  antiseptic  irrigation  of  the 
uterine  cavity  cannot  be  exaggerated  in  any  case  in  which  decomposing 
portions  of  membranes  and  the  like  are  retained  in  utero.  It  is  not 
uncommon  under  such  circumstances  to  see  very  threatening  symptoms  at 
once  cut  short  (Chart  4),  and  there  are  few  cases  in  which  they  should 
not  be  administered.  To  be  effectual,  however,  the  irrigation  must  be 
thorough,  and  it  is  useless  to  trust  it  to  the  nurse,  as  is  frequently  done. 
Two  or  three  intra-uterine  douches  should  be  sufficient,  and  as  the  process 
is  often  painful,  and  always  annoying  to  the  patient,  it  is  rarely  needful 
to  continue  it.  Of  late,  especially  in  Vienna,  curettement  of  the  uterine 
cavity,  followed  by  swabbing  with  linimentum  iodi,  has  been  much  rec- 
ommended. It  is  likely  to  be  very  useful  when  there  are  portions  of 
retained  placenta  in  the  uterus ;  and  in  skilled  hands  it  is  a  very  effec- 
tive way  of  thoroughly  disinfecting  the  uterine  cavity,  but  it  requires  a 
certain  aptitude  and  experience,  and  the  procedure  is  not  free  from  risk. 

The  sanitary  condition  of  the  house  should  be  investigated  and,  if 
found  defective,  the  patient  should  be  removed  at  once  to  another  room, 
or  even  to  another  house,  if  practicable.  In  any  case  it  is  often  use- 
ful to  remove  the  patient  from  the  lying-in  chamber,  the  atmosphere 
of  which  must  generally  be  unwholesome  from  long  occupation,  even 
if  it  be  not  otherwise  tainted.  It  is  impossible  to  exaggerate  the  impor- 
tance of  thorough  ventilation,  and  of  a  plentiful  supply  of  pure  fresh 
air.  I  have  frequently  been  struck  with  the  improvement  following 
this  simple  procedure. 

The  general  treatment  resolves  itself  into  measures  for  supporting 
the  strength  of  the  patient  during  the  progress  of  the  disease,  and  into 
the  administration  of  such  drugs  as  are  likely  to  alleviate  the  symptoms 
and  to  lessen  their  intensity. 

The  former  indication  is  best  met  by  administering  an  abundance  of 
easily  assimilated  nourishment  at  frequent  intervals,  say  every  second  or 
third  hour,  such  as  strong  beef  tea.  Brand's  essence,  milk,  eggs  beaten  up 
with  milk,  and  the  like ;  and  nowhere  is  the  value  of  trained  and  efficient 
nursing  more  apparent  than  in  the  conduct  of  this  important  part  of  the 
treatment.  In  a  disease  in  which  there  is  generally  a  marked  tendency 
to  jjrostration  stimulants  will  sooner  or  later  be  required.  It  must  be 
admitted  that  they  have  often  been  given  in  needless  excess,  an  error 
which  it  is  necessary  to  guard  against ;  nevertheless,  in  bad  cases  their 
use  in  moderate  quantities  (such  as  a  tablespoonful  of  good  old  brandy 
or  whisky  every  four  or  six  hours)  will  be  very  valuable,  strictly  pro- 
portioning the  quantity  to  the  degree  of  debility  and  prostration.  In 
very  severe  cases,  in  which  the  pulse  is  rapid  and  thready,  and  there  is 
much  low  delirium,  tympanites  and  sweating,  their  free  use  in  larger 
quantities  may  be  necessary  to  save  the  life  of  the  patient. 


650  SYSTEM  OF  MEDICINE 

Medicinally  drugs  which  lower  the  temperature  are  most  useful.  In 
an  early  stage  probably  antipyrine  in  doses  of  20  grains,  combined 
with  30  minims  of  sal-volatile  to  counteract  depression,  answers  best ; 
or  in  its  place  2  or  3  grains  of  salicylic  acid,  or  salicylate  of  soda,  may 
be  given.  These  cannot,  however,  be  continued  more  than  a  day  or  two, 
and  later  it  is  best  to  trust  to  the  antipyretic  action  of  quinine.  Quinine 
is  not  uncommonly  given  in  small  doses  of  5  grains  thrice  daily,  but  I 
much  prefer  to  administer  it  in  full  doses  of  20  grains  night  and  morn- 
ing ;  this  will  often  reduce  the  temperature  two  or  three  degrees.  It 
may  be  advantageously  combined  with  15  or  20  minims  of  tincture  of 
perchloride  of  iron,  with  a  drachm  of  glycerine,  thrice  daily.  The  iron 
is  unquestionably  a  valuable  drug,  and  the  glycerine,  by  its  antiseptic 
properties,  seems  to  lessen  the  distressing  tympanites  which  is  frequently 
present.  In  a  protracted  case  it  is  often  advisable  to  change  the  drug ; 
and,  not  rarely,  when  other  antipyretics  have  failed,  two  or  three  doses 
of  Warburg's  tincture  have  proved  very  efficacious  in  reducing  the 
temperature  (Charts  5,  6  and  7). 

In  cases  marked  by  hyperpyrexia,  with  a  temperature  reaching  105° 
and  upwards,  cold  may  be  advantageously  tried  to  bring  down  the  body 
heat.  One  of  the  best  ways  of  applying  it  is  a  Thornton's  ice-cap,  by 
means  of  which  a  current  of  iced  water  is  kept  running  continuously  round 
the  head.  It  is  comforting  to  the  patient,  and  often  relieves  the  throbbing 
headache  from  which  she  suffers.  When  in  use  it  often  brings  down 
the  temperature  two  or  three  degrees.  The  external  application  of 
cold,  by  sponging  or  by  the  use  of  towels  soaked  in  ice-water,  may  be 
tried  in  very  severe  cases  ;  but  this  treatment  is  troublesome,  and  as  it 
is  palliative  and  not  curative,  it  is  not  often  called  for. 

The  only  other  remedial  means  specially  calling  for  notice  is  the  use 
of  aperients,  formerly  much  employed.  In  the  early  stage  of  the  disease 
•  one  or  two  doses  of  calomel  (of  4  or  5  grains  each)  certainly  seem  to  act 
well,  and  may  generally  be  administered  with  advantage.  It  is  to  be 
remembered,  however,  that  as  the  disease  progresses  diarrhoea,  often 
uncontrollable,  is  very  apt  to  supervene,  and  aperients  should  therefore 
be  employed  with  caution. 

It  is  to  be  hoped  that  further  research  will  give  us  soipie  means  of 
counteracting  the  septic  state  of  the  blood ;  and  it  is  not  unreasonable  to 
look  for  some  valuable  aid  in  this  direction  from  the  advances  now  being 
made  in  sero-therapeutics. 

Abdominal  section  has  been  much  discussed  of  late  years  in  connec- 
tion with  puerperal  septicaemia.  The  successful  cases  have  been  chiefly 
where  localised  collections  of  pus  were  present,  as  in  pelvic  peritonitis, 
or  in  diffuse  general  peritonitis  occurring  six  or  seven  weeks  after  the 
commencement  of  the  disease.  Although  septic  in  origin,  such  cases 
can  scarcely  be  called  true  cases  of  puerperal  septicaemia.  In  the  acute 
form  of  the  disease,  with  great  abdominal  distension,  laparotomy  would 
not  only  be  a  most  difficult  and  hazardous  operation,  but  since  the 
septic  infection  is  general  and  not  local,  would  promise  little  or  no 
hope  of  benefit,  even  if  practicable. 


FURUNCLE  651 


In  every  case  special  events  and  complications  may  present  themselves 
for  which  no  exact  rules  of  management  can  be  laid  down,  and  which 
must  be  dealt  with  on  general  principles  as  they  arise 

W.    S.   Playfair. 

REFERENCES 

1.  Barker,  Fordyce.  The  Puerperal  Diseases.  —  2.  Black,  J.  Watt.  Inaugural 
Address  on  the  Bacteriology  of  Paerperal  Fever,  Obstet.  Trans,  vol.  xxiv. — 3.  Boxall, 
"  Fever  in  Childbed,"  Obst.  Trans,  vol.  xxxv.;  "The  Mortality  of  Childbirth,"  Lancet, 
1st  July  1893;  "  Scarlatina  during  Pregnancy,"  Obst.  Trans,  vol.  xxx.  —  4.  Doederlbin. 
Arch.f.  Gynsek.  1891,  xl.,99.  —  5.  Gueniot.  "Du  Mephitisme  de  Pair  comme  cause  de 
Septicsemie  Puerperal,"  Bui.  de  I'Acad.  de  Med.  1892. — 6.  Kirkland,  Thos.  On  Child- 
bed Fevers.  London,  1774.  — 7.  Leopold  and  Goldberg.  Arch.f.  Gynsek.  1891,  xl. 
439.  —  8.  Playfair,  W.  S.  "  On  Defective  Sanitation  as  a  Cause  of  Puerperal  Disease," 
Lancet,  5th  February  1887 ;  "  A  Lecture  on  a  case  of  Puerperal  Septicaemia  vrith  Hyper- 
pyrexia treated  by  the  continuous  Application  of  Cold,"  Brit.  Med.  Journ.  1877,  v.  2, 
p.  687. — ^9.  Semmelvfeiss.  Der  Aetiologie,  der  Begriff,  und  die  Prophylaxis  des  kind, 
bet  Fiebern.  Wien,  1861.  — 10.  Simpson.  "The  Analogy  between  Puerperal  and  Sur- 
gical Fever,"  Edin.  Month.  Journ.  of  Med.  Science,  November  1850.  — 11.  Weiss.  "  On 
Curettement  in  Puerperal  Septicaemia,"  Amer.  Journ.  of  Obstet.  1st  August  1892.  — 12. 
W1LLLA.MS,  J.  W.  Eridge.  "Puerperal  Infection  considered  from  a  Bacteriological 
Point  of  View,"  Amer.  Journ.  of  Med.  Science,  1893. 

w.  s.  p. 


FURUNCLE 

(boils) 


A  Furuncle  is  accompanied  by  intense  inflammation  of  the  entire 
thickness  of  the  skin,  and  of  the  underlying  connective  tissue.  It  com- 
mences with  thickening  and  induration  of  the  dense  tissue  immediately 
surrounding  a  sweat  gland  or  hair  follicle,  and  produces  a  slight  eleva- 
tion of  the  skin,  which  rapidly  increases  until  the  third  or  fourth  day, 
when  it  attains  its  full  development.  The  area  which  it  now  occupies 
depends  upon  the  density  of  the  skin  and  the  facility  with  which  infiltra- 
tion has  occurred.  Sometimes  it  has  a  diameter  of  one  inch,  at  other 
times  of  more  than  five  inches.  The  central  portion  is  a  dusky  red  and 
surrounded  with  an  intensely  congested  zone  of  a  bright  red  colour; 
beyond  this,  again,  is  an  area  which  is  less  congested,  but  often  contains  a 
considerable  quantity  of  oedema  fluid.  The  induration  about  the  centre 
is  sometimes  so  great  that  the  part  feels  like  a  piece  of  cartilage  set  in 
the  softer  tissues  round  it.  Very  soon  a  small  orifice  appears .  at  the 
most  prominent  part  of  the  swelling,  and  through  this  orifice  a  small 
quantity  of  purulent  fluid,  and  later  the  characteristic  slough,  escape, 
leaving  behind  a  small  cavity,  with  ragged,  shreddy,  and  readily  bleeding 
walls.  The  slough  consists  of  a  network  of  coarse  connective  tissue, 
containing  in  its  interstices  a  quantity  of  pus  cells  and  micro-organisms. 


652  SYSTEM  OF  MEDICINE 

With  the  escape  of  pus  and  separation  of  the  slough  the  tension  and 
pain  are  greatly  diminished.  The  healing  process  commences  in  the 
usual  manner,  and  finally  a  permanent  scar  results. 

Situation.  —  Furuncles  may  occur  on  any  part  of  the  body,  but  the 
favourite  seats  are  those  parts  which  are  subject  to  dirt  or  friction,  such 
as  the  nape  of  the  neck,  the  nates,  the  outer  surface  of  the  thighs,  the 
auditory  meatus  and  nostrils.  They  are  very  rare,  however,  on  the  palm 
of  the  hand  and  sole  of  the  foot,  and  are  not  common  upon  the  abdomen  or 
scalp.  They  are  unusual  in  infants  and  in  persons  over  thirty,  but  are 
most  common  during  the  period  of  life  when  severe  and  irregular  exercise 
is  taken.     This  is  especially  noticeable  in  schoolboys  and  young  men. 

Etiology.  —  Women  are  much  less  frequently  attacked  than  men. 
Persons  whose  general  tone  is  impaired  by  poor  living,  or  by  a  severe 
illness,  are  very  prone  to  these  affections ;  they  are  extremely  common 
in  persons  who  suffer  from  diabetes,  and  not  uncommon  in  albuminuria. 
On  the  other  hand  they  occur  in  young  people  while  training  for  certain 
sports,  more  especially  in  rowing  men,  who  are  apparently  in  good  health 
and  are  carefully  fed. 

Whatever  part  constitutional  states  may  play,  it  is  certain  that  the 
occurrence  of  a  furuncle  is  impossible  without  the  intervention  of  pus 
micro-organisms.  Staphylococcus  pyogenes  aureus  or  albus,  or  both 
together,  are  invariably  present,  and  pure  cultivations  of  these  organisms 
can  be  readily  obtained  by  transferring  a  little  of  the  pus  to  any  of  the 
nutrient  media  which  are  commonly  used  for  such  purposes.  When 
inoculated  into  man,  either  in  the  form  of  pure  culture  or  directly  from 
a  furuncle,  they  give  rise  to  similar  circumscribed  suppurative  inflamma- 
tions. This  has  been  repeatedly  demonstrated  by  good  observers.  The 
occurrence  of  furuncles  in  successive  crops  is  due  to  reinoculation  from 
the  surface,  and  has  nothing  to  do  with  the  circulation.  The  impetigo 
or  scrum-pox  of  Rugby  football  players,  described  by  Mr.  Armstrong  of 
Wellington  College  and  other  authors,  seems  to  be  traced  to  chafing 
by  jerseys  infested  with  pyogenetic  cocci.  Frequent  washing  and  stov- 
ing  of  flannels  is,  therefore,  very  important  in  all  such  cases  [vide  art. 
"  Impetigo  "].  If  the  micro-organisms  were  carried  to  the  capillaries  of 
the  skin  by  the  blood  stream,  we  should  expect  to  find  evidence  of 
abscesses  localised  in  internal  organs.  Moreover,  if  the  skin  round  the 
furuncle  be  kept  perfectly  clean  no  such  crops  occur. 

In  a  simple  furuncle  the  struggle  between  the  micro-organisms  and 
the  tissues  is  confined  to  the  abscess  wall ;  and,  though  inflammation  and 
oedema  may  exist  for  a  considerable  distance  round  it,  it  is  not  possible 
to  obtain  a  culture  from  the  oedema  fluid  of  this  area.  Sometimes,  how- 
ever, when  a  furuncle  is  large,  or  is  rapidly  followed  by  the  appearance  of 
others  in  its  vicinity,  the  first  barrier  is  transgressed,  and  the  organisms 
travel  along  the  lymphatic  channels,  causing  enlargement  of  the  glands 
which  drain  them.  At  other  times,  when  the  inflammation  is  yet  more 
severe,  this  second  line  of  defence  is  also  broken  through,  and  the 
organisms  gain  access  to  the  general  circulation,  thus  producing  septi* 


FURUNCLE  653 


caemia  which  may  be  complicated  by  the  formation  of  localised  abscesses, 
and  even  terminate  fatally. 

Treatment.  —  In  order  to  prevent  the  further  formation  of  furuncles 
the  whole  of  the  skin  should  be  thoroughly  cleansed  with  soap  and 
water,  and  the  parts  around  them  with  sublimate  lotion ;  the  furuncles 
must  be  covered  with  moist,  warm,  antiseptic  compresses  frequently 
changed,  and  the  underclothing  boiled  or  stoved.  The  patient  must  be 
warned  not  to  touch  the  affected  part  lest  he  inoculate  himself  elsewhere. 
A  furuncle  may  often  be  induced  to  abort  by  injecting  a  few  drops 
of  carbolic  acid  into  its  centre.  If  pus  is  already  formed,  an  artificial 
opening  may  be  made  by  the  application  of  several  small  crystals 
of  carbolic  acid  in  succession  over  the  most  prominent  part  of  the 
swelling.  The  surrounding  skin  should  be  protected  with  vaseline  and 
the  excess  of  acid  mopped  up  as  the  crystals  liquefy.  The  crystals 
may  be  applied  with  a  heated  needle  to  which  they  readily  adhere.  This 
plan,  though  painless,  is  a  little  tedious.  Incisions  are  extremely  painful, 
and  few  people  will  submit  to  this  treatment.  There  is,  however,  no 
other  method  by  which  such  rapid  relief  may  be  given,  especially  when 
the  boil  is  large  and  the  tension  great ;  and  in  those  extremely  painful 
forms  which  occur  in  the  auditory  meatus  and  nostrils. 

After  the  escape  of  pus  an  attempt  may  be  made  to  disinfect  the 
cavity  by  thrusting  into  it  a  few  more  crystals  of  carbolic  acid  by  means 
of  a  probe.  The  dressings  are  now  to  be  applied  and  changed  every  four 
hours.  The  double  cyanide  gauze,  which  is  both  absorbent  and  anti- 
septic, is  the  best ;  poultices,  however,  retain  their  heat  longer,  and  are 
far  more  effective  in  relieving  pain,  especially  when  there  are  a  number 
of  furuncles,  many  still  in  an  early  stage.  Unfortunately  poultices 
are  not  absorbent,  and  the  discharge  is  apt  to  collect  beneath  them 
and  reinfect  the  neighbouring  skin.  This  risk  of  reinfection  can  be 
overcome  by  making  the  poultices  antiseptic.  For  this  purpose  two 
drachms  of  pure  carbolic  acid  should  be  added  to  half  a  pint  of  boiling 
water  together  with  or  immediately  before  the  addition  of  the  linseed 
meal.  The  poultice  will  contain  roughly  1  in  45  of  carbolic  acid,  and 
will  be  found  to  destroy  pus  micro-organisms;  and  although  certain 
spore-bearing  bacilli  found  in  the  linseed,  and  at  times  on  the  skin,  are 
not  destroyed  by  it,  yet  their  growth  is  entirely  arrested.  Children  are 
soon  irritated  or  even  poisoned  by  the  use  of  carbolic  acid  on  the  skin ; 
less  must  be  used  for  them,  and  a  fresh  poultice  should  be  applied  every 
four  or  five  hours.  Before  applying  it  the  skin  should  be  freed  of  all 
discharge  and  well  disinfected. 

It  is  well  to  bear  in  mind  that  although  a  furuncle  is  a  comparatively 
insignificant  lesion,  it  may  at  times  and  in  unhealthy  persons  give  rise  to 
serious  trouble.    Its  proper  treatment  should,  therefore,  not  be  neglected. 

The  urine  should  be  tested,  and  if  sugar  or  albumin  be  found  the 
recognised  treatment  for  these  conditions  should  at  once  be  adopted.  If 
the  general  health  is  good,  and  the  furuncles  few  in  number,  no  drugs  are 
required ;  good  plain  feeding  and  fresh  air  are  all  that  is  necessary.    If, 


654  SYSTEM  OF  MEDICINE 

however,  the  furuncles  are  numerous  and  the  strength  failing,  large 
doses  of  iron  should  be  given.  The  various  drugs  alleged  to  have  spe- 
cial healing  properties  in  these  affections  are,  so  far  as  we  know  at  the 
present  time,  quite  useless.  ^^  g^  Melsomb. 

CAEBUJ^CLES 

The  relation  between  a  furuncle  and  a  carbuncle  is  a  simple  one. 
Their  etiology  and  pathology  are  the  same ;  clinically,  however,  they  are 
somewhat  different.  A  furuncle  has  one  suppurating  focus  which  results 
in  the  formation  of  a  single  orifice ;  a  carbuncle  consists  of  a  number  of 
furuncles  grouped  together  upon  a  larger  area,  it  gives  rise  to  a  flattened 
rather  than  a  conical  elevation,  and  results  in  the  formation  of  several 
orifices  or  in  the  sloughing  of  a  large  portion  of  skin :  a  carbuncle  is- 
often  attended  with  very  serious  consequences. 

It  occurs  more  often  in  advanced  life,  and  is  especially  common  in 
those  who  suffer  from  diabetes  or  Bright's  disease.  It  begins  as  a  firm,, 
painful  swelling  which  rapidly  spreads.  Its  colour,  at  first  red,  soon 
changes  to  purple  or  varies  in  different  parts  so  as  to  appear  mottled.  It 
is  accompanied  by  a  rise  of  temperature  and  considerable  depression  of 
spirits.  Extensive  infiltration,  cartilaginous  firmness,  and  pain  are  the 
prominent  symptoms.  It  may  attain  enormous  dimensions ;  sometimes 
it  occupies  an  area  as  large  as  a  dinner  plate,  and  extends  deeply  intO' 
the  subjacent  tissues.  The  constitutional  symptoms  are  correspondingly 
severe.  It  is  indeed  in  these  progressive  forms  of  the  disease  that  death 
from  exhaustion  and  septicaemia  are  to  be  feared;  even  in  those  which 
are  more  limited  and  less  rapid  in  their  progress,  thrombo-phlebitis  and 
localised  abscesses  are  by  no  means  uncommon. 

Treatment.  —  Bearing  in  mind  the  exhausting  effects  on  the  constitu- 
tion and  the  liability  to  such  serious  consequences,  it  will  be  understood 
that  the  treatment  of  carbuncle  must  be  energetic.  A  conical  or  crucial 
incision  should  be  made  under  strict  antiseptic  precautions,  and  the  in- 
fected tissues  scraped  with  a  sharp  spoon.  The  cavity  is  then  dried  as 
thoroughly  as  possible  and  disinfected  by  carefully  swabbing  the  whole 
raw  surface  with  pledgets  of  cotton  wool  soaked  in  pure  carbolic  acid ; 
but  before  deciding  on  this  step  we  must  carefully  consider  the  size  of 
the  carbuncle  and  the  age  and  vitality  of  the  patient,  remembering 
that,  unless  the  incision  be  made  early,  severe  haemorrhage  may  occur. 
If  we  decide  on  incision  it  must  be  done  at  once.  Every  delay  adds  to- 
the  danger,  not  only  by  increasing  the  liability  to  haemorrhage,  but  also 
by  reducing  the  strength  of  the  patient.  During  the  last  few  years  good 
results  have  been  obtained  by  injecting  carbolic  acid  at  several  points 
round  the  circumference  of  the  carbuncle.  This  plan  has  been  especially 
advocated  for  checking  the  advance  of  facial  carbuncles,  which  are  excep- 
tionally dangerous  owing  to  the  close  connections  between  the  veins  of 
the  face  and  those  at  the  base  of  the  brain.  For  those  who  refuse 
operation  we  have  to  decide  between  hot  and  cold  applications.     If  the 


EPIDEMIC  PNEUMONIA  655 

carbuncle  be  in  an  early  stage,  frequent  poulticing  is  without  doubt  the 
best  form  of  local  treatment.  It  increases  the  vascularity  and  local 
reaction,  which  at  the  present  day  we  know  to  be  powerful  factors  in 
bringing  about  the  termination  of  localised  diseases.  If,  however,  the 
carbuncle  be  large  and  shows  signs  of  spreading,  and  especially  if  the 
general  health  be  poor,  ice  compresses  should  be  applied  continuously 
in  the  hope  of  diminishing  the  activity  of  the  disease,  and  thus  lessening 
■the  quantity  of  poison  which  is  absorbed  into  the  system.  It  is  just 
possible  that  by  this  means  we  may  for  a  time  give  the  body  a  rest,  so 
to  speak,  from  a  burden  which  is  proving  too  severe  for  it,  and  by 
allowing  it  to  recover  a  little  strength  enable  it  finally  to  overcome  the 
disease.  Meanwhile  the  general  surface  should  be  kept  very  warm  and 
opium  given  to  ally  pain. 

Great  care  should  be  taken  to  support  the  strength  by  careful  feed- 
ing, and  large  doses  of  some  easily-digested  form  of  iron  should  be  pre- 
scribed. For  old  and  weakly  persons  alcohol  is  essential,  and,  in  the 
absence  of  special  indications,  such  as  glycosuria,  they  may  be  allowed  to 
choose  the  drink  they  like  best.  The  bowels  should  be  carefully  attended 
to,  and  the  examination  of  the  urine  for  albumin  and  sugar  never  omitted. 

The  occurrence  of  thrombo-phlebitis  must  be  carefully  watched  for, 
and  when  detected  the  limb  should  be  slightly  elevated,  surrounded  with 
several  layers  of  cotton  wool,  and  kept  absolutely  at  rest.  Excision  of 
the  thrombosed  vein  is  a  very  serious  undertaking  in  old  persons  whose 
vitality  is  already  much  reduced.  Ligature  of  the  vein  on  the  cardiac 
side,  a  less  severe  operation,  may  be  performed  if  some  such  step  seem 
desirable.  ^_  S.  Melsome. 


EPIDEMIC  PNEUMONIA 

Apart  from  its  occurrence  as  a  sequela  of  certain  zymotic  diseases, 
croupous  pneumonia  is  met  with  not  only  in  sporadic  cases,  but  also 
in  groups,  and  occasionally  in  more  or  less  extensive  epidemics,  with 
clear  evidence  of  infection  from  person  to  person.  The  proof  of  infec- 
tiveness  is  strengthened  by  the  discovery  that  the  tissues  and  sputa 
of  pneumonic  patients  contain  specific  micro-organisms  which  can  be 
cultivated,  and  have  the  power  of  reproducing  the  disease  when  inocu- 
lated into  lower  animals :  moreover,  Dr.  Klein  has  found  that  animals 
so  inoculated  become  centres  of  infection  to  others  kept  near  them. 
Pneumonia  of  this  kind  is  to  be  regarded  not  as  an  affection  of  the  lung 
simply,  but  rather  as  a  constitutional  infection  —  a  "  pneumonic  fever  " 
—  of  which  pulmonary  and  pleural  lesions  are  only  the  local,  and  not 
necessarily  constant  manifestations.  Perhaps  it  would  be  more  correct 
to  speak   of  pneumonic  fevers  in  the  plural,  for  it  seems  that   more 


656  SYSTEM  OF  MEDICINE 


than  one  kind  of  microbe  can  give  rise  to  infectious  pneumonia.  At  any 
rate  some  of  the  sporadic  cases  are  of  like  nature,  as  bacteriological 
examination  proves,  notwithstanding  the  frequent  absence  of  any  clue 
to  the  source  of  infection  and  of  extension  of  the  malady  to  other 
persons.  Similar  obscurity  often  surrounds  the  etiology  of  enteric 
fever,  diphtheria,  and  other  diseases  of  the  mobile  and  more  or  less 
saprophytic  class.  It  is  more  than  possible  that  such  diseases  may 
occur  in  forms  so  modified  or  attenuated  as  to  be  distinguishable  with 
difficulty,  if  at  all ;  or  that  their  continuity  may  be  maintained  in  lower 
animals,  or  even  in  external  media  such  as  soil. 

Although  epidemics  have  been  recorded  in  this  country  for  nearly 
two  centuries  much  of  our  present  knowledge  of  infectious  pneumonia 
dates  from  1888,  when  an  outbreak  of  unusual  extent  and  severity 
occurred  at  Middlesborough,  and  was  carefully  studied  by  Dr.  Ballard. 
The  ordinary  clinical  history,  in  attacks  admittedly  of  the  infective 
kind,  may  perhaps  best  be  gathered  from  his  observations,  which  were 
briefly  as  follows  :  — 

The  incubation  was  short,  not  exceeding  five  or  seven  days;  and 
here  it  may  be  remarked  that  in  other  epidemics  the  latent  period  has 
seemed  to  be  shorter  still,  sometimes  not  more  than  one  or  two  days. 
The  onset  of  the  symptoms  was  sudden,  with  rigors,  pain  in  the  side  or 
epigastrium,  and  rapid  rise  of  temperature,  often  accompanied  with 
vomiting  and  diarrhoea.  The  temperature  sometimes  reached  104° 
within  a  few  hours;  the  highest  point  recorded  was  105°  on  the 
morning  of  the  third  day.  Delirium  almost  invariably  set  in,  occasion- 
ally as  early  as  the  first  day,  but  more  commonly  on  the  second  or 
third.  As  a  rule  the  physical  signs  of  pleuro-pneumonia  were  observed, 
in  one  or  both  lungs,  on  the  second  day ;  but  in  many  cases  they  were 
delayed  and  of  slight  intensity ;  generally  speaking  "  the  constitutional 
disturbance  was  out  of  all  proportion  to  the  evidence  of  local  pulmonary 
disease."  There  was  not  much  cough,  but  the  sputa  presented  the 
characters  nsual  in  pneumonia.  The  tongue,  in  fully-developed  attacks, 
was  dry  and  brown,  with  moist  white  edges.  Fatal  cases  for  the  most 
part  terminated  on  the  third,  fourth,  or  fifth  day  of  illness,  or,  at  all 
events,  within  a  week.  Convalescence  usually  began  by  a  crisis  on  the 
seventh  to  the  tenth  day.  Three  or  four  days  after  the  crisis  a  relapse 
sometimes  occurred,  which  often  coincided  with  commencing  pneumonia 
in  the  other  lung.  Among  the  occasional  phenomena  to  which  Dr.  Ballard 
directed  attention  were  haemorrhages  (especially  epistaxis,  which  some- 
times appeared  to  be  critical),  and  painful  swellings  of  the  knees,  ankles, 
shoulders,  and  other  joints.  By  other  observers,  and  in  other  localities, 
similar  arthritic  complications  have  been  found  to  be  due  to  the  specific 
pneumococcus.  In  only  one  of  the  cases  seen  by  Dr.  Ballard  was  there 
any  herpetic  eruption  about  the  mouth.  The  mortality  was  very  high. 
Out  of  682  attacks  which  came  under  observation,  143  (21  per  cent) 
were  fatal.  In  the  workhouse  the  proportion  was  over  40  per  cent; 
and  it  was  exceptionally  high  also  in  certain  portions  of  the  town. 


EPIDEMIC  PNEUMONIA 


657 


Two  years  later  an  epidemic  on  a  smaller  scale  occurred  at  the  vil- 
lage of  Scotter,  in  Lincolnshire,  and  was  investigated  by  Dr.  Parsons. 
Here  the  more  severe  cases,  which  were  practically  limited  to  adults 
and  aged  persons,  corresponded  closely  with  the  above  description ;  but 
at  the  same  time  there  was  among  children  a  wide-spread  prevalence  of 
a  slight  and  ill-defined  form  of  sickness,  marked  principally  by  headache, 
vomiting,  diarrhoea,  and  some  rise  of  temperature.  Proof  is  wanting 
of  the  identity  of  these  slight  attacks  with  true  "pneumonic  fever,"  but 
the  probability  seems  to  lie  in  that  direction. 

Several  other  village  epidemics  of  severe  type  have  been  recorded 
in  recent  years :  one,  for  example,  in  the  spring  of  1893  at  Yeadon, 
reported  by  Dr.  Russell  M'Lean,  where  the  non-fatal  cases  ended  by 
crisis  between  the  third  and  eighth  days,  usually  on  the  sixth.  As  early 
as  1875  Mr.  Wynter  Blyth  called  attention  to  the  infectious  character 
of  the  pneumonia  then  prevalent  in  certain  North  Devon  villages. 

Sometimes  the  prevalence  has  been  limited  to  particular  streets,  or 
to  certain  industrial  sections  of  the  population.  Still  more  localised 
epidemics  have  occurred  in  barracks,  schools,  hospitals,  workhouses, 
prisons,  and  on  board  ship ;  usually  in  association  with  unwholesome  con- 
ditions which  may  be  thought  likely  to  offer  maximum  facilities  for  the 
transmission  of  infection,  and  to  lessen  the  resistance  to  disease.  And, 
lastly,  both  in  epidemic  and  in  non-epidemic  times,  groups  of  cases  are 
met  with  in  single  households,  often  without  any  clue  to  importation  of 
infection  from  without,  and  here  the  type  is  frequently  most  fatal,  and 
the  indication  of  infection  from  person  to  person  most  convincing. 

Etiology.  —  The  incidence  of  attack,  and  case-mortality  too,  increase 
with  advancing  years,  from  childhood  onwards.  Thus  at  Middlesborough 
Dr.  Ballard  found  the  following  relation  to  age,  in  cases  which  were 
fully  recorded :  — 


Attacks. 

Deaths. 

Estimated 

Case  Mortality. 

Tears  of 
Age. 

Attack-Kate 
per  1000 

M. 

F. 

M.  &  F. 

M. 
13 

F. 
4 

F. 
17 

Population. 

M. 

F. 

M.  &  F. 

0to41 

]23 

84 

207 

10-8 

10-6 

4-8 

8-2 

15  to  45 

'2H3 

58 

821 

55 

12 

«7 

16-3 

20-9 

20-7 

20-9 

45  to  6.5 

88 

36 

124 

37 

9 

46 

34-3 

42-0 

25-0 

37-1 

Over  G5 

18 

12 

30 

5 
110 

8 
33 

13 
143 

53-4 

27-8 

66-6 

43-3 

All  ages. 

492 

190 

682 

10-7 

22-4 

17-4 

2M 

The  usual  experience  is  that  attacks  of  pneumonia  are  less  fatal,  but 
much  more  common  in  men  than  in  women,  the  net  result  being  a 
higher  death-rate  among  the  former.  In  the  Middlesborougli  epidemic, 
however,  the  case-mortality  was  lower  among  females,  except  at  ages 
above  sixty-five. 


VOL.    I 


2  u 


658  SYSTEM  OF  MEDICINE 

Debility,  especially  if  due  to  habits  of  intemperance,  must  be 
counted  among  the  most  important  of  the  conditions  which  dis- 
pose to  infection  and  lessen  the  chance  of  recovery.  Wherever  the 
opportunity  for  comparison  has  arisen,  the  fatality  has  been  found 
excessive  among  intemperate  persons,  and  also  among  the  poor  and 
aged.  Most  observers  agree  with  Hirsch  in  classing  infectious  pneu- 
monia with  the  filth  diseases,  in  the  sense  that  its  incidence  and  severity 
tend  to  be  greatest  where  insanitary  conditions  exist,  Avhether  drainage 
defects,  effluvia  from  foul  accumulations,  overcrowding,  insufficient 
ventilation,  or  unhealthy  surroundings  of  other  kinds.  Striking  in- 
stances are  on  record  in  which  localised  outbreaks  of  so-called  "  pytho- 
genic  pneumonia"  have  followed  closely  upon  exposure  to  air  from 
foul  drains.  The  effect  of  climatic  conditions  is  not  always  clear,  but 
it  seems  that  cold,  and  especially  sudden  and  frequent  changes  of  tem- 
perature, are  important  disposing  conditions;  and  the  same  may  be 
said  of  absence  of  rain  and  low  level  of  subsoil  water,  which  connote 
dryness  of  air  and  soil.  The  Middlesborough  epidemic,  after  extending 
during  a  period  of  comparative  drought,  appeared  to  be  arrested  by 
heavy  rain.  The  seasonal  curve  is  probably  not  very  different  from  that 
of  the  aggregate  of  fatal  "  pneumonia  "  of  all  kinds,  as  recorded  in  the 
Kegistrar-General's  reports,  which  is  above  the  mean  from  November 
to  April.  Epidejuics  have  occurred  in  the  summer  and  autumn,  but 
by  far  the  greater  number  take  place  in  the  winter  and  spring.  Oc- 
casionally there  is  some  indication  of  endemic  localisation,  repeated 
epidemics  following  each  other  at  intervals  in  the  same  community. 
The  geographical  distribution  of  epidemic  pneumonia  is  not  without 
interest  in  this  connection.  Hirsch  recounts  many  epidemics  in  the 
several  countries  of  Europe,  from  the  sixteenth  century  onwards,  nearly 
all  of  them  presenting  in  a  very  marked  degree  the  fatal  typhoid  or 
asthenic  type  which  characterises  these  outbreaks  in  general.  In  some 
of  the  higher  Swiss  valleys  it  recurs  almost  annually,  in  the  spring,  and 
is  known  as  the  Alpenstich.  In  Italy  and  France  and  adjacent  countries 
it  has  more  than  once  attained  pandemic  diffusion,  but  although 
epidemics  have  been  frequent  in  Europe  during  the  nineteenth  century 
"  they  have  been  mostly  far  apart  and  confined  within  narrow  limits." 
North  America  has  suffered  severely,  especially  from  1812  to  1825 ; 
but  here  again  the  seasonal  curve  was  strongly  marked,  and  the 
prevalence  was  to  a  great  extent  limited  to  the  winter  and  spring 
seasons.  Both  in  America  and  in  Africa  the  negro  races  have  been 
found  to  be  specially  susceptible  to  pneumonia. 

As  already  stated,  the  infection  is  probably  not  always  of  the  same 
kind.  At  least  three  diiferent  microbes  have  been  regarded,  on  ap- 
parently conclusive  evidence,  as  pathogenetic  in  infectious  pneumonia : 
an  oval  capsulated  micrococcus,  described  by  Eriedlander  ;  a  capsulated 
diplococcus,  by  Frankel  and  Weichselbaum ;  and  a  bacillus,  found  by 
Klein  in  the  Middlesborouo^h  and  Scotter  epidemics.  Each  of  these  can 
be  cultivated  and  inoculated  upon  lower  animals.     Miniature  epidemics 


EPIDEMIC   CEREBROSPINAL  MENINGITIS  659 

have  occurred  among  monkeys,  guinea-pigs,  and  mice,  when  some  of 
their  number  had  been  inoculated  with  Klein's  bacillus.  The  same 
bacillus  was  found  in  several  samples  of  bacon  obtained  in  Middles- 
borough  during  the  epidemic,  and  in  all  which  came  from  infected 
houses ;  but  the  proof  that  infection  was  actually  imparted  to  man  in 
this  way  was  necessarily  incomplete.  Evidence  is  also  wanting  as  to 
the  possibility  of  water  or  milk  conveying  infection ;  no  recorded  out- 
break of  pneumonia  has  been  traced  to  such  a  source. 

It  may  safely  be  assumed  that  the  infection  is  given  off,  or  tends  to 
be  given  off,  in  the  breath  and  sputa,  and  possibly  in  other  modes  also ; 
and  that  it  is  acquired  by  inhalation  and  perhaps  by  swallowing.  The 
facility  of  transmission  from  person  to  person  is  largely  determined  by 
lowered  vitality  on  the  part  of  the  recipient,  and  by  close  and  prolonged 
contact  with  the  patient,  especially  if  in  a  confined  atmosphere.  Whether, 
apart  from  this,  the  transmission  requires  an  exceptional  intensification 
of  the  virus,  or  is  of  frequent  though  unobserved  occurrence  in  series 
of  cases  too  slight  and  indefinite  in  character  to  be  recognised  as  pneu- 
monia, cannot  be  decided  by  the  light  of  present  evidence.  Xor  is  it 
at  all  clear  what  is  the  true  relation  of  epidemic  pneumonia  to  other 
infective  diseases  with  which  it  is  not  infrequently  associated  in  locality 
and  time,  and  even  in  sequence  of  attack  in  the  same  individual ;  such 
diseases  are  enteric  fever,  influenza,  and  malarial  fevers  \yid.Q  art.  on 
" Cerebro-spinal  Meningitis"].  It  has  been  suggested  that  there  may 
be  an  underlying  identity,  that  the  pneumonic  fever  may  be  in  truth 
only  a  variety  of  one  or  other  of  those  zymotics,  but  the  bacteriological 
aspects  of  well-marked  epidemics  of  pneumonia  lend  little  support  to 
this  view.  Dr.  Klein  has  found  the  Middlesborough  bacillus  in  two 
out  of  five  cases  examined  in  which  croupous  pneumonia  followed 
influenza,  so  that  the  occasional  sequence  of  the  two  different  infections 
must  be  admitted. 

The  recognition  of  the  infective  character  of  croupous  pneumonia 
at  once  suggests  the  application  of  ordinary  preventive  measures  of 
isolation  and  disinfection.  Treatment  will  be  considered  in  another 
section. 

Arthur  Whitelegge. 


EPIDEMIC  CEREBEO-SPIKAL  MENINGITIS 

Synonyms.  —  Cerebro-spinal  fever.  Malignant  purpuric  fever. 

Cerebro-spinal  meningitis,  in  its  epidemic  form,  is  a  disease  of  which 
we  in  England  have  had  very  scanty  experience.  Yet  there  are  many 
reasons  why  we  should  not  neglect  to  consider  it;  its  historical  and 
geographical  interest  is  great ;  its  exact  etiology  is  yet  undiscovered ; 


66o  SYSTEM  OF  MEDICINE 

and  a  country,  hitherto  immune,  cannot  expect  always  to  escape  out- 
breaks in  the  future. 

This  disease  was  unkno-wna,  or  at  least  undistinguished,  till  the  pres- 
ent century ;  within  the  nineteenth  century  there  have  been  two  wide- 
spread epidemics  of  it  in  Europe,  and  three  in  the  United  States. 

Professor  Hirsch,  upon  whos6  exhaustive  writings  I  must  largely 
draw,  divides  the  history  of  epidemic  cerebro-spinal  meningitis  into 
four  periods  (1). 

The  first  of  these  periods  ranges  from  1805  to  1830.  In  Europe 
the  outbreaks  were  then  isolated  and  not  very  extensive ;  as  at  Geneva 
(1805),  at  Grenoble  and  Paris  (1814),  Metz  (1815),  in  the  province  of 
Genoa  (1815),  at  Vesoul  (1822),  in  Westphalia,  and  possibly  at  some 
other  places,  as  for  instance,  in  Sunderland  (1830).  But  in  the  United 
States  this  i^eriod  was  characterised  by  a  wide-spread  epidemic,  includ- 
ing the  New  England  states  (1814  to  1816),  and  other  more  westerly 
states  as  far  as  Kentucky  and  Ohio  (1808).  Nor  was  Canada  altogether 
exempt. 

The  second  period  is  from  1837  to  1850.  France  was  first  attacked ; 
in  1837  the  disease  began  in  two  separate  districts  of  the  south  of 
France  —  namely,  Bayonne  and  the  valley  of  the  Adour  on  the  one  hand, 
Foix  and  Narbonne  on  the  other  —  and  thence  spread  through  towns  of 
S.  W.  and  S.  E.  France  respectively.  In  many  instances  the  epideinic  was 
limited  to  the  garrison  of  a  town ;  and  an  epidemic  at  Versailles  appeared 
to  be  produced  by  the  transference  thither  of  soldiers  from  an  infected 
spot.  Other  independent  foci  appeared  in  N.  E.  France,  as  at  Metz 
(1839  to  1840),  and  N.  W.  France,  as  at  Laval  (1840),  Brest,  Caen,  and 
Cherbourg,  whence  the  disease  also  spread  mainly,  but  not  wholly, 
among  garrisons.  These  outbreaks  continued  till  1842  and  then  abated, 
but  from  1846  to  1850  a  fresh  series  appeared,  chiefly  in  garrison  towns 
of  N.  E.  and  S.  E.  France,  but  also  in  Orleans  and  Paris.  Throughout 
this  French  epidemic  the  central  parts  of  France  were  the  least  affected. 

Coincidently,  and  doubtless  in  connection  with  the  French  epidemic, 
there  occurred  an  epidemic  in  Algiers  (1840  to  1847). 

Southern  Italy  and  Sicily  were  severely  attacked  between  1840  and 
1845,  the  disease  spreading  widely  among  the  villages.  In  Denmark 
also  and  Iceland  the  disease  was  widely  prevalent  between  1845  and 
1848. 

In  no  other  European  country  was  there  a  severe  and  extensive 
pestilence,  though  minor  outbreaks  were  reported  from  various  places, 
as  from  Gibraltar  in  1847  (2).  In  Great  Britain  certain  cases  appeared 
in  Irish  workhouses  in  Dublin,  Bray,  and  Belfast  (1846),  and  some  at 
Liverpool. 

The  United  States  were  again  the  theatre  of  a  wide-spread  epidemic, 
which  manifested  itself  in  the  western  and  southern  states,  "  at  places 
as  remote  as  possible  from  Transatlantic  communication,  and  hundreds 
of  miles  distant  from  each  other  "  (3).  Somewhat  later  it  appeared  in 
Pennsylvania  (1848),  and  at  New  Orleans  (1850). 


EPIDEMIC   CEREBROSPINAL   MENINGITIS  66i 

The  third  period,  1854  to  1874,  exhibited  quite  a  different  distribu- 
tion of  the  disease  in  Europe.  The  countries  of  South  and  West  Europe 
(except  for  a  somewhat  wide  epidemic  in  South  Italy,  an  outbreak  in 
Portugal  and  one  in  Ireland)  were  spared;  Sweden,  Germany,  and  some 
parts  of  Russia  were  the  chief  sufferers. 

Beginning  at  Gothenburg  in  1854,  and  reinforced  from  other  foci  in 
the  south  of  Sweden  in  the  following  year,  the  disease  spread  through 
Sweden  in  a  northerly  direction.  The  outbreaks,  which  proved  extremely 
fatal,  appeared  in  winter  or  spring  time,  and  gradually  extended  north- 
wards till  in  1858  the  latitude  of  63°  IST.  was  reached.  After  that  year 
the  pestilence  gradually  declined.  The  neighbouring  countries  of  Nor- 
way and  Denmark  did  not  wholly  escape. 

In  1861  to  1862  there  were  outbreaks  in  Portugal. 

Next  Germany  was  widely  ravaged.  The  disease  appeared  in  North 
Germany,  namely,  in  the  eastern  districts  of  Silesia  (1863),  Posen, 
Pomerania,  East  and  West  Prussia;  and  also  in  Brandenburg,  Saxony, 
Hanover,  etc.  Southern  Germany  was  severely  attacked ;  beginning  at 
Erlangen  and  Nuremburg  (1864),  the  disease  spread  over  the  bulk  of 
Bavaria,  and  appeared  also  in  Hesse  and  Baden.  The  acme  of  the  Ger- 
man epidemic  was  in  1864  and  1865 ;  after  1866  the  outbreaks  became 
limited  and  scanty. 

Austria  and  Hungary  largely  escaped.  Russia  suffered  at  various 
points,  and  notably  in  the  Crimea  (1867  to  1868). 

At  Dublin  and  in  some  other  parts  of  Ireland  (1866  and  1867)  there 
was  an  epidemic  which  affected  both  the  troops  quartered  there  and  the 
civil  population.  There  were  some  scattered  cases  in  England,  namely, 
in  Rochester  and  South  London,  and  a  small  epidemic  at  Bardney  in 
Lincolnshire. 

The  United  States  witnessed  a  third  great  epidemic.  This  began  in 
North  Carolina  and  in  New  York  State  (1856  to  1857),  spread  widely 
during  the  War  of  Secession  (1861  to  1863),  and  afterwards  covered 
nearly  the  whole  area  of  the  States,  and  did  not  subside  till  1874.^ 

Hirsch's  fourth  period,  namely,  from  1876  to  1884,  to  which  we  may 
fairly  add  the  next  ten  years,  is  one  of  quiescence.  There  have  been  no 
great  epidemics,  though  limited  outbreaks  have  been  reported  at  inter- 
vals from  divers  countries.  In  Great  Britian  we  may  mention  sundry 
minor  attacks,  as  at  Dublin  (1885  to  1886),  Birmingham  and  its  neigh- 
bourhood (1876),  Galston  near  Kilmarnock  (1884),  and  certain  villages 
in  the  eastern  counties  (1890). 

Epidemic  cerebro-spinal  meningitis  may  be  regarded  in  a  twofold 
light :  (1)  as  an  acute  specific  fever ;  (2)  as  a  disease  which,  like  many 
other  specific  fevers,  is  characterised  by  certain  definite  local  lesions. 

Morbid  Anatomy.  —  This  consists  essentially  in  an  acute  inflammation 

1  Stille's  taV)le  (1883)  of  the  annual  deaths  from  this  cause  in  Pennsylvania  showed 
that  altliou;<h  tho  numbers  (lror)|ied  from  24(!  in  1S7.'5  to  82  in  1874,  they  still  remained 
hif,4i.  ran'^inti  from  .W  to  <)f)  per  juiniim.  Per'pf''''''*  eontinniaion  of  this  table  shows  a 
sudden  ri.se  iu  1884  to  124  deatks,  thcu  a  decrease  to  2o  iu  1891. 


662  SYSTEM  OF  MEDICINE 

of  the  pia-arachnoid,  both  of  the  brain  and  cord,  usually  manifesting 
itself  by  a  purulent  effusion  into  the  sub-ai"achnoid  space.  In  some  few 
cases,  indeed,  where  death  has  taken  place  at  a  very  early  stage,  no 
effusion  may  be  perceptible  to  the  naked  eye,  nothing  more  being  evi- 
dent than  mere  hypersemia,  or  (it  may  be)  cloudiness  of  the  membranes. 
Even  then,  however,  the  microscope  may  show  that  they  are  infiltrated 
with  cells.  But  most  commonly  the  effusion  is  visible.  This  when 
quite  recent  may  appear  serous  or  simply  cloudy,  or  it  may  be  blood- 
stained, or  again  it  may  be  transparent  and  gelatinous  in  consistence ; 
but  most  commonly  it  is  purulent,  either  yellowish  and  semi-solid  like 
butter,  or  a  purulent  liquid.  Such  purulent  effusion  has,  indeed,  been 
found  where  death  took  place  only  five  hours  after  the  onset  (4).  The 
pus  is  in  the  sub-arachnoid  space,  and  thus  remains  in  situ  after  removal 
of  the  dura.  Upon  the  brain  it  is  distributed  either  at  the  base  only 
or  over  the  hemispheres,  or  in  both  places,  and  also  upon  the  cere- 
bellum. It  may  occur  in  streaks  and  patches  along  the  line  of  the  vessels, 
or  in  the  recesses  of  the  fissures  and  sulci,  or  in  a  more  or  less  continuous 
sheet  covering  the  whole  brain.  Of  the  cord  it  affects  by  preference  the 
posterior  aspect,  aftd  the  dorsal  and  lumbar  regions  and  cauda  equina, 
rather  than  the  cervical  region ;  but  the  whole  cord  may  be  covered  by  it 
and  the  nerve  roots  as  well.  An  effusion,  though  less  frequently  purulent, 
may  take  place  into  the  ventricles  of  the  brain,  resulting  from  inflamma- 
tion of  the  choroid  plexus.  There  is  therefore  nothing  to  distinguish 
acute  meningitis  of  the  epidemic  type  from  that  due  to  any  other  consti- 
tutional cause,  tubercle  excepted. 

The  effusion  consists,  according  to  von  Ziemssen,  of  pus  cells, 
granules,  fibrin,  and  mucin.  Micrococci  have  been  found  in  it  —  to 
which  point  we  shall  return  later. 

Dr.  Burdon-Sanderson  says  the  cells  bear  a  general  resemblance 
to  pus  cells,  but  are  Isss  uniform  in  size  and  character.  They  may  form 
almost  a  continuous  layer,  or  may  be  embedded  in  a  granular  amorphous 
interstitial  substance. 

In  the  two  cases  examined  by  Flexner  and  Barker  they  found  three 
varieties  of  cells,  namely,  small  round  cells  with  one  large  nucleus  (lym- 
phocytes), large  and  more  irregularly  shaped  cells  with  several  nuclei 
(leucocytes),  and  larger  cells  of  epithelioid  type  with  vesicular  nuclei, 
and  some  red  blood-cells.  There  was  an  amorphous  intercellular  sub- 
stance staining  deeply  with  logwood;  a  little  fibrin  in  one  case  and 
none  in  the  other. 

The  subjacent  nerve  centres  are  also  involved  in  the  morbid  process. 
This  may  be  recognised  to  a  certain  extent  from  their  naked-eye  appear- 
ance—  the  surface  of  the  brain  being  either  congested,  or,  perhaps  more 
commonly,  sodden,  soft  and  pale  — •  but  it  is  more  definitely  ascertained 
by  microscopic  sections.  These  show  that  the  cell  infiltration  spreads, 
as  we  might  expect,  by  contiguity  into  the  superficial  layers  of  the  brain 
and  cord,  and  further  that  it  penetrates  still  more  deeply  along  the 
sheaths  of  the  vessels  that  dip  into  the  nerve  substance.     Microscopic 


EPIDEMfC   CEREBROSPINAL   MENINGITIS  663 

abscesses  and  haemorrhages  may  thus  arise,  and  sometimes  these  are 
large  enough  to  be  visible  to  the  naked  eye.' 

There  is  little  to  be  said  about  the  other  organs  of  the  body.  The 
skin  may  exhibit  the  remains  of  eruptions.  There  may  be  marked 
post-mortem  lividity,  fluidity  of  blood,  and  ecchymoses  of  internal  organs, 
as  in  other  acute  blood  diseases.  The  skull-bones  and  dura  are  often 
highly  congested.  The  spleen  may  or  may  not  be  enlarged.  Bronchitis, 
broncho-pneumonia,  and  hypostatic  congestion  of  the  lungs  may  be 
present  (the  patients  often  dying  from  pulmonary  embarrassment).  Some- 
times there  is  lobar  pneumonia  or  acute  pleurisy;  sometimes  endo- 
carditis or  pericarditis.     But  the  meningitis  is  the  only  essential  lesion. 

Any  description  of  the  symptoms  and  course  of  this  disease  must  be 
prefaced  by  the  statement  that  they  are  liable  to  much  more  variation 
than  is  usual  in  specific  fevers,  both  in  different  epidemics  and  in 
different  cases  of  the  same  epidemic.  Nevertheless  there  ai-e  certain 
cardinal  symptoms ;  namel}',  on  the  constitutional  side  —  fever  of  sudden 
onset,  with  depression  of  the  vital  powers,  with  or  without  rash ;  on 
the  nervous  side  —  pain  in  the  head  and  neck,  retraction  of  the  head,  and 
oftentimes  delirium  and  coma:  and  out  of  the  commonest  symptoms 
and  their  most  frequent  association  authors  have  endeavoured  to  con- 
struct a  "  simple  type  "  of  the  disease. 

In  this  type  there  may  be  prodroma,  such  as  chills,  malaise, 
headache,  vague  pains  in  the  back  and  limbs  ;  or  the  disease  may 
commence  suddenly  with  a  rigor,  fever,  severe  vomiting,  vertigo,  and 
above  all  with  pain  in  the  head,  chiefly  at  the  occiput.  This  pain  is 
intense,  and  accompanied  or  soon  followed  by  stiffness  at  the  back  of  the 
neck,  or  actual  retraction  of  the  head.  The  pain  is  apt  to  spread  down 
the  spinal  column  and  to  radiate  into  the  limbs  and  abdomen.  Along 
with  it  there  may  be  tenderness  of  the  skin  of  the  trunk.  The  eyes  are 
suffused,  the  pupils  (at  this  stage)  are  often  small,  the  face  pale,  and 
the  mind  clear ;  an  extreme  restlessness  is  common,  a  lethargy  is  less 
frequent. 

In  mild  cases  the  disease  may  stop  short  here  and  the  symptoms 
pass  off;  in  severe  cases  they  become  worse,  the  pain  increases,  the 
rigidity  of  the  neck  spreads  down  the  spine,  producing  perhaps  actual 
opisthotonus,  the  mind  begins  to  wander,  or  downright  delirium  sets  in, 
which  may  pass  into  furious  mania.  At  such  a  stage,  after  only  a  few 
days'  illness,  the  patient  may  die,  apparently  from  the  mere  violence  of 
the  nervous  symptoms. 

But  if  neither  death  nor  abatement  of  the  disease  take  place  the 
delirium  is  often  succeeded  by  coma.  The  two  conditions  may  alternate, 
or  the  coma  may  be  persistent  and  eventually  deepen  into  death.  But 
should  the  coma  also  clear  up,  the  patient,  after  a  varying  interval, 

1  StriimpoH,  who  has  drawn  spoiiial  attc,nt:if)ii  to  this  process,  believes  that  the  in- 
flammation tluis  set  up  is  by  no  moans  limited  to  tlao  surface  of  tlio  brain.  He  also 
thin]<s  tliat  a  lar<,'e  lorialisod  abscess  may  arise  after,  and  in  consequence  of  an  attack 
of  epidemic  cerebro-spinal  meningitis.— />'(?(f<sc/tes  Archiv  f.  kiln.  Med.  xxx.  pp.  523  foil. 


664  SYSTEM   OF  MEDICINE 

and  in  an  extreme  condition  of  emaciation  and  enfeeblement,  enters  on  a 
tedious  convalescence. 

Other  common  events  are  —  (1)  cutaneous  eruptions,  notably  herpes, 
and  petechial  spots ;  (2)  affections  of  the  eye  and  ear,  which  too  often 
prove  irremediable. 

The  duration  of  the  attack  varies  greatly  —  from  two  or  three  days 
to  three  or  four  weeks  or  more.  Death  may  occur,  or  recovery  set  in, 
at  variable  stages,  and  such  recovery  may  be  complete,  or  may  leave 
the  patient  with  persistent  headache,  or  crippled  in  limb  or  special 
senses. 

IS"umerous  other  types  are  described.  The  most  important  of  these 
is  the  "  type  f oudroyante  "  of  French  authors,  which  may  also  be  called 
the  fulminant,  siderant,  apoplectic,  or  malignant  type.  The  character- 
istics of  this  are  extreme  suddenness  of  onset,  severe  collapse,  and  early 
coma,  which  may  prove  fatal  ere  diagnostic  symptoms  have  appeared. 
Cutaneous  haemorrhages,  often  extensive,  are  common  in  this  form  of 
the  disease.  Recovery  is  a  rare  event.  Such  cases  are  compai*able  to 
the  malignant  forms  of  measles  and  of  other  specific  fevers,  in  which  the 
patient,  overwhelmed  by  the  poison,  dies  early.  They  are  said  to  be 
most  common  at  the  commencement  of  epidemics,  and  obviously  this 
must  render  the  diagnosis  of  their  true  nature  more  difficult. 

The  abortive  ti/pe  is  that  in  which  the  patient  suffers  for  a  short  time 
and  in  a  limited  degree  from  vertigo,  headache,  occipital  pain  and  the 
like,  but  recovers  rapidly  without  any  serious  illness.  Similarly  during 
cholera  epidemics  cases  of  simple  diarrhoea  are  often  prevalent ;  and 
during  epidemics  of  scarlet  fever  or  diphtheria  cases  of  sore  throat. 

The  intermittent  type  is  a  curious  variety.  In  this  there  appear 
alternate  remissions  and  exacerbations  of  the  symptoms.  Sometimes 
these  appear  to  have  the  periodicity  of  true  ague ;  but  according  to  von 
Ziemssen  the  regular  use  of  the  thermometer  shows  that  the  periodicity 
is  more  apparent  than  real.  This  peculiar  tendency  may  be  observed 
in  any  stage  of  the  disease,  even  in  the  prodromal  period  where  such 
exists. 

The  clinical  features  of  the  disease  must  be  considered  more  in 
detail ;  and  first,  the  general  features.  Acuteness  of  onset  and  violence 
of  local  symptoms  are  dominant  facts.  Yet  the  temperature  does  not 
necessarily  run  high.  All  authors  agree  that  the  temperature  is  not 
characteristic,  it  neither  corresponds  to  the  type  of  any  other  fever,  nor 
has  it  a  type  of  its  own.  Maintained  elevation  of  any  high  degree  is 
exceptional ;  101°  to  103°  appears  to  be  about  the  average.  But,  as  in 
other  diseases  of  the  nerve  centres,  sudden  rises  may  take  place,  which 
are  either  transitory  or  prolonged  into  veritable  hyperpyrexia.  Neither 
can  any  rule  be  laid  down  about  the  pulse  rate;  it  is  rai-ely  much 
accelerated,  except  it  be  towards  the  end  of  a  fatal  coma ;  it  may  vary 
greatly  from  time  to  time.  But  in  character  the  pulse  is  compressible 
and  of  low  pressure,  not  hard  or  bounding ;  in  this  respect  corresponding 
to  the  general  loss  of  strength,  prostration,  and  tendency  to  collapse 


EPIDEMIC   CEREBROSPINAL  MENINGITIS  665 

which  from  the  outset  form  a  striking  feature  of  the  disease.  ^  There  is 
no  constant  increase  in  the  respiration  rate ;  the  character  of  the  respira- 
tion in  the  early  stages  may  be  simply  indicative  of  pain,  but  in  the 
graver  conditions  it  becomes  embarrassed  and  "  suspirious,"  marked,  that 
is,  "  by  a  slow,  laboured  inspiration  followed  by  a  quick  expiration  and  a 
long  pause  "  (5).  When  in  deepening  coma  there  is  a  steady  rise  in  the 
pulse  rate,  respiration  rate  and  temperature,  with  blueness  and  a  clammy 
skin,  a  fatal  pulmonary  paralysis  is  indicated.  The  tongue,  except  in 
very  severe  cases  or  towards  the  later  stages,  when  a  so-called  typhoid 
condition  has  appeared,  may  give  no  indication  that  the  patient  has  a 
grave  constitutional  disease.  The  bowels  are  usually  confined.  There  is 
neither  burning  heat  of  skin  nor  profuse  sweating.  The  conjunctiva  may 
present  a  diffuse  pink  suffusion  upon  which  some  authors  lay  much 
stress  (3)  ;  the  face  is  usually  pale,  and  till  stupor  or  delirium  intervene 
the  expression  is  not  dazed  and  heavy,  but  indicative  of  pain,  restless- 
ness and  irritability. 

The  urine  is  normal,  but  sometimes  contains  albumin,  and  in 
hsemorrhagic  cases  blood ;  glycosuria  has  been  observed  rarely  (8,  9). 

The  blood,  as  obtained  by  venesection,  shows,  according  to  Stille, 
the  characters  indicative  of  inflammation ;  while  from  microscopic  ex- 
amination Flexner  and  Barker  conclude  that  there  exists  in  the  early 
stages  of  the  malady  a  well-marked  leucocytosis,  associated  with  certain 
other  changes,  not  peculiar  to  this  disease,  which  may  exist  in  any  kind 
of  local  inflammation  with  exudation. 

The  nervous  symptoms  must  evidently  be  similar  to  those  which  occur 
in  other  forms  of  meningitis,  but  their  acuteness  and  severity  are 
greater. 

The  headache  is  not  a  mere  dull  aching,  but  an  intense  and  often  an 
intolerable  pain.  Without  definite  localisation  at  first,  it  soon  concen- 
trates itself  upon  the  occiput  and  back  of  the  neck.  Pain,  too,  may 
affect  the  spinal  column,  and  may  radiate  thence  into  the  limbs  and 
round  the  trunk,  and  into  the  abdomen  particularly;  so  that  in  some 
cases  abdominal  pain  becomes  quite  a  leading  symptom.  The  jjain  is 
aggravated  by  all  movements. 

Cutaneous  hyperalgesia  is  common.  This  probably  originates,  like 
the  pain,  in  irritation  of  the  sensory  nerve  roots.  Numbness  and 
angesthesia  may  follow  as  the  nerve  irritation  gives  place  to  paralysis. 

The  pain  is  accompanied  or  soon  followed  by  another  symptom,  so 
common  as  to  be  almost  pathognomonic,  namely,  retraction  of  the  head.  The 
head  is  thrown  backwards  (in  extreme  cases  so  far  that  it  appears  to  lie 
between  the  scapulse),  the  patient  generally  lying  on  his  side  with  the 
legs  drawn  up.  Dr.  Burdon-Sanderson  thinks  this  pose  of  the  head  is 
assumed  in  order  to  mitigate  the  pain  in  the  muscles  of  the  nucha ;  but 
most  authors  regard  it  as  due  to  a  toni(;  muscular  spasm.     Sometimes  the 

1  I  do  nof,  fitrl  that  anthnrs  lay  much  stress  on  sli<?lit  irregularity  of  pulse,  such  as 
is  coiniiioii  ill  tul)ercii]ar  meningitis,  though  Zieiussen  remarks  that  irregularity  iu 
rhythm  is  not  uncommon. 


666  SYSTEM   OF  MEDICINE 

extensor  muscles  of  the  wliole  back  are  implicated  so  that  there  is  actual 
opisthotonus.  The  limbs  also  may  become  rigid,  ^  or  the  face  may  be 
drawn  into  a  risus  sardonicus,  or  in  bad  cases  there  may  be  trismus. 
All  these  muscular  spasms  are  more  continuous  than  those  of  tetanus, 
not  presenting  such  perfect  alternations  of  paroxysm  and  remission  as 
does  that  disease. 

Voniiting  is  another  early  symptom ;  it  is  of  more  common  occurrence, 
more  severe  and  intractable  than  in  most  other  fevers.  It  may  occur 
independently  of  food,  without  furring  of  the  tongue  or  other  sign  of 
gastric  disturbance,  and  is  therefore  to  be  ascribed  to. the  irritation  of 
the  nervous  system.  Vomiting  in  the  later  stages  of  the  disease,  especially 
when  associated  with  coma  and  convulsions,  is  indicative  of  distension  of 
the  ventricles  by  effusion,  and  is  of  bad  import  (7). 

There  may  be  distressing  vertigo,  particularly  when  the  patient  lifts 
his  head  from  the  pillow ;  this  may  be  sufficiently  accounted  for  by  the 
derangement  of  the  cerebral  centres,  but  it  must  be  remembered,  too, 
that  sometimes  the  auditory  apparatus  is  specially  involved. 

TLoitchings  of  the  limbs  are  very  common,  genei-al  convulsions  may 
occur,  but  (except  in  children)  are  less  frequent  than  we  might  expect, 
considering  the  amount  of  cortical  irritation.  Prolonged  convulsions 
are  a  bad  sign,  particularly  when  they  occur  late  in  the  disease. 

Paralysis  of  the  ocular  nerves,  causing  squint  (possibly  due  sometimes 
to  muscular  spasm),  ptosis,  dilatations  and  inequalities  of  the  pupils, 
are  as  common  as  in  other  forms  of  meningitis.  Nystagmus  is  some- 
times seen.  Facial  paralysis  may  also  occur.  Paralyses  of  the  limbs 
do  not  appear  to  be  common;  still  they  may  occur,  and  particularly 
in  the  later  stages :  they  may  be  of  very  various  type  (hemiplegic, 
paraplegic,  monoplegic),  as  is  evident  from  the  wide  distribution  of  the 
lesion ;  and  may  be  transitory  or  permanent,  according  to  the  degree  of 
damage  to  the  nerve  roots  and  centres. 

The  tendon  reactions,  according  to  Striimpell,  may  vary.  Thus,  in 
thirty-tAvo  cases  examined  by  him  in  Leipzig  in  1879,  the  knee-jerks 
were  absent  in  five ;  in  three  they  disappeared,  to  reappear  during  con- 
valescence, which  change  was  probably  due  to  varying  pressure  on  the 
nerve  roots ;  sometimes  they  were  lively,  sometimes  much  increased. 

Ojytic  neuritis  was  found  by  Randolph  of  Lonaconing,  Maryland,  six 
times  in  forty  cases  examined  ophthalmoscopically. 

The  mental  condition  we  have  already  noticed.  Extreme  restlessness 
is  often  a  characteristic  of  the  early  days  of  the  disease.  Delirium  very 
commonly  supervenes,  whether  it  be  a  mere  wandering  at  night,  or  a 
kind  of  rambling  stupor  from  which  the  patient  can  be  aroused  by 
sharply  speaking,  or  an  active  and  often  violent  delirium.  The  access  of 
coma  is  always  a  grave  sign,  though  recovery  from  it  is  by  no  means 
impossible;    the   more   deep   and   persistent   the   coma  the  worse  the 

1  Kernig  pointed  out  that  by  puttins:  the  patient  into  a  sitting  posture  (or  tiexing 
his  thighs  as  he  lies)  a  certain  spasm  is  induced  in  the  flexors  of  the  knee,  so  that  this 
joint  cannot  be  completely  straightened  out  (10). 


EPIDEMIC  CEREBROSPINAL  MENINGITIS  667 

prognosis.  It  must  not  be  supposed  that  these  mental  states  always 
succeed  each  other  in  regular  order ;  delirium  may  occur  at  the  outset, 
and  the  worst  type  of  case,  the  "  foudroyante,"  is  marked  by  early  coma. 

There  are  symptoms  which  cannot  be  wholly  referred  to  the  disease 
of  the  nervous  centres,  and  of  these  the  most  striking  are  the  rashes. 
These  are  by  no  means  constant.  In  some  epidemics  there  has  been  no 
rash  ;  in  others  very  various  rashes  have  been  described,  as  for  instance 
erythema,  urticaria,  rose-spots  like  those  of  typhoid,  measly  eruptions, 
vesicular  and  bullous  eruptions.  But  the  most  common  are  herpetic 
and  hsemorrhagic  rashes. 

Herpes  of  the  lips  and  face  is  so  frequent  that  it  has  been  called 
characteristic  of  the  disease.^  Tourdes  observed  it  in  two-thirds  of  his 
cases.  Von  Ziemssen  says  that  in  no  other  disease  has  he  observed 
facial  herpes  to  spread  so  widely.  It  commonly  occurs  within  the  first 
five  days  of  tlie  illness,  but  sometimes  later  than  this  ;  and,  indeed,  there 
may  be  several  crops  of  herpes  coming  out  at  various  dates.  It  has  no 
prognostic  significance.  Eruptions  of  herpes  may  come  out  on  the  limbs 
and  trunk,  and  are  often  symmetrical ;  they  have  been  referred,  there- 
fore, to  the  nervous  lesion  as  a  cause.  According  to  Klemperer,  herpes 
labialis  stands  on  a  different  footing  to  herpes  zoster.  He  finds  micro- 
cocci in  the  vesicles  of  herpes  labialis,  and  thinks  that  this  eruption 
indicates  some  acute  inflammatory  affection.  Petechiae  were  so  common 
and  so  abundant  in  the  early  American  epidemics  that  the  name  "  spotted 
fever"  was  applied  to  the  disease  —  a  name  peculiarly  unfortunate; 
first,  because  of  the  confusion  thereby  created  between  epidemic  men- 
ingitis and  exanthematic  typhus  ;  and  secondly,  because  in  many  other 
epidemics  petechige  have  not  been  seen  at  all.  This  rash,  like  herpes, 
may  appear  early,  and  has  little  relation  to  the  gravity  of  the  disease. 

Cutayieous  hcemorrhages  other  than  mere  petechiae  are  a  more  serious 
matter,  as  they  generally  indicate  a  severe  form  of  the  disease.  In  the 
Dublin  epidemic  of  1866-67  such  heemorrhagic  rashes  were  particularly 
common,  so  that  the  name  "  malignant  purpuric  fever  "  was  then  pro- 
pounded. Dr.  Samuel  Gordon,  describing  the  condition  of  the  skin  in 
this  epidemic,  notes  that  there  may  be  — (1)  a  coldness  or  blueness  of 
the  extremities  or  whole  body  like  that  of  cholera;  (2)  bruises  and  ecchy- 
moses  like  those  of  typhus  or  scurvy ;  (3)  a  hsemorrhagic  eruption  com- 
ing out  all  over  the  body,  but  chiefly  in  the  lower  limbs,  dark  in  colour, 
being  brown,  purple,  or  black  as  ink ;  some  spots  small  and  round,  others 
larger  and  irregular,  others  like  large  spots  of  very  black  purpura,  but 
more  mottled  and  more  irregular  in  colour  and  shape,  others  raised 
above  the  level  of  the  skin.  These  may  be  gradually  absorbed,  or  may 
in  some  cases  become  gangrenous.  Hasmorrhages  from  the  mucous 
surfaces,  for  example,  of  the  nose,  stomach,  bowels,  kidneys,  may  also 
take  j)lace. 

1  Yfit  Stillc  says  of  thr3  Miissacliiisetts  opidemic:  —  "  Herpes  labialis  was  noticorl  in  a 
ffiwiiistaiiooH  .  .  .  it,  is  certainly  much  loss  CDinmon  as  a  symptom  of  epidemic  meningitis 
than  either  the  roseolous  or  petechial  spots  "  (3). 


668  SYSTEM  OF  31  ED  I  CINE 

There  are  other  important  possibilities,  which  are  perhaps  best 
reckoned  as  complications  and  sequelae. 

Foremost  amongst  tliese  are  affections  of  tlie  special  sense  organs. 

The  eye  may  be  attacked,  even  in  the  early  stages  of  the  disease, 
by  severe  conjunctivitis,  or  by  iritis  or  keratitis  leading  to  corneal 
opacities.  Still  more  to  be  dreaded  is  inflammation  of  the  deeper  parts, 
such  as  a  purulent  infiltration  of  the  choroid,  leading  to  detachment  of 
the  retina,  or  (still  worse)  to  inflammation  and  disorganisation  of  the 
whole  eyeball.  It  is  possible  that  this  deep-seated  inflammation  is  prop- 
agated from  the  meninges  along  the  sheath  of  tlie  optic  nerve  to  the 
structures  at  the  back  of  the  eyeball.  Other  ophthalmic  complications 
are  optic  atrophy,  secondary  to  optic  neuritis ;  thrombosis  of  the  retinal 
veins ;  amaurosis  without  obvious  cause. 

Disease  of  the  auditory  apparatus  is  even  more  frequent  than  that  of 
the  eye.  The  onset  of  deafness  may  be  difficult  to  time  in  the  presence 
of  a  severe  constitutional  disease,  particularly  when  there  is  delirium  or 
stupor.  But  in  some  cases,  at  any  rate,  it  is  an  early  symptom.  Deaf- 
ness may  be  due  either  to  purulent  otitis  media,  or  to  disease  of  the 
labyrinth  (15).  In  the  latter  case  it  is  probable  that  the  meningeal 
inflammation  spreads  along  the  auditory  nerve  to  the  cochlea  and  semi- 
circular canals.  If  these  parts  are  destroyed  total  and  hopeless  deaf- 
ness must  result ;  and  in  little  children  this  means  deaf-mutism.' 
With  this  is  sometimes  associated  a  staggering  gait.^ 

Of  less  importance  are  anosmia  and  loss  of  taste,  which  have  also 
been  described. 

Chronic  hydrocephalus  is  a  very  serious  sequela.  This  has  been 
particularly  studied  by  von  Ziemssen  (7).  It  would  appear  that  in 
cases  which  survive  the  acute  stages  of  the  disease  the  meningeal  exu- 
dation gradually  degenerates,  and  is  absorbed ;  but  the  pia-arachnoid 
becomes  thickened  and  shrunken,  and  the  ependyma  ventriculorum  hy- 
pertrophies. The  ventricular  effusion,  probably  in  consequence  of  these 
cicatricial  changes,  either  remains  unabsorbed  or  increases  in  amount, 
albeit  now  less  purulent  and  more  passive  in  character;  while  the 
cerebral  substance  becomes  pallid  and  atrophied  from  pressure.  The 
symptoms  of  such  hydrocephalus  show  themselves  during  the  period 
of  convalescence,  a  distinct  interval  having  elapsed  since  the  acute 
stage  of  the  meningitis ;  they  consist  of  headache  and  pains,  vomitings, 
coma,  convulsions.  Sometimes  they  have  a  paroxysmal  character,  and 
may  thus  last  for  weeks.     The  onset  of  such  symptoms  at  this  late 

1  How  frequent  these  aural  complications  may  be  is  shown  hy  the  observations  of 
Moos,  who  f  jund  that  out  of  6i  convalescents  from  epidemic  cerebro-spinal  meningitis,  38 
were  deal-mutes  ;  20,  absolutely  deaf ;  5,  partially  deaf ;  1,  not  at  all  deaf  ;  and  32  had  a 
staggering  gait.  And  von  Ziemssen  found  that,  in  an  institution  for  deaf-mutes,  contain- 
ing 42  children,  every  one  had  become  deaf-mute  after  cerebro-spinal  meningitis,  while  in 
another  of  32  inmates  the  number  due  to  this  cause  was  22. 

2  Voltolini's  disease,  the  symptoms  of  which  are  deafness,  deaf-mutism,  and  stagger- 
ing gait  coming  on  after  a  short  feverish  attack,  perhaps  accompanied  with  severe  cere- 
bral symptoms,  which  Voltolini  ascril)es  to  primary  intlammatiou  of  the  labyrinth,  is 
thougiit  by  many  physicians  to  be  a  meningitis  spreading  to  the  ear. 


EPIDEMIC   CEREBROSPINAL   MENINGITIS  669 

stage  of  the  disease  must  give  rise  to  serious  alarm,  for  though  recovery 
from  hydrocephalus  may  take  place  it  is  very  rare. 

Joint  disease  is  not  unfrequent ;  it  is  mentioned  both  by  the  older 
writers  and  by  several  recent  authors.  Sometimes  the  joints  are  painful, 
red  and  swollen,  as  in  gout  or  acute  rheumatism ;  sometimes  there  is  a 
simple  serous  effusion,  sometimes  they  contain  pus.  This  last  fact  seems 
to  point  to  the  general  blood  state  as  the  cause  of  the  joint  disease, 
rather  than  to  a  perverted  trophic  influence  of  the  nerve  centres.  The 
appearance  of  joint  affections  has  in  some  instances  coincided  with 
amelioration  of  the  meningeal  symptoms.  Nonpurulent  arthritis  has 
been  treated  successfully  by  salicylates. 

Pulmonary  congestion  and  collapse  are  frequent,  as  is  natural  in  the 
course  of  an  exhausting  acute  disease ;  broncho-pneumonia  may  occur, 
and  sometimes  acute  lobar  pneumonia.  It  will  be  remembered  that  con- 
versely acute  pneumonia  may  be  complicated  by  meningitis  ;  this  occur- 
rence, rare  on  the  whole,  is  said  to  be  more  frequent  after  an  epidemic 
of  meningitis  than  at  other  times  (16). 

Other  complications,  apparently  of  a  pymmic  nature,  may  be  men- 
tioned; such  as  ulcerative  endocarditis,  pericarditis,  pleuritis,  peritonitis, 
parotitis  with  abscess,  and  diffuse  abscesses  in  the  connective  tissues  of  the 
limbs  and  trunk.  Sometimes,  instead  of  the  usual  constipation  there  is 
an  enteritis,  which  causes  a  dysenteric  diarrhma. 

Lastly,  a  rapid  and  great  emaciation  accompanies  the  disease,  which 
may  take  long  to  amend. 

As  to  treatment,  it  must  be  admitted  at  once  that  we  have  no 
specific  to  arrest  the  morbid  process.  In  the  earlier  epidemics  free 
blood-letting  was  employed,  not  with  much  success :  but  local  depletion 
by  leeches  or  cups,  or  blisters  to  the  temples,  nucha  or  spine,  have  been 
much  used.  Such  remedies  are  suitable  only  for  the  early  stages  of 
the  disease,  when  they  are  said  to  relieve  symptoms,  and  possibly 
to  modify  the  local  inflammation  of  the  meninges.  Cold  in  the  shape 
of  ice-bags  is  recommended  for  the  same  purpose.  Mercurial  purga- 
tives have  been  freely  given,  and  mercury  has  been  used  so  as  to 
produce  its  constitutional  effect.  One  author  writes :  —  "  The  jugular 
vein  was  opened,  and  blood  drawn  in  a  full  stream  as  long  as  the  boy's 
strength  would  permit.  This  was  followed  up  by  relays  of  leeches  to 
the  temples  and  mastoid  processes.  The  mercurial  plan  was  at  the  same 
time  most  energetically  pursued,  and  blisters  with  mercurial  dressings 
were  applied  to  the  head  and  along  the  spine.  Yet  all  was  of  no  avail, 
my  patient  died  in  convulsions  on  the  fourth  day."  All  such  heroic 
measures  in  the  way  of  bleeding,  purgation,  emetics,  mercurialisation,  and 
the  like,  are  contra-indicated  by  the  tendency  to  depression  and  collapse 
which  may  exist  from  the  very  outset.  Such  tendency,  when  present, 
must  be  met  by  alcohol,  used  sparingly  in  ordinary  cases,  liberally  in 
those  which  are  of  the  malignant  type.  The  diet  miist  necessarily  be 
light  at  first,  while  vomiting  and  other  acute  symptoms  prevail,  but 
it  may  be  increased  earlier  than  in  most  fevers,  as  there  is  seldom  any 


670  SYSTEM  OF  MEDICINE 

gastric  or  intestinal  lesion,  and  severe  emaciation  is  common.  The 
importance  of  carefully  feeding  comatose  patients,  by  the  rectum  or  by 
the  nasal  tube  if  necessary,  need  hardly  be  insisted  upon.  There  is 
an  almost  universal  testimony  in  favour  of  one  drug,  namely,  opium  or 
morphia.  Burdon-Sanderson  says  that  its  advantages  in  calming  rest- 
lessness and  relieving  pain  after  the  initial  symptoms  have  subsided  seem 
unequivocal  (in  doses  of  i  to  ^  grain  of  opiuui  by  the  mouth,  or  better 
as  morphia  hypodermically).  Von  Ziemssen  says,  "  Morphia  may  be 
regarded  as  one  of  the  most  indispensable  remedies  in  the  treatment  of 
epidemic  meningitis."  Stille,  going  further,  gave  one  grain  of  opium 
every  hour  in  severe  cases,  or  one  grain  in  moderately  severe  cases 
every  two  hours,  under  the  conviction  that  it  is  not  merely  a  palliative, 
but  also  influences  favourably  the  Avhole  condition  of  the  patient,  and 
that  the  opium  treatment  is  most  useful  when  it  is  begun  early  in  the 
attack. 

In  the  later  stages  of  the  disease,  for  such  symptoms  as  may  depend 
upon  meningeal  thickenings  and  deposits,  iodide  of  potassium  is  the  best 
accredited  remedy,  with  tonics  to  restore  the  exhausted  strength.  But 
for  secondary  hydrocephalus,  von  Ziemssen  says,  little  can  be  done. 
Local  paralyses  must  be  treated  by  massage  and  electricity.  For  the 
severe  disorganisations  of  eye  and  ear  nothing  can  be  done. 

Prognosis.  — The  course  of  the  disease,  as  already  mentioned,  is  very 
variable,  but  the  outlook  is  always  serious.  In  the  fulminant  or  malig- 
nant cases,  where  the  patient  is  stricken  down  suddenly  and  rapidly 
passes  into  coma,  recovery  is  very  rare.  In  mild  cases,  at  the  end  of 
the  first  few  days,  after  the  irritative  stage  of  headache,  vomiting,  and 
perhaps  even  delirium,  the  disease  may  take  a  favourable  turn  and 
convalescence  begin.  Such  convalescence  is  sometimes  rapid,  but  more 
often  slow.  "  The  disease  is  distinguished  by  the  slowness  of  its  cure 
and  the  rapidity  of  its  fatal  issue,"  says  Tourdes.  But  death  may  oc- 
cur during  the  stage  of  delirium,  or  still  more  commonly  during  coma, 
in  any  case  comparatively  early;  Simon  and  Sanderson  say,  "  generally 
from  the  fifth  to  eightli  day ;  "  Hirsch  says,  "  commonly  within  the  first 
eight  days,  and  as  a  rule  between  the  second  and  fourth  day."  Nor  are 
the  later  stages  free  from  danger,  looking  to  the  risk  of  hydrocephalus 
and  to  the  extreme  exhaustion  and  emaciation. 

The  prognosis  is  influenced :  — 

1.  By  the  character  of  the  epidemic ;  Hirsch's  tables  of  forty-one 
epidemics  give  all  grades  of  mortality  from  20  to  75  per  cent  (17)  ; 
and  by  the  duration  of  the  epidemic,  for  rapidly  fatal  cases  are  most 
frequent  at  the  commencement  of  an  outbreak,  mild  cases  towards  its 
close. 

2.  In  the  individual  case  by  the  following  circumstances :  — 
Absence  of  prodroma,  sudden  and  severe  onset,  early  appearance  of 

coma,  depth  and  prolongation  of  coma,  wideness  in  the  distribution  of  the 
local  nervous  symptoms  (showing  brain  and  cord  to  be  alike  involved), 
trismus,  complications  involving  other  organs  —  especially  the  hmgs,  the 


EPIDEMIC   CEREBROSPINAL  MENINGITIS  671 

reappearance  of  grave  cerebral  symptoms  (vomiting,  convulsions,  coma) 
in  the  stage  of  convalescence ;  all  these  things  are  unfavourable. 

As  to  age,  Hirsch  says  that  children  and  people  over  forty  run 
greater  risk  than  those  of  middle  age.  Concerning  a  Dublin  epidemic 
Grimshaw  says  that  of  the  children  admitted  to  Cork  Street  Hospital 
many  recovered,  while  the  recruits  admitted  to  Steeven's  Hospital  mostly 
died. 

The  diagnosis  should  in  general  be  aided  by  two  considerations :  — 

1.  The  knowledge  that  an  epidemic  prevails. 

2.  The  appearance  of  meningeal  symptoms  early  in  the  illness. 
There  are  not  many  epidemic  diseases  with  which  confusion  is  likely. 

Typhus  may  resemble  it  in  the  rash,  the  prostration,  and  the  coma; 
and  true  typhus  may  be  complicated  by  meningitis:  but  the  attack  of 
epidemic  meningitis  is  more  sudden,  there  is  no  regular  upward  march 
and  maintenance  of  temperature,  the  initial  headache  is  more  severe  and 
persistent,  and  the  meningeal  symptoms  come  on  early.  Influenza  pre- 
sents similarities  in  the  sudden  onset  with  fever,  headache,  and  pains  in 
the  back  and  limbs,  and  in  the  prostration  to  which  it  gives  rise.  Giyen 
coincident  epidemics  of  the  two  diseases,  it  might  indeed  be  difficult  to 
distinguish  severe  influenza  from  mild  meningitis ;  but  in  general  the 
shorter  course,  the  less  serious  character  of  the  nervous  symptoms,  and 
the  absence  of  retraction  of  the  head,  and  of  positive  signs  of  organic 
nerve  disease  (such  as  squint,  etc.),  would  point  to  influenza  rather  than 
to  meningitis.  Should  an  epidemic  of  meningitis  begin  with  fulminant 
cases,  which  prove  fatal  before  nervous  symptoms  set  in,  it  may  be 
impossible  to  recognise  their  true  nature  at  the  time.  The  opposite 
difficulty  may  occur  when  an  epidemic  is  characterised  by  many  mild 
or  abortive  cases ;  in  that  case  minor  complaints,  such  as  rheumatism 
of  the  neck,  migraine,  hysteria  with  opisthotonus,  may  be  taken  for 
meningitis,  and  particularly  febrile  diseases  in  children  beginning  Avith 
convulsions,  vomiting,  nervovis  irritability,  and  perhaps  with  retraction 
of  the  head. 

Tubercular  meningitis  (in  children,  at  any  rate)  has  generally  a  more 
gradual  onset,  a  less  violent  headache,  and  a  more  regular  course  than 
the  epidemic  disease. 

In  acute  meningitis  of  the  ordinary  type  diagnosis  is  aided  by  the 
presence  of  a  recognised  cause,  for  example,  suppurative  disease  of  ear 
or  nose,  disease  of  bone,  injury,  pyasmia,  or  other  acute  illness;  more- 
over, spinal  symptoms  are  less  commonly  present. 

Isolated  cases  of  cerebro-spinal  meningitis  occur  without  obvious 
causation,  and  the  recognition  of  them  before  death  may  be  very  difficult. 
Whether  such  sporadic  meningitis  is  essentially  the  same  as  the  epidemic 
or  no,  we  cafi  hardly  say  till  we  have  attained  more  certain  knowledge 
concerning  the  etiology  of  the  two  varieties.  The  rash  which  is  so 
striking  a  feature  of  many  epidemics,  and  which  seems  to  assimilate  them 
to  acute  fevers  in  general,  is  absent  in  most  sporadic  cases,  but  not 
invariably.     It  is  said  that  sporadic  cases  crop  up  particularly  in  places 


672  SYSTEM  OF  MEDICINE 

which  have  suffered  from  the  epidemic  disease,  as  in  the  Franco-Prussian 
war  (19) ;  if  this  be  so,  it  points  to  the  identity  of  the  two  varieties. 

Etiology.  —  Cold  contributes  to  the  outbreak,  but  cannot  be  tlie  sole 
cause.  Most  epidemics  have  begun  in  winter  or  spring,  and  further  the 
attack  seems  in  individual  cases  sometimes  to  be  determined  by  exposure 
to  cold.  But,  on  the  other  hand,  in  many  of  the  severest  Avinters  there 
have  been  no  epidemics,  and  recrudescences  of  epidemics  have  begun 
during  spells  of  mild  weather.  Neither  is  the  disease  known  in  Arctic 
climates,  but  only  in  the  temperate  and  sub-tropical  zones.  Hirsch 
gives  its  limits  in  W.  hemisphere  from  45°  N.  (Montreal)  to  30"  N. 
(Mobile) ;  in  E.  hemisphere  from  63°  N.  (Sweden  and  Russia)  to  30°  N. 
(Jerusalem,  Persia,  Algiers). 

It  is  independent  of  malaria,  and  of  local  peculiarities  of  soil  and 
situation:  this  is  shown  by  its  very  wide  distribution  over  manifold 
countries,  altitudes  and  soils. 

It  has  no  special  predilections  for  race  or  sex ;  as  to  age,  it  selects 
principally  children  and  adults  in  the  prime  of  life.  As  to  conditions 
of  life,  it  may  be  that  privation,  overcrowding,  bad  sanitation, — in 
short,  the  circumstances  of  the  very  poor,  —  favour  its  outbreak,  but 
they  have  never  been  shown  to  form  an  essential  cause  thereof.  It  has 
been  seen  alike  in  town  and  country.  One  fact,  however,  is  most  promi- 
nent, namely,  that  soldiers  are  especially  obnoxious  to  it,  and  particularly, 
as  it  would  appear,  during  garrison  life.  Recruits,  too,  suffer  more  than 
seasoned  troops.  J^articular  battalions  or  regiments,  or  again  particular 
barracks,  have  sometimes  been  picked  out  by  the  disease.  The  counter- 
part to  this  has  been  seen  in  civil  life,  when  a  particular  workhouse  or 
school  has  been  selected  by  it. 

The  manner  of  its  appearance  and  spread  is  peculiar.  It  spreads 
from  no  one  centre  of  origin  or  of  activity  either  by  contiguity  or  on 
special  lines,  Avhether  lines  of  traffic  or  other  mode  of  distribution ;  ^  but  it 
breaks  out  at  diverse  and  apparently  disconnected  foci,  in  separate  towns^ 
villages  or  tenements ;  and  it  spreads  in  a  similar  discontinuous  way. 
In  point  of  time,  an  epidemic  of  meningitis  does  not  steadily  mount 
to  a  maximum  and  then  decline,  but  proceeds  by  fits  and  starts,  crops 
of  fresh  cases  appearing  at  irregular  intervals. 

Its  ordinary  methods  of  propagation  are  not  known.  It  has  not  been 
traced  to  food  -  or  water-supply.  Direct  propagation  from  one  patient  to 
another  is  certainly  not  the  rule,  albeit  there  are  a  few  instances  of  this. 
There  may  be  a  certain  infection  of  locality,  as  already  said,  it  may  hang 
about  places  where  it  has  once  appeared ;  and  it  has  been  transferred 
from  place  to  place  by  human  beings. 

I  find  no  statements  bearing  on  the  question  of  immunity,  as  to 
whether  one  attack  protects  against  another. 

1  There  are  a  few  exceptions  to  these  statements,  for  example,  the  transference  of  the 
disease  when  troops  have  been  moved  from  place  to  place,  and  the  Swedish  epidemic 
which  spread  steadily  in  one  dii-ection  {vide  supra). 

2  The  surmise  of  Sir  Benjamin  Richardson,  that  it  is  due  to  diseased  grain  has  not 
been  generally  adopted. 


EPIDEMIC   CEREBROSPINAL  MENINGITIS  673 

Although  epidemics  of  meningitis  have  coincided  with  or  followed 
epidemics  of  other  specific  fevers,  such  as  typhus,  cholera  and  others, 
it  has  no  constant  relation  with  a,ny  one  of  them,  and  its  history  and 
clinical  features  are  sufficient  to  stamp  it  as  specifically  different  from 
them  and  probably  dependent  on  a  virus  of  its  own. 

Can  we  go  further,  and  say  what  this  virus  is  ? 

We  naturally  looli  to  bacteriology  for  an  answer.  But  bacteriologists 
are  at  this  disadvantage,  that  since  their  science  has  established  itself, 
there  have  been  no  large  epidemics  of  meningitis,  and  therefore  their 
researches  have  been  limited  to  certain  minor  outbreaks.  Taking  these, 
however,  as  a  basis,  a  somewhat  surprising  conclusion  is  indicated,  namely, 
that  the  organism  associated  with  epidemic  meningitis  is  identical  with 
or  closely  related  to  that  which  is  responsible  for  croupous  pneumonia. 

Now,  inasmuch  as  these  two  diseases  appear  clinically  to  be  utterly 
dissimilar,  it  may  be  well  to  state  some  of  the  facts  which  seem  to 
support  the  alleged  connection.  The  micro-organism  of  croupous 
pneumonia  was  originally  supposed  to  be  a  bacillus,  discovered  by 
Friedlander  and  named  after  him.  But  this  bacterium  has  been  de- 
throned in  favour  of  a  micrococcus  ^  which  bears,  it  is  true,  just 
sufficient  resemblance  to  Friedlander's  bacillus  to  allow  us  to  suppose 
that  the  two  were  originally  confounded.  This  micrococcus,  which  we 
may  briefly  term  the  pneumococcus,  usually  occurs  in  pairs  (diplococcus), 
surrounded  by  a  transparent,  easily -disintegrated  capsule.  The  individual 
cocci  of  each  pair,  when  seen  in  the  blood  or  in  pneumonic  exudate,  are  oval 
or  lance-shaped  (like  a  grain  of  wheat  or  of  ba^rley) ;  but  in  most  cultivation 
media  they  are  round.  They  stain  with  aniline  colours,  but  are  not  (like 
Friedlander's  bacilli)  decolorised  by  Gram's  iodine  solution.  They  grow 
in  most  cidtivation  media  provided  these  are  not  acid.  They  are  sen- 
sitive to  temperature,  so  that  they  do  not  grow  at  the  ordinary  tem- 
perature of  a  cool  room,  nor  at  higher  temperatures  than  42°  C  In 
cultivations  they  rapidly  lose  vitality,  and  changes  may  be  wrought  — 
(1)  in  their  form,  so  that  the  cocci  become  more  rounded  and  are  asso- 
ciated not  so  much  in  pairs  (diplococci)  as  in  chains  (streptococci)  ;  (2) 
in  their  virulence,  so  that  they  lose  their  power  of  generating  disease 
till  they  have  been  passed  de  novo  through  the  living  tissue  of  some 
susceptible  animal.  Rabbits  and  mice  are  extremely  susceptible  to 
inoculation  with  the  pneumococcus,  so  that  a  subcutaneous  injection 
thereof  produces  at  the  point  of  injection  an  acute  oedema  or  cellulitis 
followed  by  rapidly  fatal  septicgemia.  Dogs  and  sheep  have  more  resist- 
ing power,  so  that  a  subcutaneous  injection  produces  little  effect  on  them. 
But  injection  into  the  pulmonary  tissue  of  dogs,  sheep  or  rabbits,  which 
have  been  rendered  impervious  to  the  septicsemic  effect,  produces  a 
characteristic  croupous  yjueumonia.  This  last  fact,  and  the  fact  that 
the  micrococcus  is  found  in  pneumonic  sputum,  in  pneumonic  exudate 

1  Desorilxtr]  ])y  Friiiikf,!  in  frin-rnariy,  Talamon  and  Pastenr  in  France,  Si.ernl)ers  in 
America;  and  nffnn  called  I''rJi.nkcr.s  diploco"cuH,  or  tlie  mifirocoinnis  lanccolatns.  Tl)« 
de8crix)tion  in  the  text  is  mainly  taken  from  Sternberg's  Manual  of  Bacteriology. 

VOL.    I  2    X 


674  SYSTEM  OF  MEDICINE 


drawn  by  a  syringe  from  the  chest  during  life,  and  in  hepatised  lungs 
post-mortem,  are  held  to  justify  its  claims  to  be  the  cause  of  pneumonia.  A 
most  remarliable  fact  is  that  this  micrococcus  is  often  present  in  normal 
human  saliva,  and  inoculation  of  rabbits  with  such  saliva  has  produced 
a  characteristic  septicaemia  \yide  article  on  "Epidemic  Pneumonia"]. 

iSTow  it  would  seem  that  when  a  pneumonia  affects  tissues  other  than 
the  lung  proper,  this  micro-organism  may  be  found  in  such  diseased  parts ; 
not  only  in  the  lymph  upon  the  pleura  and  pericardium,  which  are  so 
commonly  inflamed  in  acute  pneumonia,  but  in  rarer  cojnplications  also, 
such  as  ulcerative  endocarditis  ;  and  even  in  disease  of  organs  beyond 
the  chest,  as  in  peritonitis  and  (what  concerns  us  mostly)  meningitis 
(20,  21). 

Again,  diseases  such  as  these  may  occur  without  demonstrable 
pneumonia.  Most  physicians  have  seen  cases  of  acute  pleurisy,  the 
clinical  course  of  which  has  been  indistinguishable  from  that  of  a 
pneumonia,  but  in  which  post-mortem  the  lung  is  not  found  hepatised. 
In  these  it  is  not  surprising  to  learn  that  the  pneumococcus  has  been 
found  in  the  pleural  lymph  by  Dr.  Washbourn  (67).  But  it  has  been 
found  also  in  ulcerative  endocarditis  (without  pneumonia),  idiopathic 
peritonitis,  otitis,  encephalitis,  meningitis  after  injury,  and,  lastly,  in 
acute  purulent  meningitis  which  has  no  obvious  cause  (21,  22,  23,  24). 

ISTot  that  in  all  cases  of  purulent  meningitis  this  identical  organism 
is  present.  For  in  some  there  has  been  found  a  micrococcus  bearing  a 
general  resemblance  to  it,  but  presenting  some  slight  points  of  difference 
(25,  26)  ;  in  others  the  ordinary  streptococcus  pyogenes ;  in  others,  again, 
where  the  meningitis  occurred  in  connection  Avith  some  acute  infectious 
disease,  such  as  typhoid,  the  organism  proper  to  that  disease  (27,  28). 

Yet  the  fact  that  in  most  cases  of  idiopathic  meningitis  which  have 
been  investigated  the  pneumococcus  has  been  found,  and  that  its  intro- 
duction into  the  cranial  cavity  of  animals  produces  meningitis,  as  its 
introduction  into  the  chest  produces  pneumonia,  seems  to  show  that  it 
may  be  at  least  a  frequent  cause  of  that  disease. 

From  sporadic  to  epidemic  meningitis  is  no  great  step  ;  the  bacterio- 
logical observations  on  this  latter  are  as  follows :  — 

(a)  Jaffe,  studying  an  epidemic  in  Hamburg  (1879),  could  find  no 
micro-organisms  in  the  meningeal  lymph. 

(&)  Giuffre,  in  a  Sicilian  epidemic  of  1882,  found  oval  cocci  in  the 
meningeal  lymph,  not  in  the  blood  nor  in  the  spleen.  Attempts  at  cul- 
tivation and  inoculation  failed  (30). 

(c)  Ughetti,  in  Sicily,  1883,  found  micrococci  in  the  meningeal 
exudation  and  the  blood;  inoculations  failed  (31). 

(d)  Marchiafava  and  Celli  found  diplococci,  both  free  and  within  the 
cells  in  the  meningeal  exudation ;  cultures  were  negative  (32). 

(e)  ISTetter  states  that,  in  an  outbreak  at  Blois  and  Orleans  in  1886, 
the  micrococcus  lanceolatus  was  found  in  the  spinal  and  cerebral  exuda- 
tion b}'-  Widal. 

(/)  Friis,  at  Copenhagen,  1886,  isolated  and  cultivated  a  bacterium 


EPIDEMIC   CEREBROSPINAL   MENINGITIS  675 

in  the  shape  of  short  thick  rods,  not  unlike  an  oval  coccus ;  inoculations 
failed. 

ig)  Four  cases  from  an  epidemic  at  Turin,  1888,  were  investigated 
by  Foa  and  Bordone-Uffreduzzi ;  they  found  a  micrococcus  which  they 
identilied  with  Frankel's,  cultivated  it  and  experimented  with  it;  injec- 
tions into  the  cranial  cavity  produced  acute  general  sepsis  with  cerebral 
and  spinal  meningitis.     Two  of  their  four  cases  had  pneumonia. 

(/i)  At  an  epidemic  near  Padua  in  1890,  Bonome  obtained  from  the 
meningeal  exudation  a  micrococcus  resembling  in  some  degree  the  pneu- 
mococcus,  but  differing  from  it  in  the  peculiar  tangled  growth  which  it 
forms  on  agar,  in  its  inability  to  grow  in  blood  serum,  and  in  some  of 
its  effects  on  animals.  This  he  believes  to  be  the  specific  micrococcus 
of  epidemic  cerebro-spinal  meningitis.  There  was  no  pneumonia  in  his 
cases. 

(t)  Mirto  in  1891  (37),  as  quoted  by  Flexner  and  Barker,  discovered 
in  some  epidemic  cases  the  typical  micrococcus  lanceolatus. 

(J)  Herwerden  (1893)  (38)  gives  the  case  of  a  woman  who  died  of 
this  disease  in  an  advanced  stage  of  pregnancy.  Caesarean  section  was 
performed,  the  child  lived  five  and  a  half  days,  and  then  died  of  menin- 
gitis complicated  with  pleurisy.  In  the  meningeal  exudations  both  of 
mother  and  child,  and  in  the  blood,  the  liver  and  the  kidneys  of  the 
child,  pneumococci  were  found.  The  virulence  of  these  appeared  at  first 
to  be  slight,  but  it  was  increased  by  submitting  them  to  the  action  of 
hydrogen  and  oxygen,  so  that  injection  of  them  into  rabbits  produced 
meningitis. 

(Ti)  Leichtenstern  (39),  writing  in  1893  of  epidemics  in  Cologne  and 
the  neighbourhood  in  1885-1892,  says  that  he  found  the  pneumococcus 
in  cases  where  there  was  pneumonia,  but  not  in  other  cases.  The  special 
micro-organism  he  considers  to  be  not  the  pneumococcus  itself,  but  a 
variety  or  "  specific  derivative  "  of  it. 

(1)  Lastly,  Flexner  and  Barker,  in  an  epidemic  at  Lonaeoning,  Mary- 
land (1893),  found  lanceolate  diplococci  in  the  meningeal  exudation,  both 
free  and  enclosed  in  their  cells ;  but  their  cultures  and  inoculation  experi- 
ments did  not  succeed  well. 

Such  are  the  'primd.  facie  grounds  for  supposing  that  the  pneumo- 
coccus, or  some  allied  organism,  is  the  cause  of  epidemic  cerebro-spinal 
meningitis;  but  there  are  certainly  difficulties  in  the  way  of  a  final 
conclusion. 

For  (1)  some  of  the  observations,  especially  the  earlier  ones,  are 
admittedly  imperfect ;  and  some  are  not  quite  harmonious  in  detail  with 
respect  to  the  characters  of  the  micro-organism  described.  We  hardly 
know  what  importance  to  attach  to  small  variations  of  this  kind. 

(2)  It  has  been  suggested  that  sometimes  the  pneumococcus,  some- 
times bacteria  of  other  diseases,  may  produce  epidemics  of  meningitis. 
But  to  admit  this  is  to  give  up  the  notion  that  the  disease  is  specific  at  all. 

(3)  As  to  the  pneumococcus  theory  there  are  general  reasons  both 
for  and  against  it.     The  wide-spread  dissemination  of  that  organism, 


676  SYSTEM   OF  MEDICINE 

which  seems  to  exist  even  in  normal  human  saliva,  certainly  harmo- 
nises with  the  wide  dissemination  of  the  disease,  and  with  the  sudden 
appearance  of  it  at  isolated  foci,  without  recognisable  sources  of  infection. 
The  variability,  under  different  conditions,  of  the  virulence,  and  perhaps 
of  the  morphology  of  the  micrococcus,  which  seems  to  be  recognised  in 
the  laboratory,  may  explain  the  paroxysmal  appearance  of  the  disease, 
and  why  it  is  not  always  with  us.  But  this  only  puts  the  inquiry  a 
step  farther  back.  The  question  then  would  be.  What  are  the  external 
influences  v/hich,  either  by  augmenting  the  virulence  of  the  micrococcus 
or  by  reducing  our  resisting  power,  render  us  obnoxious  to  its  attack  ? 
And  of  these  we  are  profoundly  ignorant. 

And,  it  may  be  objected,  if  identical  or  closely-related  organisms  pro- 
duce the  two  diseases,  pneumonia  and  meningitis,  why  do  they  not  more 
commonly  co-exist? 

Doubtless  such  co-existence  has  been  observed,  but  chiefly,  I  believe, 
in  the  later  and  more  limited  outbreaks ;  it  does  not  seem  to  have  struck 
the  observers  of  the  older  and  more  extensive  epidemics,  who  would  have 
been  disposed  to  identify  the  virus  of  this  disease  with  that  of  typhus 
or  cholera. 

We  cannot  then  consider  the  question  of  etiology  as  yet  settled. 


APPENDIX 

It  may  be  of  interest  to  Englisli  readers  if  I  refer  briefly  to  the  outbreaks 
of  this  disease  which  have  taken  phice  in  the  United  Kingdom.  ]\Iany  of  these 
(though  the  Irish  epidemic  of  1866  and  18(37  constitutes  a  notable  exception) 
can  scarcely  be  called  epidemics,  and  some  indeed  are  merely  groups  of  two  or 
more  cases  occurring  at  the  same  time  and  place.  Yet  their  essential  identity 
with  the  epidemic  meningitis  of  the  Continent  and  America  is,  in  some  instances, 
hardly  to  be  doubted,  and  in  others  is  very  probable. 

1807. — In  1807,  at  Blackaton,  a  small  village  on  Dartmoor,  a  peculiar 
group  of  cases  was  observed  by  Gervis,  the  nature  of  which,  in  the  absence  of 
a  post-mortem,  remains  somewhat  uncertain,  but  they  may  possibly  have  been 
instances  of  this  disease.  There  were  five  cases,  four  of  them  in  one  family, 
and  four  of  the  five  died  very  rapidly.  Headache,  vomiting,  collapse,  slight 
convulsive  movements,  sore  throat,  and  an  haemorrhagic  rash  are  mentioned  as 
symptoms,  but  no  retraction  of  the  head. 

1830.  —  In  the  autumn  of  1830,  at  Sunderland,  several  cases  occurred,  in 
one  of  which  meningitis  was  found  post-mortem  (41). 

1846.  —  The  first  Irish  outbreak  occurred  in  the  first  half  of  1846;  there 
were  cases  in  the  workhouses  of  Belfast,  Bray,  and  Dublin,  mostly  in  boys  under 
twelve  years  old;  and  two  fatal  cases  in  the  Hardwick  Hospital,  Dublin  (42). 

During  the  same  year  Whittle  records  cases  in  Liverpool,  some  of  which  he 
distinctly  ranks  with  epidemic  meningitis  as  seen  in  Ireland  and  on  the  Conti- 
nent. Of  nine  such  cases  three  were  fatal.  Some,  on  the  other  hand,  were  of 
a  milder  type. 

In  1846,  also,  a  case  was  seen  at  Haslar  Hospital  (44). 

1846-1850.  —  It  would  seem  from  the  statements  of  M'Dowell  that  from 


EPIDEMIC   CEREBROSPINAL  MENINGITIS  677 

the  time  of  the  first  Dublin  outbi-eak  mild  cases  presenting  symptoms  of  menin- 
gitis continued  to  appear  in  Dublin  till  1850  at  least. 

Three  cases  of  somewhat  doubtful  nature  are  mentioned  at  Rochester  in 
1850  (M). 

1864-1868.  —  At  Rochester,  also,  in  1864  and  1865,  some  four  or  five  cases 
occurred,  one  of  which  was  examined  post-mortem  (46). 

During  1865  it  appears  that  there  were  further  cases  in  Dublin  (47) ;  while 
the  succeeding  years  (1866  and  1867)  saw  the  second  Irish  epidemic,  the  most 
severe  manifestation  of  the  disease  which  has  yet  appeared  in  these  islands  (48). 

This  epidemic  raged  principally  in  Dublin,  but  also  affected  other  parts  of 
Ireland,  attacking  both  military  and  civil  population.  It  was  marked  by  great 
fatality,  and  by  the  prevalence  of  hsemorrhagic  rashes,  so  that  the  name  of 
"  Black  Death  "  was  at  one  time  proposed  for  it,  and  also  that  of  "  Malignant 
Purpuric  Fever." 

In  England  about  the  same  time  there  were  some  isolated  cases :  two  in 
London  which  were  rapidly  fatal  (49),  and  one  at  Devizes  (50)  (May  and  June 
1867). 

At  Bardney,  a  Lincolnshire  village,  there  was  a  small  epidemic  —  over  nine- 
teen cases,  with  one  death  (51). 

Somewhat  later,  namely,  March  1868,  we  read  of  four  cases  within  three 
weeks  at  Shorncliffe  Camp  (52). 

In  1867,  too,  there  was  a  fatal  case  with  petechial  rash  at  Stafford,  where 
there  formerly  had  been  two  similar  cases,  namely,  in  1865  and  1859  resj)ec- 
tively  (53). 

1876-1878.  —  The  Irish  epidemic  of  1866  and  1867,  with  the  minor  out- 
breaks which  we  have  just  mentioned  in  England,  evidently  corresj^onds  to  the 
great  wave  which  had  just  passed  over  the  Continent. 

The  next  notice  of  the  disease  is  in  1876,  in  the  Midlands.  Two  cases 
occurred  among  the  militia  at  Oxford  (54),  and  an  epidemic  in  and  round 
Birmingham;  fourteen  cases  were  admitted  to  the  Queen's  Hospital  in  nine 
months,  and  there  were  others  in  the  neighbourhood  (55). 

In  the  winter  of  1877-1878  a  good  many  cases  were  seen  at  Dundee,  several 
of  which  had  a  roseolar  rash,  or  an  hsemorrhagic  rash  like  typhus.  There 
seems  to  have  been  evidence  that  the  disease  was  contagious.  One  case  died 
with  rupture  of  the  spleen  (56) . 

At  Dublin,  in  the  commencement  of  1878,  there  were  three  fatal  cases 
within  two  months  (57). 

1884-1886.  —  In  the  spring  of  1884  two  cases  occurred  at  the  Seaman's 
Hospital,  Greenwich  (58),  and  two  at  the  London  Hospital  (59);  but  as  three 
of  these  patients  were  sailors  the  local  character  of  the  outbreak  cannot  be 
insisted  upon. 

In  Dublin,  again,  during  1885  and  1886  a  somewhat  serious  outbreak  took 
place,  largely  in  the  suburban  districts,  and  amongst  comparatively  well-to-do 
people  (60).  There  were  fifty-two  deaths  during  1885.  Rapidly  fatal  cases 
with  purpuric  spots  were  not  wanting  (61). 

In  1884  a  small  but  very  fatal  outbreak  took  place  at  Galston  near 
Kilmarnock.  Out  of  seven  cases  five  were  fatal,  some  with  extreme  rapidity. 
Personal  intercourse  was  traced  between  the  various  patients,  so  that  contagion 
seemed  probable  (62). 

At  Aberdeen,  in  1885,  Ogston  examined  the  body  of  a  child  which  died  of 


678  SYSTEM   OF  MEDICINE 

acute  cerebral  meningitis ;  this  he  referred  to  disease  of  the  nasal  bones,  but  he 
notes  that  another  child  of  the  family  died  of  meningitis,  and  that  the  father 
had  symptoms  of  the  same  disease. 

Similarly,  near  Faversham  in  1886  two  deaths  occurred  in  one  family  from 
meningitis  (64). 

1890.  —  In  July,  August,  and  September  1890  (65),  there  was  an  outbreak 
in  five  neighbouring  villages  on  the  border  of  Norfolk  and  Suffolk  (Oakley, 
Broome,  Scole,  Kenton,  Bressinghaiu)  ;  the  symptoms  appear  to  have  been  typi- 
cal ;  there  were  twenty  cases  and  two  deaths :  one  post-mortem  was  made,  in 
which  evidence  of  meningitis  was  found.  No  cause  could  be  assigned  for  the 
disease.  In  a  village  thirty  miles  away,  Great  Horkesly,  near  Colchester,  there 
was  another  case.  Near  Maiden,  in  Essex,  some  obscure  and  rapidly  fatal  cases 
of  fever  had  been  seen  that  same  autumn.  In  certain  Lincolnshire  villages 
scattered  cases  possibly  of  a  similar  nature  occurred ;  thus  at  Willingham,  near 
Gainsborough,  a  gipsy  boy  died  apparently  from  pneumonia  and  meningitis;  at 
Holbeach,  near  Spalding,  a  woman  died  with  symptoms  of  meningitis ;  and  a 
severe  though  non-fatal  case  occurred  at  Gedney  Hill,  about  ten  miles  from 
Holbeach.  Two  cases  are  said  to  have  occurred  in  the  preceding  year  near 
Oundle,  in  a  village  distant  about  twenty  miles  from  Gedney  Hill. 

In  March,  April,  May  and  June  1890  four  cases  of  idiopathic  cerebro-spinal 
meningitis  were  examined  post-mortem  at  St.  Bartholomew's  Hospital  (66). 

J.  A.  Ormerod. 

REFERENCES 

1.  Htrsch.  Handbook  of  Geographical  and  Historical  Patholof/y.  New  Syd.  Society 
Trans,  vol.  ill.  p.  3i7  foil.  — 2.  Gilkrest.  Lotidon  Medical  Gazette,  18i4,.— 3.  Stille. 
On  Epidemic  Meningitis.  Philadelphia,  1807.-4.  Gordon.  Dublin  Quarterly  Journal 
of  Medical  Science,  i8(57  (Case  I.) .  —  5.  Bubdon-Sanderson.  Eighth  Report  of  Medical 
Officer  of  Privy  Council,  ISVi'i,  ]}.  2S6.—(^.  Flexner  and  Barker.  American  Journal 
of  Medical  Science,  February  and  March  1894.-7.  Von  Ziemssen.  Cyclopedia  of 
Medicine  (American  translation),  vol.  ii.  — 8.  Mannkopf.  Ueber  Meningitis  Cerebro- 
spinalis  Epidemica.  Brunswick,  18(56. —9.  Klebs.  Virchoiv's  Archiv,  vol.  xxxiv.— 
10.  Kernig.  Neurolog.  Centralblatt,  1884,  p.  391.-11.  Randolph.  Bulletin  of  the 
Johns  Hopkins  Hospital,  iv.  .32.  — 12.  Strumpell.    Devtsches  Archiv  f.  klin.  Medic,  xxx. 

—  13.  ToURDES.  Hist,  de  I'epidemie  de  meningite,  etc.,  a  Strasbourg.  Paris,  1842.  — 14. 
Klemperer.  Neurolog.  Centralblatt,  lS'i)3.  —  15.  Moos.  Ueber  Mening it.  Cerebro-spin. 
Epidemica.  Heidelberg,  1881.  — l(i.  Immermann  and  Heller.  Beutsches  Arch.  f.  klin. 
Med jcin,  1869.  — 17.  Hirsch.     Die  Meningitis  Cerebro-spinalis  Epidemica.  Berlin,  1866. 

—  18.  Gbimshaw.  Brit.  Medical  Journal,  1886,  vol.  i.  p.  1216.  — 19.  German  Army 
Medical  Reports  as  abstracted  in  Neurolog.  Centralblatt,  1886,  p.  23.5.— 20.  Frankel. 
Deutsch.  Med.  Wochetischrift,  ISSS.  — 21.  Weichselbaum.  Wiener  klin.  Wochenschrift, 
1888,1.28-32.-22  Leyden.  Centralblatt  f.  klin.  Medicin,l%?>'i,yLd.vc\i\Q.—2Z.  Kan- 
THACK.  Pathol.  Soc.  Transactions,  vol.  xlv.  p.  230.-24.  Kanthack.  St.  Bartholomew's 
Hospital  Journal,  Yo\.  i.  p.  67.— 25.  Weichselbaum.  Fortschritte  die  Medicin,  1887, 
vol.  v.— 26.  GoLDSCHMiDT.  Centralblatt  f.  Bakteriologie,  ii.  649.-27.  Neumann, 
Virchow's  Archiv,  c\7i.  ^11.— 28.   Adenot.    Des  meningites  microbiennes.    Paris,  1890. 

—  29.  Jaffe.  Deutsches  Archiv  fiir  klin.  Medicin,  vol.  xxx.  p.  372. —30.  Neurolog. 
Centralblatt,  1886,  p.  184  (original  pamphlet  published  at  Palermo,  188.5).  —31.  Neurolog. 
Centralblatt,  1886,  p.  184,  and  as  quoted  in  Hirsch's  Handbook.  Original  article  in 
Giorn.  delta  Societa  ital.  d'igiene.,  October  1883.  — .32.  As  quoted  by  Hirsch.  Original 
article  in  Gazzetta  degli  Ospedali,  1884.-33.  Netter.  Archives  Generates  de  Medecine, 
1887.-34.  Friis.  Virchoiv's  Jahresbericht,1881,  vol.  ii.  p.  12.-35.  Foa  and  Bordone- 
Uffreduzzl  Zeitschrift  f.  Hygiene,  1888,  t}.  67.  — m.  BonomI?.  Z\es:\ev's  Beitrage, 
etc.  1890,  p.  .377.-37.  Giaro  delta  Assoc.  Napoli  di  Medic,  etc.  1891,  No.  2,  129.-38. 
Schmidt's  Jahrbucher,  1893,  vol.  iv.  p.  227.-39.  Scuuidt's  Jahrbiicher,  1893,  vol,  iv. 


INFLUENZA  679 


p.  153. — 40.  Gervis.  Medico-Chirurgical  Transactions,  vol.  ii. — 41.  John  Scott. 
Medical  Times  and  Gazette  for  ISfiS,  vol.  i.  p.  515. — 42.  Mayne.  Dublin  QuarterUj 
Journal  of  Medical  Science,  vol.  ii.  p.  90.  —  4.3.  Whittle.  London  Medical  Gazette  lor 
1847,  p.  807. —44.  F.T.Brown.  jTVans.  £:/)i'iem.  Sjc.  vol.  ii.  p.  391.  — 45.  M'Dowell. 
London  Journal  of  Medicine  for  1851,  p.  8.50. — 46.  F.  T.  Brown,  Ut  antea,  and  in 
Privy  Council  Reports,  18(w. — 47.  Kennedy.  Medical  Press  and- Circular,  Unwe  1807, 
p.  551.  —  48.  Dublin  Quarterly  Journal  of  Medical  Science  (various  writers)',  vols,  xliii. 
and.  xliv. ;  Mapother  and  Marston,  Trans.  Epidem.  Society,  1874.  —  49.  Crisp  and 
Clarke.  Lancet  for  1867,  vols.  i.  and  ii. — 50.  Clapham.  Medical  Times  and  Gazette, 
18(i7,  vol.  i.  p.  709.  —  51.  Lowe  and  Woolley.  lancet  for  18(57,  vols.  i.  and  ii.  — .52. 
Medical  Times  and  Gazette  for  April  4,  18(;8. — 53.  Day.  Vlinical  Histories  and  Com- 
ments.—  54.  Lancet,  1876,  vol.  i.  p.  812.  —  55.  Neville  Hart.  St.  Bartholomew's 
Hospital  Reports,  vol.  xii.  p.  105.  Foster:  Lancet,  1876,  vol.  i.  p.  849.  Johnston  and 
Russel:  British  Medical  Jouj-nal,  1876,  Yol.  ii.  —  56.  Maclagan.  Edinburgh  Medical 
Journal,  Aug. -Dec.  1886;  also  Lancet  for  8th  June  1878,  and  Brit.  Med.  Journal,  1878, 
vol.  i.  p.  276.-57.  Hayden.  British  Medical  Journal,  1878,  vol.  i.  p.  740. — 58.  Car- 
RiNGTON.  Pathol.  Society's  Trans,  for  1884,  p.  51. — 59.  Turner.  Ibid.  p.  63.  —  60. 
J.  W.  Moore.  Brit.  Med.  Journal  for  1886,  vol.  i.  p.  1216.-61.  Hayes.  Ibidem. 
—  62.  Frew.  Glasgow  Medical  Journal,  ISHi,  Tp.  21. — 63.  Ogston.  British  Medical 
Journal,  16th  May  1885. — 64.  J.  Irvine  Boswell  as  quoted  by  Bruce  Low  (infra). — 
65.  Bruce  Low.  Loc.  Gov.  Boai'd  Reports  1890-1891,  y>.  111.  — 66.  Ormerod.  Lancet, 
1895,  vol.  i.  p.  735. — 67.  Washbourn.  Med.  Chir.  Travis,  vol.  Ixxvii.  p.  179.  —  For 
a  complete  Bibliography  the  reader  is  referred  to  Hirsch's  Handbook  of  Geographical 
and  Historical  Pathology. 

J.  A.  0. 


INFLUENZA 


In-  attempting  the  description  of  a  disease  we  are  often  in  doubt  how- 
best  to  set  about  the  task.  Influenza  offers  no  exception  to  this  rule, 
but  happily,  so  to  speak,  it  has  oven-eached  itself,  and  by  the  very  width 
of  its  range  of  action  over  the  human  body  has  simplified  matters  in 
a  way  that  may  not  at  first  be  apparent.  Clearly  the  only  possible 
presentation  of  a  disease  so  multiform  in  its  character  as  influenza,  is 
to  describe  it  first  of  all,  in  as  full  a  manner  as  space  permits,  on  its 
clinical  aspect,  and  thereafter  to  discuss  its  pathology  and  treatment. 

It  is  not  well  to  pay  too  much  attention  to  the  disease  as  it  has 
appeared  in  other  countries.  After  all  it  is  the  disease  as  it  appears 
here  in  England  which  concerns  us;  and  it  is  too  often  forgotten 
that,  although  the  whole  world  is  kin,  yet  there  are  racial  and  climatic 
influences  that  must  make  some  difference  in  the  picture  of  disease  as 
it  has  occurred  here  or  there,  —  a  difference  which  may  well  come  iu 
to  throw  light  upon  some  of  the  obscure  points  in  the  natural  history 
of  a  malady,  but  which  is  of  less  importance  from  the  practical  stand- 
point of  its  management  as  we  have  to  deal  with  it  amongst  ourselves. 
As  a  matter  of  fact,  however,  the  disease  has  departed  little  if  at  all 
from  certain  broad  characters,  whatever  the  affected  area. 

Description.  —  To  present  the  disease  at  all  adequately  it  is  neces- 
sary to  describe  groups  of  cases.     In.  actual  experience  all  groups  must; 


68o  SYSTEM  OF  MEDICINE 

necessarily  blend  somewhat,  nevertheless  each  is  sufficiently  distinct  to 
demand  separate  mention. 

All  cases  present,  more  or  less,  certain  features  in  common ;  it  will 
be  convenient,  therefore,  to  describe  hrst  of  all  what  we  may  call  com- 
mon influenza.  A  healthy  person  is  suddenly,  one  may  say  without 
exaggeration  that  many  are  instantaneously  attacked  Avith  violent 
aching  of  the  head  and  eyeballs ;  with  a  pain  in  the  back,  perhaps  so 
severe  as  to  resemble  the  onset  of  variola ;  with  racking  in  the  bones 
that  could  not  be  worse  if  they  were  being  broken ;  with  a  general  dis- 
tressful soreness ;  sharp  fever  without  any  corresponding  acceleration 
of  the  pulse,  and  a  hard  dry  cough,  sometimes  with  coryza  as  from  a 
bad  cold.  Often  enough  there  is  some  little  delirium  during  the  first 
day  or  two,  and  not  a  few  cases  have  even  been  ushered  in  by  an  acute 
maniacal  delirium.  The  tongue  is  thickly  coated  with  a  white  creamy 
fur,  it  is  flabby,  indented  by  the  teeth,  and  tremulous.  The  breath  has 
often  a  peculiarly  offensive  odour,  and  the  patient  suffers  from  a  sudden 
prostration,  both  mental  and  physical,  altogether  out  of  proportion  to 
the  duration  or  apparent  severity  of  his  illness.  The  spleen  has  been 
found  enlarged  in  some  cases. 

The  fever  lasts,  perhaps,  three,  four  or  five  days  and  then  subsides, 
leaving  the  patient  weak  and  much  depressed,  and  with  a  feeling  of 
having  undergone  a  serious  illness  in  a  short  space  of  time.  To  add  to 
the  discomfort,  after  a  day  or  two  chills  are  apt  to  recur,  usually  down 
the  back.  These  are  followed  by  profuse  sweats,  which  may  be  repeated 
again  and  again,  and  perhaps  only  slowly  disappear  some  time  after  the 
more  essential  symptoms  have  entirely  passed  away. 

The  first  case  of  influenza  that  I  recognised  occurred  on  December 
24, 1889.  The  disease  had  not  then  declared  itself  in  epidemic  form  in 
England.  But,  as  other  observers  have  stated,  cases  had  occurred  at 
any  rate  in  the  two  or  three  weeks  previously.  A  strong  healthy  man 
went  to  Manchester  to  play  a  football  match.  He  went  with  a  bad  cold 
upon  him,  and  there  he  became  so  much  worse  that  he  returned  home 
again,  by  which  time  he  was  so  exceedingly  ill  that  his  brother,  a 
medical  man,  became  much  alarmed.  He  was  delirious,  prostrate, 
restless,  with  a  temperature  of  102°,  a  very  distressing  dry  cough,  a 
generally  tremulous  condition  of  the  muscles,  and  a  thickly  furred 
tongue.  His  lungs  gave  no  evidence  of  pneumonia,  but  the  air  entered 
badly,  and  there  were  plenty  of  sibilant  rhonchi  and  rales,  a  state  of 
things  that  indicated  that  the  bases  were  engorged  —  "  congested,"  as  I 
should  prefer  to  say.  These  various  symptoms,  combined  with  a  little 
diarrhoea,  gave  the  case  the  appearance  of  typhoid  fever,  but  the  tem- 
perature, falling  almost  at  once  to  normal,  led  to  a  correct  diagnosis, 
and  he  rapidly  convalesced. 

Of  the  simple  catarrhal  form,  with  its  prostration  and  pulmonary 
congestion,  this  is  an  ordinary  case  of  moderate  severity;  but  there  are 
cases  in  which  the  poison  is  apparently  much  more  virulent,  and  where  in 
consequence  the  disease  assumes  still  more  of  the  characters  of  typhoid 


INFLUENZA 


fever.  A  striking  example  of  this  occurred  also  early  in  the  epidemic  of 
1889.  A  young  healthy  man  came  to  town  to  spend  Christmas  with  his 
relatives  who  were  in  an  hotel.  Within  a  short  time  from  his  arrival  he 
was  seized  with  an  overwhelming  drowsiness  and  fever.  His  drowsiness 
was  indeed  so  great  that  he  could  by  no  means  be  kept  awake,  and  in 
this  respect  the  case  corresponded  to  a  mild  attack  of  the  sleeping  form 
of  influenza  as  it  has  occurred  in  this  epidemic,  and  has  been  recorded  as 
"nona"  by  Braun  and  others  (1).  He  was  removed  to  a  nursing  home 
because  of  some  slight  roseola  which  suggested  scarlatina,  but  within  a 
few  hours  he  was  so  prostrate,  with  so  much  subsultus,  and  a  tongue  so 
dry,  brown,  and  cracked,  that  he  presented  the  appearance  of  some 
severe  form  of  continued  fever.  There  was  somewhat  of  the  dusky 
appearance  of  a  case  of  typhus,  the  engorgement  of  lung  either  of  that 
or  of  enteric  fever,  the  pulse  about  the  ordinary  rate  of  typhoid  ;  but 
the  pyrexia  did  not  run  the  course  of  either  of  these,  and  in  live  or  six 
days  the  fever  had  spent  itself  and  the  man  was  convalescent. 

Another  group  may  well  be  styled  "  pulmonary  influenza,"  for  the 
violence  of  the  disease  expends  itself  chiefly  upon  the  respiratory  tract. 
There  is  the  same  sudden  attack,  with  the  aching  head  and  limbs,  the 
fever,  the  thickly-coated  tongue.  But  the  cough  is  more  troublesome, 
there  is  more  obvious  impediment  to  the  respiration,  and  the  posterior 
parts  of  the  lungs  are  full  of  sharp,  sticky  rales  of  a  quality  quite 
peculiar  to  the  disease.  This  condition  will  often  slowly  increase,  and 
extend  over  the  lung,  the  fever  continuing,  and  the  condition  of  the 
patient  becoming  more  and  more  embarrassed.  Delirium  supervenes, 
the  pulse  at  last  mounts  up,  and  the  case  terminates  fatally,  without,  so 
far  as  the  physical  signs  go,  any  evidence  of  consolidation  being  at  any 
time  present.  Sometimes  in  the  course  of  the  bronchial  catarrh  patches 
of  solid  lung  will  appear  here  and  there,  or  an  acute  pleuro-pneumonia 
will  suddenly  light  up.  In  some  of  these  the  influenza  bacillus  has  been 
found,  thus  showing  the  disease  in  truth  to  be  influenzal  pneumonia; 
in  others,  again,  only  the  pneumococcus,  giving  support  to  another  con- 
tention that  the  consolidation  is  in  some  cases  a  sequel  or  complication, 
and  not  the  primary  disease. 

When  pleurisy  occurs  it  often  runs  on  into  an  empyema.  In  most 
cases,  happily,  the  catarrh,  though  slow  in  taking  its  departure,  gradu- 
ally becomes  of  a  less  glutinous  quality,  and  the  expectoration  more 
and  more  free,  until  the  amount  of  the  purulent  discharge  expectorated 
becomes  so  excessive  that  one  wonders  where  it  can  all  come  from,  see- 
ing that  there  are  seldom,  any  physical  signs  adequate  to  so  profuse  a 
flux.  Sometimes  the  pulmonary  affection  leads  to  haemoptysis,  occa- 
sionally profuse,  and  to  hoarseness,  and  may  thus  have  much  superficial 
likeness  to  tuberculosis.  Into  this  —  the  pulmonary  form  —  the  simple 
or  common  influenza  often  passes.  There  is  often,  indeed,  a  much 
quickened  respiration,  even  when  there  are  no  physical  signs  of  any 
pulmonary  disease,  and  Graves  (quoted  by  Thompson  (10))  describes 
a  dyspnoea  which  is  not  to   be  explained   by  any  stethoscopic  signs. 


682  SYSTEM  OF  MEDICINE 

Over  and  over  again,  too,  there  is  the  history  of  three  or  four  days  of 
fever,  then  a  return  to  a  normal  temperature  and  apparent,  convales- 
cence ;  and  then,  after  perhaps  twenty -four  or  more  hours,  a  relapse, 
not  infrequently  ascribed  to  some  indiscretion  in  uncovering  or  what 
not,  but  which,  in  most  cases,  is  probably  a  part  of  the  disease.  And 
with  the  relapse  come  more  pulmonary  symptoms  —  more  cough,  more 
expectoration,  more  fever,  a  gradual  and  too  often  uncontrollable  inva- 
sion of  the  lung  by  the  glutinous  bronchitis  already  described,  and  in 
too  many  cases  death  eventually  by  the  delirium  and  the  exhaustion  of  a 
gradually  asphyxiating  bronchitis,  or  of  a  pneumonia  that  knows  no  crisis. 

Even  when  the  disease  clears  up  it  is  very  slow  in  its  progress ;  the 
expectoration  remains  profuse  and  purulent ;  the  lung  is  slow  in  expand- 
ing to  its  full  extent  again,  and,  until  it  has  completely  recovered,  is 
very  prone  to  temporary  recurrences  of  the  old  physical  signs. 

Influenza  that  spends  itself  primarily  and  chiefly  upon  the  heart  is 
not  a  common  occurrence,  but  it  is  a  very  grave  matter  when  it  does 
happen.  The  symptoms  are  a  frequent  and  alarming  tendency  to 
syncope,  and  a  feeble,  irregular,  and  often  a  very  rapid  pulse. 

A  waiter,  aet.  thirty-five,  who  had  drunk  freely,  was  suddenly  taken 
ill  with  influenza.     He  kept  at  his  work  as  long  as  he  found  himself  able 

—  a  matter  of  a  day  or  two  only  —  and  then  sent  for  his  doctor.  His 
state  was  as  follows :  He  Avas  a  well-nourished  man,  sitting  half  upright 
in  bed,  with  a  short,  panting  respiration  and  slight  lividity  of  the  lips. 
His  pulse  at  the  wrist  was  hardly  perceptible,  though  regular,  120  in  the 
minute.  His  general  condition  reminded  me  most  of  cases  of  severe  peri- 
cardial effusion,  but  there  was  no  evidence  of  any  increase  of  the  precor- 
dial dulness,  nor  Avere  the  sounds  muffled  in  any  way.  The  impulse  was 
diffused  and  palpable  beyond  the  nipple,  the  first  sound  was  metallic 
and  flapping  in  character,  but  there  was  no  murmur.  The  other  viscera 
were  in  good  order.  The  only  conclusion  that  seemed  possible  was  that 
an  acute  dilatation  of  the  heart  had  taken  place,  and  the  man  was  so  ill 
that  he  appeared  likely  to  die.  As  a  rather  forlorn  hope  strychnia  was 
injected  subcutaneously  with  much  apparent  benefit,  and  he  recovered. 

The  signs  of  cardiac  failure  are  for  the  most  part  a  ready  tendency 
to  fainting,  a  feeble,  irregular  pulse,  sometimes  pallor,  precordial  dis- 
tress or  pain,  and  sweating.  There  are  records  of  a  fatal  issue  under 
such  circumstances,  sometimes  sudden,  like  the  paralysis  of  diphtheria ; 
at  other  times  deferred  for  a  few  days,  after  the  manner  of  acute  dila- 
tation of  the  heart.  For  example,  a  middle-aged  man  of  very  nervous 
temperament  was  taken  ill  Avith  influenza.  He  was  kept  in  bed  and 
had  no  alarming  symptoms,  but  as  he  flagged  and  was  depressed  he  was 
told  to  get  up.  In  the  exertion  attendant  upon  the  effort  he  was  seized 
with  most  alarming  faintness,  from  Avhich  it  Avas  difficult  to  rally  him 

—  indeed,  he  never  did  rally  thoroughly,  for  his  hands  and  feet  remained 
cold,  his  face  was  a  dusky  gray,  his  pulse  beat  140  per  minute,  and  was 
very  feeble,  the  first  sound  of  the  heart  was  so  feeble  as  to  be  hardly 
audible,  he  was  constantly  sick,  and  he  died  in  about  thirty-six  hours. 


INFLUENZA  683 


When  recovery  takes  place  from  attacks  of  this  kind  the  heart  may 
yet  be  long  in  returning  to  a  natural  action,  the  pulse  remaining  feeble, 
intermittent,  irregular,  or  easily  disturbed;  and  Dr.  Sansom  has  re- 
corded cases  of  persistent  tachycardia.  The  pulse  is  sometimes  unnat- 
urally slow  as  well  as  intermittent  or  irregular  —  40  to  50  per  minute 
only  —  in  this  also  showing  a  striking  likeness  to  one  of  the  ominous 
symptoms  in  diphtheria. 

As  an  affection  of  the  circulation  thrombosis  of  one  or  other  of  the 
larger  veins  of  the  extremities  may  here  be  mentioned.  I  have  seen 
seven  cases  of  this  complication  which  occurred  in  all  the  cases  before 
convalescence  had  set  in,  but  in  some,  probably  in  all,  the  fever  was  a 
long  one  ;  this  feature,  occurring  in  the  second  or  third  week  of  the  dis- 
ease, helped  in  two  or  three  cases  to  determine  the  real  nature  of  an 
otherwise  indeterminate  fever. 

Passing  next  to  the  more  strictly  nervous  phenomena  of  influenza 
we  are  confronted  by  the  most  bewildering  as  it  is  the  most  interesting 
feature  of  the  disease.  And  surely  of  these  the  suddenness  of  onset  is 
both  the  earliest  and  most  striking.  A  medical  man  went  to  bed  in  his 
usual  health,  as  he  thought,  and  getting  up  during  the  night  to  void 
urine,  he  fell  to  the  ground,  and  was  so  weak  that  he  was  unable  to  get 
into  bed  again  without  assistance.  Another  man  was  out  in  his  dog- 
cart driving  and  quite  well.  He  suddenly  fell  out  insensible.  He  was 
picked  up,  got  into  the  cart  and  drove  himself  home ;  but  although  he 
had  broken  a  rib  he  remembers  nothing  about  the  drive,  and  when  he 
arrived  was  so  dazed  that  he  wanted  to  get  into  bed  with  his  boots  on, 
and  was  thought  to  be  intoxicated.  Many  similar  and  even  more  strik- 
ing instances  might  be  given  of  the  extraordinary  rapidity  with  which 
strong  men  were  instantaneously  laid  low ;  but  these  must  suffice. 

Then  there  is  the  intense  headache ;  the  extreme  prostration,  quite 
out  of  proportion  to  the  severity  of  the  fever ;  the  occasional  maniacal 
delirium  of  the  onset,  or  it  may  be,  even  definite  symptoms  of  menin- 
gitis ;  the  marked  mental  depression  that  marches  with  the  disease  or 
follows  it.  Neuralgia,  too,  is  very  common,  sometimes  mapping  out 
the  distribution  of  certain  nerves,  and  followed  by  paralysis  or  other 
evidence  of  neuritis;  sometimes  attacking  organs  and  producing,  for 
example,  pain  in  the  eyeball,  chest  pang,  nephralgia,  neuralgia  of  the 
testis.  Then  there  are  the  racking  pains  in  the  bones  —  pains  indeed 
almost  anywhere ;  subjective  sensations  of  all  sorts  and  in  all  parts,  for 
this  short  summary  is  bald  indeed  in  comparison  with  the  multitudinous 
effects  described  by  the  many  who  were  affected. 

Of  the  disease  as  it  spends  itself  upon  the  abdominal  organs,  it  will 
suffice  perhaps  to  say  that  in  one  of  the  later  recrudescences  of  the  1889 
to  1895  epidemic,  there  were  a  fair  proportion  of  cases  in  which  the  chief 
symptom  was  of  choleraic  character  —  the  attack  being  ushered  in  by  a 
profuse  watery  diarrhoea.  A  gentleman  who  lived  upon  a  well-appointed 
flat,  and  who,  therefore,  had  everything  handy  to  his  convenience,  re- 
lated that  his  attack  was  so  sudden,  so  urgent,  and  so  profuse,  that  it 


SYSTEM  OF  MEDIC/ATE 


was  impossible  for  him  to  retain  his  control  over  his  sphincter,  and  that 
in  the  few  yards  between  his  room  and  the  water-closet  a  stream  of  fluid 
poured  from  him.  Dr.  Simon  of  Birmingham  has  put  on  record  (2) 
a  series  of  similar  cases,  abdominal  pain  and  collapse  being  added  to 
the  liquid  discharges  in  true  cholera  fashion.  Of  other  less  common 
modes  of  onset  it  is  less  necessary  to  speak,  for  it  is  quite  impossible  to 
mention  all  the  vagaries  of  the  attack  of  this  most  searching  disease ; 
but  I  have  heard  of  a  series  of  cases  all  of  which  presented  haematuria; 
and  many  cases  have  commenced  with  sore  throat,  or  acute  pain,  swell- 
ing and  abscess  in  the  ear. 

And  now  before  dismissing  the  primary  disease  and  passing  on  to 
conditions  that  may  with  some  propriety  be  called  sequelae,  there  is  good 
reason  for  taking  the  leading  phenomena  of  the  attack  as  here  enumer- 
ated, and  considering  them  a  little  more  in  detail. 

Of  the  suddenness  of  onset  enough  has  perhaps  been  said.  It  was  so 
sudden  in  some  cases  as  to  be  instantaneous,  and  the  completeness  of 
the  prostration  by  which  it  not  only,  as  it  were,  flung  strong  men  down, 
but  kept  them  down,  was  a  thing  that  appears  to  be  almost  peculiar  to 
the  disease.  Only  in  Cholera  Asiatica  is  the  collapse  anything  like  so 
sudden  and  continuous,  and  herein  it  is  due,  perhaps,  not  so  much  to 
physical  weakness  as  to  retardation  of  the  circulation  and  the  mental 
helDetude  entailed  by  it. 

The  headache  was  of  an  unusually  severe  character.  Descriptions 
of  it  varied,  but  it  was  mostly  frontal  or  orbital,  and  of  that  terrible 
kind  that  forbids  sleep  and  goads  the  patient  into  delirium.  It  was 
very  like  the  bad  headache  that  ushers  in  many  a  case  of  typhoid  fever; 
but  it  seldom  lasted  so  long,  and  usually  subsided  after  two  or  three 
days,  often  earlier. 

The  aches  and  pains  in  the  bones  and  general  soreness,  in  like  man- 
ner, were  very  severe ;  sometimes  they  were  like  the  pain  of  a  breaking 
bone;  sometimes  they  resembled  not  a  little  the  lightning  pains  of 
tabes  dorsalis ;  sometimes  there  was  a  more  general  ache  and  soreness 
in  head,  in  shoulders,  loins,  thighs,  that  forbade  ease  in  any  position 
and  gave  rise  to  an  indescribable  unrest.  Fortunately,  as  with  the 
headache,  the  pains  did  not  usually  last  in  any  severity  over  two  or 
three  days. 

The  appearance  of  the  tongue  was  quite  characteristic.  With  occa- 
sional exceptions,  such  as  have  been  mentioned,  it  was  tremulous,  large, 
soft,  indented  by  the  teeth,  moist,  and  uniformly  coated  with  a  thick, 
perhaps  rather  dirty,  creamy  fur.  This  was  usually  associated  with  a 
peculiarly  offensive  fetid  odour  of  breath,  which  one  cannot  attempt  to 
describe.  Indeed,  who  should  attempt  to  describe  a  smell  unless  there 
be  an  easily  recognisable  odour  with  which  to  compare  it  ?  The  chief 
characteristic  of  this  influenza  smell  was  its  overpowering  nastiness. 
The  odour  of  the  sweat  of  influenza  has  also  been  described  as  peculiar 
—  peppery,  mousy,  fusty,  or  mouldy  (3). 

Of  the  pulse,  the  most  distinguishing  characteristic  seemed  to  me  to 


INFLUENZA  68; 


be  that  for  the  severity  of  the  illness  it  seldom  underwent  any  propor- 
tionate acceleration.  A  sharp  fever  with  a  pulse  of  only  80  or  90  was 
quite  a  usual  occurrence. 

Coryzai  symjjtoms  were  sometimes  severe,  but  they  were  not  a  pre- 
dominant feature  in  this  epidemic.  Probably  they  were  more  often  in 
evidence  in  the  earlier  part  of  the  outbreak  than  in  its  later  years. 

The  cough  no  less  had  features  of  its  own.  It  was  hard,  dry,  and 
racking.  It  did  not  ease  itself  by  its  occurrence.  It  often  came  on  in 
violent  paroxysms,  suggestive,  as  some  have  said,  of  whooping-cough,  and 
with  the  headache,  often  existing  meanwhile,  would  give  rise  to  the  most 
intolerable  disquiet.  It  was  not  accompanied  by  any  expectoration  to 
speak  of,  and  it  was  exceedingly  intractable  to  remedies.  From  one  to 
another  went  the  question  —  What  is  the  best  remedy  for  the  cough  of 
influenza  ?  and  the  common  experience  seemed  to  be  that  no  drug  could 
be  relied  upon. 

Passing  next  to  the  fever,  it  had  no  very  definite  type,  and  unless 
disturbed  by  any  complication,  pulmonary  or  other,  it  did  not  usually 
run  to  any  unusual  height.  Its  duration  was  variable ;  in  many  cases 
not  more  than  three  or  four  days ;  but  in  many  also  it  would  run  ten  or 
twelve,  or  even  more.  In  not  a  few  it  ran  the  twcnty-one-day  fever  of 
typhoid  very  close.  It  might  be  said  by  some  that  the  fever  was  also 
very  liable  to  relapse,  but  this  would  not  perhaps  be  strictly  true,  for 
this  relapse  was  almost  always  associated  with  the  occurrence  of  some 
complication,  even  though,  as  I  should  certainly  contend,  such  com- 
plications—  pneumonia,  for  example  —  by  their  frequent  occurrence 
showed  themselves  to  be  a  part  of  the  disease.  It  has  been  asked  by 
some  whether  influenza  is  ever  an  apyrexial  disease.  There  can  be  no 
doubt  that  it  is  so  sometimes,  as  virulent  forms  of  other  infectious 
diseases  may  be.  A  lady  in  the  height  of  one  of  the  outbreaks  came 
to  feel  so  exceedingly  ill  that  she  was  obliged  to  take  to  bed.  She 
had  excessive  headache,  and  neuralgic  pains  in  various  parts  of  the 
body,  and  was  ill  for  ijiany  days,  and  much  depressed  for  some  time 
afterwards.  Her  temperature  was  below  normal  all  the  time.  My 
colleague,  Dr.  Wilks  (4),  records,  amongst  several  others,  the  case  of  a 
gentleman,  with  whom  he  is  well  acquainted,  who  suffered  severely,  and 
was  many  weeks  ill  with  influenza,  yet  who  had  no  fever  at  any  time. 
A  very  well-known  and  able  practitioner  of  my  acquaintance  in  the 
provinces  even  contends  that  "  typical  influenza "  has  no  fever.  It 
is  not  possible  to  accept  such  a  statement  of  influenza  in  general, 
but  it  is  possible  that  it  may  be  true  for  a  special  locality  or  a  special 
period  of  an  outbreak.  At  any  rate  the  observation  is  of  importance 
as  bearing  upon  the  general  question,  and  the  point  cannot  be  con- 
tested. And  why  should  it  be?  Contagious  diseases  are  by  no 
means  wanting  which  show  a  similar  peculiarity.  Cholera  is  one;  but 
the  most  comparable  is  diphtheria,  a  disease  mostly  associated  with 
pyrexia,  but  in  which  pyrexia  may  be  quite  absent,  and  that  witliout 
allowing  thereby  of  any  more  hopeful  forecast.     Any  poison  specially 


686  SYSTEM  OF  MEDICINE 

noxious  to  the  nerve  centres  may  so  alter  the  natural  heat-regulating 
processes  as  to  appear  upon  occasion  as  an  apyrexial  disease.  That 
influenza  is  a  malady  that  expends  its  force  largely  upon  the  nervous 
centres  cannot  at  this  date  be  denied,  and  it  is  equally  certain  that  it 
may  strike,  and  strike  hard,  and  yet  the  sufferer  be  free  from  fever  all 
the  time  \_oide  arts,  on  other  Infections]. 

Another  common  and  characteristic  symptom,  at  any  rate  after  two 
or  three  days  had  passed,  was  the  occurrence  of  drenching  sweats. 
They  were  variable  in  severity  —  to  judge  from  the  descriptions  of  the 
sufferers  —  from  a  peculiarly  unpleasant  feeling  of  cold  down  the  back 
up  to  the  most  profuse  sweats.  Moreover,  as  with  other  features  of  the 
disease,  they  were  very  obstinate  in  their  tendency  to  recurrence,  and 
many  were  the  cases  in  which  this  symptom  outlasted  all  the  others, 
and,  indeed,  only  gradually  died  out  after  many  weeks,  or  even 
months. 

The  occurrence  of  rigors  is  another  characteristic  that  may  be 
coupled  with  the  sweats,  because  it  emphasises  the  likeness  of  this  dis- 
ease to  those  of  malarial  origin  —  a  likeness  that  has  shown  itself  from 
the  earliest  days  of  the  histoiy  of  the  disease  when  ague  and  influenza 
appear  to  have  been  considered  in  common.  So  far  as  my  own  experi- 
ence goes,  I  think  it  may  be  said  that  hitherto,  and  until  the  occurrence 
of  the  late  epidemic,  those  of  the  present  generation  were  unfamiliar 
with  severe  and  repeated  rigors,  except  as  the  heralds  of  acute  disease  or 
of  true  ague,  or  of  localised  suppuration  in  this  part  or  that,  for  example, 
in  the  cellular  tissue  or  liver.  But  influenza  introduced  us  to  another 
common  cause  of  rigors,  and  severe  and  repeated  shiverings  which,  before 
1889,  would  certainly  have  been  taken  to  indicate  the  formation  of  pus, 
have  now  to  be  considered  from  a  wider  point  of  view.  I  have  several 
times  known  of  rigors  so  severe  and  so  repea,ted,  and  the  patient  to  be 
so  ill,  as  to  give  the  appearance  and  the  subjective  sensation  of  impend- 
ing death ;  that  one  could  not  but  surmise  the  case  to  be  one  of  virulent 
septic  poisoning,  or  of  the  local  formation  of  pus;  and  yet,  after  pro- 
voking this  diagnosis,  the  symptoms  have  disappeared  again  without 
any  such  untoward  resiilt.  I  have  also  known  of  three  cases,  at  least, 
in  which  daily  recurring  rigors  lasted  over  several  weeks. 

Yet  one  more  symptom  may  be  insisted  upon,  because  I  have  repeat- 
edly found  it  of  value  in  diagnosis,  namely,  the  extensive  diffusion  over 
the  bases  of  the  lungs  of  characteristic  sharp,  sticky  rales.  It  is  a  pity 
that  no  verbal  description  can  convey  an  idea  of  the  peculiarity  of 
this  feature  of  the  disease.  It  will  occur  to  many  that  the  bronchitis 
of  typhoid  cannot  be  very  different,  and  yet  any  one  familiar  with  the 
pulmonary  sounds  in  the  tAvo  diseases  would  surely  bear  out  the 
statement  that  the  two  conditions  are  distinguishable  by  the  ear.  In 
typhoid  fever  the  abnormal  sounds  are  chiefly  sibilant  and  musical 
wheezings,  with  no  great  amount  of  rale.  In  influenza  the  rales  were  of 
medium  size,  sharp  in  quality,  and  conveying  the  idea  of  a  peculiar 
viscidity  of  the  contents  of  the   smaller   bronchial   tubes.     And   the 


INFLUENZA  687 


clinical  course  of  the  pulmonaiy  affection  was  quite  in  accord  with  this 
presumption  of  the  nature  of  the  diseased  product.  For  in  many  cases 
the  mucus  could  not  be  expelled,  and  it  was  long  before  there  was  any 
expectoration.  And  for  the  same  reason  the  lung  was  long  in  returning 
to  its  healthy  state.  In  many  cases,  indeed,  here  was  one  of  the  chief 
dangers  of  the  disease ;  the  mischief  crept  from  some  small  area  at  the 
base  of  one  lung  over  a  larger  and  larger  area  of  that  lung,  and  then  to 
the  other  lung,  without  showing  any  sign  of  giving  way  :  in  not  a  few 
cases  the  patient  was  slowly  choked  by  the  spread  of  an  exudation  or 
secretion,  with  the  formation  or  expectoration  of  which  medicine  was 
quite  powerless  to  deal. 

And  now  to  pass  to  the  after  effects  of  influenza :  I  can  hardly  do 
better  than  set  out  with  the  words  of  a  layman  who,  in  describing  its 
effects,  said:  "It  hit  me  hard,  for  it  ridged  my  nails."  As  with  the 
initial  symptoms  of  the  disease,  so  with  the  sequelae,  the  general  pros- 
tration may  well  take  precedence  of  any  other  more  definite  nerve 
lesions.  For  of  all  the  complaints  that  are  made  there  is  certainly  none 
more  common  than  this :  "  I  had  the  influenza,  and  have  never  been 
well  since."  It  may  be  that  the  sufferer  complains  of  frequent  head- 
ache ;  but  more  often  of  a  feeling  of  constant  "  good-f or-nothingness," 
an  everlasting  sense  of  fatigue,  both  of  body  and  mind:  to  move  is  an 
exertion  that  is  almost  insupportable,  and  is  followed  by  profuse  sweats ; 
all  power  of  sustained  thought  is  gone.  Dr.  Gowers  has  well  de- 
scribed this  state  of  things.  "  It  is,"  he  says,  "  an  intense  feeling  of 
inertia.  Every  action,  physical  or  mental,  requires  an  effort  of  the  will 
to  initiate  and  maintain  it  that  is  almost  painful.  Immobility  of  mind 
and  body  alone  seem  possible,  and  yet  even  rest  has  to  be  endured,  for 
it  brings  no  freedom  from  the  sense  of  prostration.  So  strange  and 
unfamiliar  is  the  state  that  it  seems  at  first  as  if  it  be  only  transient, 
and  would  be  gone  to-morrow  ;  but  the  mistake  is  realised  when  day 
after  day,  week  after  week,  pass  without  relief.  In  perhaps  the  majority 
it  is  only  after  some  months  that  the  natural  freedom  of  untrammelled 
effort  is  regained."  To  this  may  be  added  that  even  now,  five  years  after 
the  original  outbreak  of  this  the  latest  epidemic,  there  are  many  who 
still  suffer  more  or  less  from  sensations  such  as  are  here  described. 

Again,  frequent  is  the  case  where  peculiar  "  all-overish  "  attacks  have 
repeatedly  seized  the  man  or  woman ;  sometimes  flushings,  sometimes 
indescribable  internal  sensations,  but  in  all  cases  associated  with  such  a 
dread  or  panic  of  impending  death  that,  as  several  persons  have  told 
me,  they  would  far  sooner  die  outright  and  have  done  with  it. 

Of  more  definite  disease  of  the  nervous  system  I  have  myself  seen 
several  cases  of  temporary  mental  aberration,  and  Dr.  Althaus  has  col- 
lected many  cases  of  all  kinds,  from  simple  hypochondriasis  to  melan- 
cholia, mania,  and  general  paralysis.  Suicidal  temptations  seemed 
especially  to  follow  influenza.  Cases  of  this  sort  are  observed  after  other 
severe  febrile  affections  —  tyjjhoid  fever,  for  instance  —  but  after  no  one 
can  it  be  said  that  such  an  occurrence  is  anything  lik''i  so  common  as 


688  SYSTEM   OF  MEDICINE 

has  been  our  experience  in  influenza.  But  we  are  not  dependent  upon 
what  may  be  called  functional  maladies  such  as  these,  for  there  have 
been  cases  of  acute  meningitis,  for  example,  during  the  recent  epidemic 
which  have  afforded  presumptive  evidence  of  being  related  to  influenza. 
Or  if  such  cases  as  these  allow  of  doubt,  there  are  other  acute  lesions 
of  spinal  cord  and  nerves  which  have  been  recorded  in  considerable 
number.  Neuralgia,  of  one  distribution  or  another,  has  been  noted  in 
any  nuinber  of  cases ;  and  of  still  more  serious  lesions,  Dr.  Buzzard, 
in  a  later  volume  of  this  work,  will  record  a  case  of  acute  multiple 
neuritis  that  came  under  the  cognisance  of  Professor  Clifford  AUbutt 
and  himself,  which  terminated  fatally.  Dr.  Gowers  alludes  to  cases  of 
neuritis,  and  also  to  the  curious  circumstance  that  disturbances  of 
sensation  appear  to  be  less  common  in  this  form  than  in  that  produced 
by  other  toxic  agents.  Dr.  Gowers  also  notes  that  influenzal  neuritis 
appears  more  prone  to  attack  the  face  than  other  forms.  A  case  is 
quoted  from  Westphal,  where  a  man  aged  twenty-five,  on  the  eighth  day 
of  convalescence  from  a  sharp  attack  of  influenza,  found  that  his  limbs 
were  becoming  weak.  The  loss  of  power  rapidly  increased,  included  all 
his  limbs,  and  extended  to  both  sides  of  his  face.  The  nerve  trunks  and 
muscles  of  the  trunk  were  tender,  and  the  muscles  quickly  lost  faradaic 
irritability,  but  preserved  voltaic  —  the  reaction  characteristic  of  nerve 
degeneration.  There  was  but  slight  disturbance  of  sensation.  When 
the  loss  of  power  had  reached  a  considerable  degree  it  was  accompanied  by 
the  peculiar  oedema  of  the  extremities,  often  met  with  in  multiple  neuritis. 
Then  the  palsy  ceased  to  increase,  and  after  two  weeks  more  began 
to  lessen — at  first  slowly,  and  then  rapidly;  and  went  on  to  complete 
recovery.  Dr.  Clitt'ord  AUbutt  tells  me  of  a  case  of  peripheral  neuritis 
of  the  lower  extremities,  in  which  the  gait  resembled  a  case  of  loco- 
motor ataxy  ;  the  knee  jerks  however  remained.  I  have  myself  seen  two 
cases  of  paresis  of  the  lower  extremities  associated  with  muscular  wast- 
ing, and  have  seen  or  heard  of  many  cases  of  local  wasting  of  groups  of 
muscles  that  indicated  a  localised  neuritis.  A  very  interesting  group 
of  this  sort  are  the  ophthalmoplegias.  Of  the  external  group  the 
external  recti  appear  to  be  the  most  often  affected.  Of  internal  ocular 
palsies  loss  of  accommodation  has  been  described,  and  is  said  by  Althaus 
to  be  very  common:  this  is  one  of  the  several  points  of  resemblance 
between  this  disease  and  diphtheria.  Many  other  ocular  troubles  have 
been  described  in  influenza;  chief  of  them  is  neuritis  of  the  optic 
nerve  or  of  its  sheath,  followed  by  optic  atrophy  and  amaurosis. 
Ulceration  of  the  cornea  was  not  very  uncommon  (Higgens),  and,  in  thus 
mentioning  the  loss  of  sight,  one  may  link  with  it  also  a  loss  of  smell 
sometimes  complained  of,  and  still  more  often  a  loss  of  taste  that 
lingered  long  after  the  disease  had  subsided. 

Besides  these  conditions  changes  have  been  recorded,  both  at  home 
and  abroad,  that  have  not  usually  been  attributed  to  any  toxic  agency 
such  as  we  suppose  this  disease  to  be.  Of  these  is  acute  myelitis, 
occasionally  localised,  but  more  usually  disseminated  through  more 


INFLUEIVZA  689 


or  less  of  the  spinal  cord.  Even  more  chronic  changes  still  are  said  to 
have  followed  it,  such  as  locomotor  ataxy,  spastic  paralysis,  and  so  on. 
It  is  said  that  these  serious  lesions  are  more  likely  to  occur  in  the  later 
of  repeated  attacks  than  in  the  first,  and  it  is  certain  that  they  bear  no 
relation  to  the  severity  of  the  attack.  The  post-influenzal,  like  the  post^ 
diphtheritic  nerve  lesions,  may  be  just  as  severe  after  mild  as  after 
severe  attacks.  Dr.  Wilks,  in  respect  of  this  very  point,  contends  that 
we  have  no  right  to  call  many  of  these  nervous  phenomena  "  sequelae," 
for,  inasmuch  as  in  many  cases  they  are  the  only  symptoms,  they  are 
the  essential  disease.  As  another  sequela  diabetes  may  next  be  men- 
tioned, not  because  it  has  been  common,  but  because  of  its  nervous 
origin :  Dr.  Saundby  has  described  post-influential  diabetes,  so  also  has 
Eischel,  and  I  have  seen  a  case.  Sir  T.  Grainger  Stewart  asserts  that 
a  considerable  number  of  cases  took  origin  after  influenza,  and  that  in 
a  considerable  number  of  those  already  diabetic  coma  supervened  as  the 
result  of  the  intercurrent  malady. 

Of  the  p^dmonary  sequeke  pneumonia  was  the  most  frequent.  That 
it  is,  often,  an  integral  part  of  the  disease  has  already  been  said,  but  in 
many  it  was  probably  rather  a  sequela,  the  influenza  bacillus  being 
absent  and  the  pneumococcus  present.  It  is  necessary,  therefore,  to 
suppose,  as  I  shall  presently  say  of  typhoid  fever,  that  the  influenza  in 
some  cases  laid  its  victim  open  to  an  attack  of  pneumonia. 

In  another  large  number  of  cases  this  seemed  certainly  true  as  re- 
gards pulmonary  tuberculosis.  Many  a  case  seemed  to  start  from,  an 
attack  of  influenza,  and  many  a  case  of  phthisis  was  certainly  sent  on  its 
way  with  an  alarming  increase  in  the  rapidity  of  its  progress.  Asthma, 
though  in  nothing  like  the  same  degree,  is  another  malady  that  has  in 
some  cases  been  definitely  traced  to  an  attack  of  influenza  ;  and  in  two 
instances  I  have  known  it  to  be  the  initial  symptom  of  the  ej^idemic 
disease.  There  is  also  no  doubt,  too,  that  empyema  is  unusually  prone  to 
follow  upon  the  acute  pulmonary  inflammations  that  arise  in  influenza. 
Probably  the  same  may  be  said  of  pyo-pericardium.  I  met  with  four 
cases  in  the  height  of  the  epidemic,  and  I  shall  also  state  my  strong 
belief  that  idcerative  endocarditis  was  no  uncommon  outcome  ;  at  any  rate 
it  seemed  to  me  to  be  disproportionately  frequent  during  the  epidemic. 
Quite  recently  a  woman  with  mitral  disease  in  G-uy's  Hospital  took  influ- 
enza, and  thenceforward  remained  feverish  and  died  after  several  weeks 
of  malignant  endocarditis  with  infarctions  in  the  spleen  and  pneumonia. 

The  mention  of  unhealthy  inflammations  of  this  sort  may  well  lead 
on  to  the  next  sequela  that  was  very  common,  namely,  the  formation  of 
abscesses  in  various  parts  of  the  body.  Many  were  glandular  abscesses, 
but  not  all.  Abscesses  in  the  brain,  in  the  lungs,  in  and  about  joints, 
in  the  neck,  axilla,  groin,  have  all  been  met  with,  and,  at  one  period  of 
the  epidemic,  otitis  of  the  middle  ear  and  abscess  following  upon  influ- 
enzal sore  throat  was  quite  a  common  occurrence.  Suppuration  in  the 
antrum  of  Highmore  is  a  distressing  and  possibly  fatal  sequela  which 
for  a  time  may  escafje  diagnosis. 

VOL.    I  2    Y 


690  SYSTEM   OF  MEDICINE 

These  are  the  main  results  of  this  strange  and  terrible  disease. 
But  the  list  is  by  no  means  exhausted.  Tliere  would  appear  to  be  no 
organ  or  tissue  that  may  not  become  the  subject  of  its  attack.  Dr. 
Boulting  tells  me  of  four  cases  of  myxozdema  that  he  believes  to  have 
been  consequences  of  attacks  of  influenza,  and  acute  thyroiditis  was 
twice  recorded  (in  the  British  Medical  Journcd)  during  the  year  1895  as 
a  complication  of  influenza.  Parpiira  licemorrhagica  deserves  mention. 
Dr.  Sansom  has  recorded  a  case  associated  with  acute  pemphigus,  and 
Professor  Allbutt  tells  me  of  another  that  occurred  in  a  severe  case  of 
influenza  with  pneumonia  and  recurrent  attacks  of  mild  mania.  The 
patient  was  a  gentleman  of  forty-flve,  over  the  trunk  of  whose  body, 
though  chiefly  towards  the  back  whereon  he  lay,  were  very  black,  close 
set  petechise,  that  took  many  weeks  to  fade.  A  variety  of  erythematous 
eruptions  upon  the  skin  have  been  noticed  ;  and  albuminuria  and  heema- 
turia  were  not  uncommon  with  nephritis  as  an  occasional  result.  Orchi- 
tis has  been  noticed  in  one  or  two  cases. 

Lastly,  one  may  notice  the  persistence,  long  after  the  disease  has 
spent  itself,  of  a  subnormcd  temperature,  a  condition  that  may  be  taken 
to  mean  either  the  long-lasting  influence  of  the  disease  upon  the  ner- 
vous centres,  or  no  more  than  the  dyspepsia,  the  neuralgia,  the  general 
"  good-f or-nothingness  "  which  are  expressive  of  the  severity  of  the  illness 
the  sufferer  has  passed  through.  And  in  this  regard  maybe  mentioned 
two  other  curious  results  of  the  disease  that  are  to  be  explained,  one 
may  suppose,  in  the  same  way:  one  is  the  development  in  some  people 
of  an  unnatural  appetite.  A  friend  tells  me  that  for  a  long  time  after 
the  attack,  though  habitually  a  small  eater,  and  taking  next  to  no  food 
in  the  middle  of  the  day,  he  would  eat  four  enormous  meals ;  and  if 
from  stress  of  work  he  was  unable  to  get  food,  he  would  suffer  such 
intolerable  agony  in  his  stomach  that  he  would  rather  have  died.  The 
other  point  is  the  toleration  of  alcohol  that  followed  the  disease  in 
some  persons.  A  young  man  told  me  that  he  was  so  weak  after  his 
attack  that  he  daily  took  a  quart  of  stout  at  his  lunch  and  another  at 
dinner,  and  "it  never  seemed  to  go  anywhere,"  nor  did  he  experience 
any  ill  effect.  An  old  lady,  who  in  ordinary  circumstances  was  a  small 
eater  and  seldom  took  alcohol  in  any  form,  had  a  mild  attack  of  influenza 
and  then  a  relapse  with  diffuse  phlegmonous  cellulitis  of  one  leg. 
She  now  took  food  in  large  quantities,  enough,  it  was  said,  for  three 
men,  so  as  to  be  the  astonishment  of  her  friends  ;  and  she  took  twenty- 
flve  ounces  of  brandy,  two-thirds  of  a  bottle  of  port,  and  a  pint  of  cham- 
pagne in  the  twenty-four  hours  for  ten  days  or  more  consecutively  and 
made  a  good  recovery. 

Etiology  and  Pathology.  — It  is  a  matter  of  doubt  when  the  disease 
that  we  now  call  influenza  first  appeared  in  England.  In  the  sixteenth 
and  seventeenth  centuries  ague  and  influenza  were  not  adequately 
distinguished.  The  notion  of  ague,  as  Creighton  remarks,  was  upper- 
most, and  there  were  no  means  of  distinguishing  one  disease  from  the 


INFL  UENZA  691 


other.  In  the  eighteenth  and  nineteenth  centuries  the  idea  of  catarrh 
has  been  the  more  prominent. 

But  it  would  seem  probable  that  since  1650,  or  thereabouts,  a  disease 
of  the  same  characters  as  our  visitant  of  recent  times,  or  approaching 
thereto,  has  now  and  again  appeared  in  this  country.  This,  however, 
would  hardly  be  supposed  from  the  various  appellations  given  to  it. 
Some  of  these,  as  narrated  by  Creighton,  are  as  follows :  In  1562,  "  the 
new  acquaintance ; "  in  1580,  "  the  gentle  correction ;  "  and  at  later 
dates  ''the  new  delight,"  "the  jolly  rant."  There  can  be  few  indeed, 
having  had  experience  of  our  recent  epidemic,  who  would  not  rather 
subscribe  to  the  propriety  of  the  term  "  knock-me-down  fever  "  (applied 
sometimes  to  dengue),  than  speak  of  it  thus  tenderly  as  ''the  gentle 
correction,"  and  still  less  as  "  the  new  delight."  Happy  are  we,  if  with 
our  recent  and  vivid  memory  of  such  a  scourge,  we  can  yet  smile  at  the 
conceits  of  a  bygone  day. 

So  far  as  the  attack  itself  is  concerned,  the  description  of  the 
epidemics  of  earlier  times  are  wonderfully  accurate  now.  Subjoined  is 
a  description  by  Huxham  of  the  disease  as  it  appeared  to  him  in  1733 
(5)  :  "  It  began  with  slight  shivering,  followed  by  transient  erratic  heats, 
headache,  violent  sneezing,  flying  pains  in  the  back  and  chest,  violent 
cough,  a  running  of  thin,  sharp  mucus  from  the  nose  and  mouth.  A 
slight  fever  followed,  with  the  pulse  quick,  but  not  hard  or  tense.  The 
urine  was  thick  and  whitish,  the  sediment  yellowish  white,  seldom  red. 
Several  had  racking  pain  in  the  head,  many  had  singing  in  the  ears  and 
pain  in  the  meatus  auditorius,  where  sometimes  an  abscess  formed; 
ulcerations  and  swelling  of  the  fauces  were  likewise  very  common.  The 
sick  were  in  general  much  given  to  sweating,  which,  when  it  broke  out 
of  its  own  accord  and  was  very  plentiful,  continuing  without  striking  in 
again,  did  often  in  the  space  of  two  or  three  days  carry  off  the  fever. 
The  disorder  in  other  cases  terminated  with  a  discharge  of  bilious  matter 
by  stool,  and  sometimes  by  the  breaking  forth  of  fiery  pimples.  It 
was  rarely  fatal,  and  then  mostly  to  infants  and  old,  worn-out  people. 
Generally  it  went  off  about  the  fourth  day,  leaving  a  troublesome  cough, 
often  of  long  duration,  and  such  dejection  of  strength  as  one  would 
hardly  have  expected  from  the  shortness  of  the  time.  The  cough  in  all 
was  very  vehement,  hardly  to  be  subdued  by  anodynes ;  and  it  was  so 
protracted  in  some  as  to  throw  them  into  consumption,  which  carried 
them  off  within  a  month  or  two." 

This  description,  except  in  the  statement  that  the  disease  is  rarely 
fatal  except  to  infants  and  old,  worn-out  people  —  and  it  is  still  em- 
phatically true,  that  to  the  free  liver  and  the  aged  the  risk  was  largely 
increased  —  would  include  many  of  the  main  features  of  the  disease 
now.  Moreover,  there  a,re  those  still  living  who  experienced  an  attack 
in  the  epidemic  of  1847-48,  and  who  having  suffered  again  now,  were 
able  to  identify  their  old  enemy  without  any  hesitation.  Its  prevalence 
has  been  that  of  sudden,  sharj),  short  outbursts,  mostly  exhausting  them- 
selves after  a  few  weeks  of  virulent  fury,  and  then  several  recurrences 


692  SYSTEM   OF  MEDICINE 

at  longer  or  shorter  intervals,  until  at  last  it  lias  disappeared  altogether 
for  ten,  twelve  or  twenty  years.  In  times  gone  by  the  suddenness  of 
its  invasion,  the  rapid  way  in  which  numbers  were  attacked  almost,  one 
might  say,  at  a  definite  hour,  certainly  upon  a  definite  day,  and  the 
alleged  fact  that  the  disease  attacked  not  only  those  on  land,  but  also 
appeared  upon  ships  far  away  from  land,  and  therefore  out  of  all  possible 
contact  with  sources  of  contagion,  have  led  to  the  belief  that  the  disease 
is  one  that  owns  some  atmospheric  origin.  But  in  the  last  attack  the 
observation  that  has  been  brought  to  bear  upon  this  point  has  made  it 
certain  that  the  incubation  is  very  short,  that  the  disease  is  contagious 
from  man  to  man,  that  the  contagion  is  carried  about  by  fomites,  and 
that  it  is  by  these  means  chiefly  that  the  disease  is  spread.  For  in- 
stance, the  invasion  of  a  country  or  district  when  examined  into  is 
clearly  not  so  sudden  as  has  been  thought.  In  the  first  outburst  of  the 
disease  in  the  winter  of  1889,  the  disorder  befell  us,  apparently,  almost 
upon  a  particular  day  in  the  last  week  in  December.  But,  as  I  have 
already  said,  cases  had  occurred  for  several  weeks  before ;  and  this  is 
certainly  true,  for  on  looking  over  notes  of  cases  at  that  period  I  find 
several  in  the  preceding  month  or  five  weeks  that  puzzled  me  at  the 
time,  but  which  I  know  now  to  have  been  influenza.  So  also  when  the 
outbreaks  on  vessels  far  from  land  come  to  be  inquired  into,  not  one,  in 
the  opinion  of  Dr.  Parsons,  is  free  from  the  suspicion  that  there  may 
have  been  less  complete  isolation  than  has  been  currently  reported. 
Again,  the  few  towns  or  villages  that  have  escaped  have  been  remark- 
able for  remoteness  of  situation  or  natural  inaccessibility,  curtailing, 
therefore,  within  the  narrowest  possible  limits  the  intercourse  between 
those  within  and  those  beyond  their  borders.  On  the  other  hand,  in 
instances  too  numerous  to  mention,  the  disease  has  apparently  started 
and  spread  rapidly  from  the  date  of  a  person  going  from  an  infected 
area  to  either  a  healthy  house,  village,  or  public  institution. 

The  permanent  home  of  influenza,  if  one  there  be,  is  not  yet 
absolutely  certain.  The  west  of  Russia  seems  on  the  whole  to  be  its 
most  likely  source,  for  it  would  appear  that  "  La  Grippe  "  figures  largely 
as  a  disease  in  Russia  in  ordinary  years  (6).  It  has  been  thought  by 
some  that  the  disease  is  really  dengue  fever  under  another  name,  but 
this  cannot  be.  The  two  diseases  are  no  doubt  strikingly  alike  in  some 
general  features,  but  there  are  also  striking  differences  {vide  art.  on 
"Dengue").  The  natural  habitat  is  an  important  one.  Influenza  seems 
to  spare  no  climate,  whereas  dengue  is  a  disease  of  hot  seasons  only. 
There  are  regions,  again,  where  outbreaks  of  the  one  and  the  other  have 
followed  each  other  at  such  short  intervals  (3)  that  if  the  one  disease 
has  offered  no  protection  against  the  other  the  occasion  has  yet  offered 
an  opportunity  for  skilled  observers  to  watch  the  one  disease  with  the 
other  fresh  in  memory,  and  to  contrast  the  two.  Perhaps  the  most 
marked  difference  between  the  two  is  that  dengue  is  almost  invariably 
associated  with  a  rash,  and  is  often  followed  by  desquamation  in  large 
flakes,  whilst  influenza  is  but  rarely  accompanied  by  an  eruption. 


INFLUENZA  693 


The  incubation  is  probably  short.  From  two  to  five  days  is  ap- 
parently the  limit :  usually  two  or  three  clays,  though  this  cannot  be  said 
to  be  substantiated  with  any  degree  of  certainty,  and  a  still  shorter 
period  has  been  alleged.  Not  only  is  the  incubation  short,  but  the 
infective  power  of  the  disease  develops  early,  as  might  be  expected  from 
a  disorder  so  distinctly  catarrhal  in  character;  for  a  like  reason  it  is 
not  surprising  that  instances  are  on  record  where  the  infective  power 
appears  to  have  remained  for  many  days  after  the  onset  of  the  affection. 
It  is  obvious  that  if  the  infective  agent  be  largely  present  in  the  bronchial 
secretion  as  well  as  in  that  of  the  nasal  passages,  the  duration  of  possible 
infective  power  might  need  to  be  measured  by  the  continuance  of  the 
catarrh,  whether  it  relapse  in  the  particular  case  or  not.  In  this  respect 
it  may  be  that  pertussis  and  influenza  show  a  resemblance  to  each  other. 
In  making  this  comparison,  however,  it  is  necessary  to  remember  that 
pertussis  is  prone  to  relapse  again  and  again  long  after  the  primary  dis- 
ease, and  that  there  is  no  evidence  that  the  relapses  are  infective  in 
their  nature.  It  may  perhaps  be  thus  with  influenza  —  at  any  rate  in 
those  common  cases  in  which  certain  individuals  are  said  to  have  had 
the  disease  time  after  time. 

The  shortness  of  incubation  and  early  activity  of  the  infecting  agent 
are  of  paramount  importance  when  considering  the  next  question,  namely, 
the  epidemic  character  of  the  disease.  A  short  period  of  incubation 
must  enormously  increase  the  rapidity  of  the  spread  of  any  disease  that 
is  contagious.  But  scarlatina  is  a  disease  that  has  a  similar  period  of 
incubation,  and  no  such  sudden  outbreaks  are  known  with  it.  But  tAvo 
important  qualifications  have  to  be  considered  in  this  comparison.  In  the 
first  place,  scarlatina  exhausts  the  soil  and  protects  its  subject  against 
recurrence ;  secondly,  it  is  more  or  less  always  with  us.  Influenza  does 
not  render  its  subjects  immune  —  not,  at  any  rate,  to  anything  like  the 
same  extent,  certain  persons  seem  indeed  to  be  attacked,  preferentially, 
as  it  were,  again  and  again  —  and  even  allowing  that,  as  some  insist,  the 
catarrhal  conditions  that  are  more  or  less  always  present  at  certain 
seasons  are  influenza  in  posse,  influenza  cannot  be  said  to  be  always  with 
us  in  any  such  sense  as  is  scarlatina.  It  may  be  asserted,  then, 
that  influenza  when  it  comes  finds  a  soil  prone  to  it  instead  of  proof 
against  it,  and  finds  such  conditions  over  a  very  wide  area  of  the  earth's 
surface.  No  previous  epidemics  have  prepared  man  to  resist  it  in  any 
way,  even  if  they  have  such  a  power ;  like  a  familiar  guest,  it  finds  us 
with  open  house  everywhere.  And  if  to  such  ready  access  be  added 
the  other  factor  that,  like  measles,  it  infects  actively  so  early  that  it  is 
at  work  for  this  purpose  long  before  it  can  be  recognised,  we  have  a 
coml)ination  of  circumstances  that,  as  Dr.  Parsons  insists,  explains  the 
extraordinary  rapidity  of  the  diffusion  of  the  disease,  and  one  that  must 
be  carefully  considered  and  appraised  before  any  attempt  be  made  to 
estimate  the  nature  or  the  power  of  epidemic  influence. 

What  additional  influence  or  influences  make  for  an  epidemic  are 
stiJl  unknown.     It  cannot  be  doubted  that  some  such  are  needed,  and 


694  SYSTEM  OF  MEDICINE 

that,  speaking  generally,  they  must  be  of  atmospheric  order.  We  have 
knowledge  of  epidemics  of  voles,  of  locusts,  of  wasps,  of  certain  cater- 
pillars, of  the  Colorado  beetle,  of  certain  blights,  depending  no  doubt  upon 
the  conditions  of  environment  of  these  lower  orders  of  life  by  which 
their  reproduction  has  been  extraordinarily  facilitated.  There  seems 
no  adequate  reason  against  some  assumption  of  the  kind  in  the  present 
case.  Short  incubation,  early  activity  of  infecting  power,  and  absence 
of  immunity,  would  all  seem  to  forecast  an  endemic  rather  than  an 
epidemic  disease;  whereas  iirfluenza  sweeps  over  the  world  and  it  is 
gone.  We  can  see  it  afar  off,  and  trace  its  progress,  but  can  do  nothing 
to  stop  it;  and  it  smites  the  sanitarily  pure  with  a  severity  on  the  whole 
much  the  same  as  it  shows  to  the  rest  of  the  world. 

Atmospheric  influences  no  doubt  vary  considerably  within  limits, 
else  why  should  some  suffer  headache  when  thunder  is  in  the  air,  or  the 
corns  of  others  shoot  when  dry  weather  breaks  into  wet?  And  as  in 
all  zymotic  diseases,  even  endemic  ones,  there  are  times  when  the  disease 
is  violently  active,  times  when  it  sleeps  and  seems  almost  to  disappear, 
the  conditions  of  its  life  history  remaining  constant  all  the  time,  there 
is  no  need  to  labour  the  proof  of  epidemicity.  We  know  nothing  what- 
ever, and  are  a  long  way  off  the  discovery  of  subtle  influences  of  this 
kind,  but  none  the  less  they  certainly  exist. 

The  main  point,  however,  that  has  been  made  in  the  present  epidemic 
is  that  the  influenza  is  contagious ;  this  being  so,  it  becomes  probable 
that  it  is  of  microbic  origin,  and  investigations  in  pursuit  of  a  specific 
germ  have  resulted  in  the  discovery  of  a  bacillus  that  has  distinguishing 
characteristics.  This  bacillus,  according  to  Klein,  was  first  found  by 
Canon,  and  being  found  in  the  blood  was  supposed  by  him  to  cause  the 
symptoms  by  circulating  in  that  medium.  But  so  many  subsequent 
observers  have  failed  either  to  cultivate  the  germ  or  to  produce  the 
disease  by  inoculation,  that  Dr.  Klein  suggests  that  such  bacilli  as  are 
found  in  the  blood  are  mostly  dead.  Pfeiffer  about  the  same  time 
described  the  influenza  bacillus  independently  of  Canon,  and  stated  that 
the  home  of  the  active  germ  is  in  the  gray  mucus  of  the  respiratory 
tract,  where  the  bacilli  exist  in  such  numbers,  that  by  care  in  selecting 
the  specimen  almost  a  pure  culture  may  be  obtained.  This  is  corrobo- 
rated by  Kitasato  and  others. 

As  regards  cultivation  of  the  bacillus,  Pfeiffer  has  produced  by  inoc- 
ulation in  monkeys  symptoms  similar  to  those  of  influenza.  Dr.  Klein 
(7)  has  made  numerous  experiments  by  inoculation  of  the  pure  culture 
upon  rabbits  and  monkeys ;  in  only  one  monkey  was  any  success  obtained, 
but  the  juices  from  this  animal  when  injected  into  other  monkeys  pro- 
duced the  disease  in  some  of  them.  This  difiiculty  of  reproducing  the 
disease  by  inoculation  is  of  importance,  because  it  is  believed  by  some 
that  human  influenza  exists  also  in  horses,  dogs,  and  cats.  ■  There  is 
some  evidence  in  support  of  the  belief,  but  it  is  meagre  and  equivocal. 

Pf eiffer's  bacillus,  as  it  is  now  called,  is  very  minute  —  04  m.  in  thick- 
ness,  0-8  m.  in  length  (7).    It  occurs  in  masses,  or  singly,  or  in  twos  and 


INFLUENZA  695 


threes.  In  stained  specimens  it  has  a  peculiar  appearance,  the  proto- 
plasm being  segregated  into  a  stained  granule  at  each  end,  while  the 
middle  portion  remains  unstained,  and  shows  only  the  outline  of  the 
sheath.  Thus  the  bacillus  looks  like  a  diplococcus,  and  where  two  are 
placed  end  to  end,  they  look  like  a  chain  streptococcus  of  four  spherical 
cocci.  They  are  found  in  quantities  in  the  bronchial  secretion,  and,  in 
severe  cases,  in  the  peribronchial  and  subpleural  lymphatics. 

The  bacillus  stains  with  difficulty.  My  colleague.  Dr.  Washboiirn, 
to  whom  the  three  foregoing  paragraphs  have  been  submitted,  states 
that  the  best  method  is  to  use  a  solution  of  carbolic  fuchsin  diluted 
with  water.  The  smeared  cover-glass  is  dried  and  then  stained  for 
ten  minutes,  afterwards  washed  with  water,  dried,  and  mounted  in  the 
usual  way.  The  cultivation  of  the  bacillus,  a  matter  of  some  difficulty, 
is  favoured  by  the  presence  of  haemoglobin  in  the  medium.  The  best 
method  is  to  remove  blood  from  the  blood-vessels  of  pigeons  with 
aseptic  precautions,  and  allow  it  to  clot  upon  the  surface  of  agar 
sterilised  in  a  test-tube.  The  sputum  is  sown  upon  the  surface  of  the 
blood,  and  the  tube  kept  in  an  incubator  at  blood  heat  for  twenty- 
four  hours.  By  this  time  the  influenza  bacilli  will  have  formed 
minute  transparent  colonies  hardly  visible  to  the  naked  eye.  This 
bacillus  is  characteristic  of  the  disease.  So  far  it  has  not  been  dis- 
covered in  the  blood  or  secretions  from  patients  suffering  from  other 
diseases. 

Thus  much  of  the  bacillus.  It  is  consistent  with  all  that  is  known 
of  most  of  these  minute  organisms  that  their  presence  in  the  secretions 
of  one  part  or  another  should  be  associated  with  a  specific  state  of 
pyrexia  in  the  individual  attacked.  But  we  have  yet  to  consider  the 
relation  of  the  germ  to  the  after  effects  of  the  disease,  and  the  explana^ 
tion  of  these  is  by  no  means  free  from  difficulty.  Influenza  in  its  sudden 
and  severe  prostration  is  very  like  typhus  fever ;  in  its  disturbance  of 
the  nervous  centres  and  tracts  it  is  more  like  diphtheria.  The  diffi- 
culty in  both  is  that  the  after  effects  may  come  on  when  and  indeed  long 
after  the  primary  disease  appears  to  have  spent  itself.  Up  till  recent 
times  no  explanation  of  this  phenomenon  has  been  at  all  satisfactory ;  but 
now  the  theory  of  the  production  of  toxins  during  the  growth  of  the 
bacillus  adapts  itself  reasonably  and  it  would  seem  adequately  to  the 
peculiar  explanations  of  such  cases.  Upon  this  hypothesis  the  life  and 
growth  of  the  bacillus  leads  to  the  production  of  poisonous  material  in 
the  juices  upon  which  it  thrives :  this  is  carried  into  the  circulation, 
and  gradually  works  out  the  distributed  effects  which  characterise  the 
sequel ;fi  of  each. 

Morbid  Anatomy.  — The  mortality  of  influenza  was  so  large  that  much 
information  might  have  been  expected  under  this  head.  But  indeed 
our  knowledge  has  not  been  greatly  extended.  In  all  sudden  epidemics 
of  the  kind  the  disease  is  so  distributed  that  comparatively  few  deaths 
occur  in  pid)lic  institutions  where  such  opportunities  can  be  iitilised; 
moreover,  the  outbreaks  are  so  overwhelming  that  it  is  impossible  to 


696  SYSTEM  OF  MEDICINE 


tarn  aside  from  the  living  to  the  dead.  Indeed  we  have  not  yet  arrived 
at  that  certainty  which  will  enable  us  always  to  distinguish  between  the 
changes  in  tissues  or  organs  that  are  due  to  this  acute  process  or  the 
other. 

Thus,  speaking  generally,  the  changes  in  the  lung,  for  example,  are 
those  of  bronchopneumonia,  of  acute  lobar  pneumonia,  or  of  acute 
bronchitis ;  yet  there  are  no  obvious  morbid  characters  by  which,  apart 
from  the  history  of  the  case,  we  can  recognise  such  changes  as  belong- 
ing to  influenza.  It  is  true  in  the  main  that  the  morbid  changes  of 
influenza  are  the  result  of  certain  secondary  processes :  influenza  opens 
the  door,  as  it  were,  to  various  other  poisons,  which  we  have  already 
indicated  in  the  clinical  description  —  the  streptococcus  with  the  conse- 
quent production  of  pus,  the  pneumococcus  with  the  production  of 
pneumonia,  and  so  on. 

Certain  changes,  which  appear  to  be  peculiar,  have,  however,  been 
described  in  the  lungs,  not  only  in  the  more  recent,  but  also  in  several 
of  the  earlier  visitations.  I  may  quote,  in  particular,  from  an  account 
of  the  epidemic  of  1837,  as  recorded  by  Graves  upon  the  authority  of 
Dr.  George  Green:  "The  bronchial  mucous  membrane  was  found  in 
every  case  more  or  less  congested  and  inflamed.  .  .  .  The  inflammation 
in  most  cases  occupied  the  trachea  and  the  bronchial  tubes  of  both 
lungs.  ...  A  sanguinolent  frothy  mucus  occupied  the  area  of  the  tubes, 
and  increased  in  quantity  as  they  were  traced  to  their  minuter  divisions. 
The  parenchymatous  tissue  of  the  limg  was  invariably  discoloured,  and 
it  did  not  crepitate,  or  very  feebly  so,  when  pressed  between  the  fingers. 
The  surface  of  its  section  was  not  rough  to  the  touch,  and  Avhen  pressed 
in  the  hand  a  quantity  of  the  mucus  described  was  driven  out.  .  .  . 
When  the  torn  surface  of  such  lungs  was  examined  it  did  not  appear 
granulated.  .  .  .     The  signs  of  recent  pleuritis  were  rare." 

Dr.  Louis  Hayne,  writing  of  the  morbid  anatomy  of  the  lungs  in  the 
recent  epidemics  (11),  agrees  very  closely  with  this  description.  He  notes 
the  frequency  of  lobar  pneumonia  and  its  tendency  to  attack  the  upper 
lobe.  Dr.  Ribbert  of  Berlin  is  quoted  to  the  effect  that  "  the  hepatisa- 
tion  on  section  has  a  peculiarly  smooth  aspect,  differing  from  the  ordi- 
nary granular  aspect  of  acute  croupous  pneumonia.  Sometimes  there 
is  marked  interstitial  inflammation,  explaining  perhaps  the  tendency  to 
abscess  and  pulmonary  gangrene.  This  peculiar  smooth  aspect  has  been 
frequently  observed  in  the  deaths  from  recent  epidemics,  as  has  also  the 
association  with  ib  of  areas  of  bronchopneumonia.  Often  the  solid  lung 
looks  as  though  it  were  composed  of  a  number  of  patches  of  broncho- 
pneumonic  consolidation,  these  patches  having  run  together  and  involved 
the  Avhole  lung,  suggesting  the  appearance  of  a  confluent  bronchopneu- 
monia rather  than  that  of  the  croupous  variety  of  pneumonia.  .  .  .  This 
is  often  found  in  conjunction  with  red  hepatisation.  ...  In  some  cases 
pale  patches  of  bronchopneumonia  are  scattered  throughout  the  lung  so 
as  to  suggest  at  first  sight  the  existence  of  miliary  tubercle.  As  regards 
the  bronchi,  inflammation  of  the  larger  tubes  is  very  common,  besides  the 


INFLUENZA  697 


capillary  bronchitis,  the  bronchi  being  congested  and  covered  with  thick 
mucus.  The  tubes  are  generally  tilled  even  to  considerable  dilatation 
with  muco-pus.  The  whole  thickness  of  the  bronchial  wall  is  softened. 
Sometimes  the  contents  of  the  bronchial  tubes  are  not  m.ucopurulent, 
but  fibrinous." 

I  cannot  myself  attribute  much  significance  to  this  smoothness  of 
surface.  I  am  quite  familiar  with  it  as,  at  any  rate,  an  occasional  feat- 
ure of  irregular  forms  of  pneumonia ;  and  it  has  seemed  to  me  some- 
times to  be  due  to  a  want  of  intensity  in  the  exudative  process,  sometimes 
to  the  occurrence  of  mixed  forms  of  inflammation,  particularly  in  the 
direction  of  interstitial  changes  and  nuclear  proliferation,  associated 
with  collapse  of  the  spongy  structure  of  the  lung. 

Little  more  can  be  said,  and  this  little  is  scarcely  distinctive. 
Probably  as  much  could  be  said  of  an  epidemic  of  measles.  The 
peculiarity  of  the  changes  lies  mostly  in  the  fact  that  acute  broncho- 
pneumonia, a  rare  disease  in  the  adult,  is  the  common  morbid  change 
found  in  the  bodies  of  those  who  die  of  influenza^  but  that  it  is  often 
associated  with  patches  in  which  the  microscopical  changes  are  those 
of  lobar  pneumonia. 

Before  now  quitting  the  etiology  and  pathology  of  the  disease,  I  am 
tempted  to  say  that  epidemic  disease  has  a  valuable  bearing  upon  a  very 
interesting  question,  namely,  that  of  the  "  change  of  type  "  of  disease. 

In  diseases  that  are  ever  with  us,  that  grow  old  as  we  do  and  with 
us,  it  is  difficult,  though  it  might  seem  easy,  to  express  any  opinion 
upon  such  a  point.  For  it  may  easily  be  with  disease  as  it  is  with  the 
face  of  a  familiar  friend.  How  easy  it  is  to  think  that  face  has  altered 
in  little  or  nothing  since  the  days  of  our  boyhood  together  !  Yet  what 
havoc  does  the  fashion  of  the  day,  with  its  photographs  of  the  individual 
at  various  stages  of  his  existence,  make  with  any  such  fond  idea  !  In 
influenza,  however,  we  have  a  disease  which  only  visits  us  at  considerable 
intervals,  and  thus  it  affords  a  favourable  opportunity  of  eliminating 
this  possible  source  of  fallacy ;  and  it  would  appear  from  evidence 
already  quoted  that  there  is  no  material  alteration  in  the  symptoms ; 
as  they  were  in  former  times,  so  they  are  now. 

But  it  is  possible  that  if  the  causes  be  the  same  the  individual  may 
have  altered.  Is  there  any  evidence  upon  this  head  ?  Without  answer- 
ing this  question  in  any  decisive  way,  it  may  be  worth  while  to  point  out 
that  there  is  no  record  in  former  times  of  the  long  series  of  post-influ- 
euzal  nerve  disorders  with  which  we  are  now  but  too  familiar,  and 
which  will  be  found  by  our  successors  when  in  the  heat  of  epidemics 
yet  to  come  they  study  as  we  do  to-day  the  recorded  experience  of 
the  past.  The  difference  in  this  respect  that  can  be  noticed  between 
the  past  and  present  may  indeed  be  due  to  a  simple  imperfection 
in  the  medical  record,  and  the  question  must  be  left  an  open  one  ; 
but  it  anay  well  be  considered  a  chief  object  of  the  chronicle  of  to-day 
to  put  clearly  on  record,  that  as  a  disease  influenza  has  shattered 
the    nervous    systems    of    a   large    number   of  its   victims,   in   some 


698  SYSTEM   OF  MEDICINE 

cases  permanently,  in  many  for  several  years  after  it  has  run  its 
course. 

Whether  this  disorder  has  the  power  of  modifying  the  course  of 
other  diseases  may  more  conveniently  be  considered  under  the  head  of 
diagnosis  now  to  come. 

Diagnosis. — The  general  symptoms  have  already  been  sufficiently 
considered.  All  observers  have  insisted  upon  the  extreme  prostration 
as  the  typical  feature  of  this  disease.  This  has  probably  led  us  into 
some  neglect  of  one  or  two  other  features  that  are  probably  not  less 
weighty  as  means  of  diagnosis.  Chief  of  these  I  would  place  the  thick 
coating  of  a  moist,  dirty,  creamy  material  upon  a  large,  flabby,  and  often 
tremulous  tongue.  To  this  characteristic  tongue  must  be  added  the  ten- 
dency to  profuse  sweats,  a  pulse  but  little  accelerated,  and  a  pyrexia,  if 
present,  of  indefinite  type.  In  the  great  majority  of  cases  the  key  to 
the  diagnosis  rested  upon  the  accurate  fitting  or  otherwise  of  one  or 
other  cf  these  pieces  into  the  mosaic  —  in  such,  at  any  rate,  as  presented 
any  difficulty ;  and  these  were  many.  Any  number  of  cases  have  been 
seen  that  at  their  onset  looked  like  influenza,  but  which  afterwards 
proved  to  be  typhoid  fever ;  and  who  can  wonder  that  the  diagnosis  is 
occasionally  a  halting  one?  A  large  number  of  cases  may  each  begin 
with  headache,  shivering,  general  aching,  and  a  pulse  but  little  above 
the  natural  rate.  Sometimes,  too,  the  spleen  may  be  enlarged.  How 
can  the  two  diseases  then  be  distinguished  until  some  characteristic  de- 
velopment occur  ?  Watson  noticed  the  resemblance  of  the  early  stages 
of  influenza  to  continued  fever.  Yet  it  is  possible  that  a  provisional 
diagnosis  of  influenza  and  a  final  one  of  typhoid  fever  was  by  no  means 
always  a  mere  mistake ;  and  there  are  those  who  think  that  the  occurrence 
of  the  one  disease  lays  the  patient  open  to  an  attack  of  the  other.  Such 
proclivities  are  well  recognised  between  measles  and  pertussis  ;  between 
scarlatina  and  diphtheria.  It  may  be  so  here,  although  where  mistake 
is  so  easy  it  might  seem  unnecessary  to  apply  any  such  disputable 
hypothesis.  There  is,  however,  the  more  reason  for  thinking  this  to  be 
possible,  as  there  seems  some  small  amount  of  evidence  that  influenza,  or 
the  conditions  of  our  environment  that  favour  its  development,  may  also 
modify  in  various  ways  the  natural  course  of  other  diseases.  Some  ex- 
amples of  this  tendency  have  already  been  alluded  to,  namely,  the  rapid 
development  of  pulmonary  tuberculosis  after  influenza,  the  risk  of  pleurisy 
taking  on  a  suppurative  form,  of  an  endocarditis  assuming  a  malignant 
type,  of  a  sore  throat  leading  to  an  acute  suppuration  of  the  internal  ear ; 
and  I  cannot  but  think  that  typhoid  fever  has  of  late  shown  anomalous  feat- 
ures that  may  possibly  bear  a  similar  interpretation.  For  example,  a  young 
man  had  been  exposed  to  cold  and  wet  during  the  prevalence  of  influenza, 
and  had  imperfectly  guarded  himself  against  such  influences.  He  was 
seized  with  rigors  and  went  to  bed,  and  thenceforth  his  sole  complaint  — 
for  he  was  quite  clear  in  his  mind  —  was  that  he  was  constantly  drenched 
with  perspiration.  His  temperatiire  was  104°,  his  pulse  only  90,  his 
tongue  moist  and  rather  creamy,  his  bowels  required  some  mild  laxative. 


INFLUENZA  699 


Clearly  the  disease,  although  undoubtedly  typhoid  fever,  for  he  had  pro- 
fuse intestinal  haemorrhage  about  the  twelfth  day,  from  which  he  rapidly 
sank,  was,  in  respect  of  the  rigors  and  sweating,  of  an  influenzal  type. 
Of  late  there  have  been  many  such  cases  of  typhoid  fever  associated  with 
inordinate  sweating.  Another  case  that  I  have  some  knowled.ge  of  began 
with  wild  maniacal  delirium,  much  more  like  influenza  than  typhoid ; 
and  other  examples  could  be  given  where  premonitory  symptoms  of 
influenza  ushered  in  typhoid  fever,  and  this  would  seem  to  be  a  new 
experience.  That  this  is  no  more  than  a  personal  opinion  I  fully  admit, 
but  even  the  opinions  of  those  who  have  lived  through  an  epidemic  of 
a  disease  that  may  not  visit  us  again  for  many  years  are  worth  mention. 
They  must  be  recorded  now  or  not  at  all,  and  they  may  be  useful  in  the 
future  as  suggestions  for  observation  and  inquiry. 

But  difficulties  of  diagnosis  arise  in  other  directions.  I  well  remember 
seeing  a  lady  who  was  suffering  severe  and  repeated  rigors,  which,  to- 
gether with  high  fever,  seemed  ominously  indicative  of  hepatic  abscess, 
or  some  internal  source  of  grave  septicaemia.  She  had  undergone,  a  few 
weeks  before,  some  slight  operation  upon  the  uterus,  but  was  supposed 
to  have  quite  recovered,  and,  as  it  proved,  had  recovered.  Had  it  not 
been  for  the  late  epidemic  of  influenza  which  has  enlarged  our  breadth 
of  view  in  the  matter  of  rigors,  the  diagnosis  would  have  been  unhesi- 
tatingly of  a  very  grave  character.  As  it  was  it  remained  doubtful,  and 
the  doubt  was  solved  by  the  patient  convalescing  without  a  drawback 
of  any  kind. 

One  other  point  may  be  mentioned,  namely,  that  influenza  is  often  so 
indefinite  in  its  features  that  the  diagnosis  can  only  be  arrived  at  after 
the  event,  if  then.  And  it  is  probable  that  this  is  of  importance  if  any 
adequate  notion  of  the  impact  of  the  disease  upon  the  population  is  to  be 
obtained.  Here  is  an  illustration  of  the  sort  of  case  that  was  constantly 
occurring.  One  member  of  a  family  had  a  sharp,  febrile  attack  of  qiiite 
indefinite  nature.  Within  a  few  days  another  member  had  earache  and 
double  otitis ;  and  then  another  had  otitis,  or  a  threatening  of  it,  and 
mastoid  pain,  and  this  was  followed  by  a  troublesome  orbital  neuralgia. 
Taking  the  eases  separately  there  is  nothing  to  justify  such  a  diagnosis, 
but  putting  them  together,  and  bearing  in  mind  the  intimate  relation  that 
exists  between  influenza  and  inflammation  of  the  internal  ear,  it  is  surely 
not  improbable  that  the  disorder  in  each  case  was  influenza.  To  take 
another  case :  a  man,  apparently  in  perfect  health,  and  having  committed 
no  indiscretion  in  diet  that  could  by  any  means  explain  it,  awakes  in  the 
middle  of  the  night  with  indigestion  and  diarrhoea.  The  diarrhoea  was  a 
pure  watery  flux,  was  associated  with  slight  pyrexia,  lasted  forty-eight 
hours,  and  left  the  man  well  but,  for  him,  unusually  limp  and  tired.  There 
was  no  thought  whatever  of  influenza.  But,  nevertheless,  for  weeks  after- 
wards he  was  much  troubled  with  an  evening  neuralgia  of  one  side  of  the 
face ;  and  not  long  afterwards,  after  a  little  excess  of  work  and  exposure 
that  under  ordinary  circumstances  would  not  have  done  any  harm,  he 
was  seized  again  with  a  bad  neuralgia,  that  woke  him  regularly  for  several 


700  SYSTEM   OF  MEDICINE 

nights  out  of  his  first  sleep  and  compelled  liim  to  sit  up  for  the  rest  of 
the  night.  There  is  surely  some  ground  for  suspicion  that  the  initial 
attack  of  choleraic  diarrhoea  Avas  of  influenzal  nature,  and  that  the 
neuralgia  afterwards  was  the  sequela  that  made  the  diagnosis  possible. 

Two  other  aspects  remain  to  be  considered,  namely,  prophylaxis  and 
treatment,  and  these,  though  the  most  important  of  all,  unhappily  allow 
of  a  very  brief  statement. 

As  regards  prophylaxis,  the  obvious  thing  is  to  keep  out  of  the  way 
of  contagion.  Where  strict  isolation  has  been  possible,  as  in  certain 
institutions,  the  disease  has  seldom  appeared ;  most  risk  of  catching  the 
disease  is  run  in  public  buildings  or  ill-ventilated  rooms  of  any  sort,  a 
railway  carriage  with  closed  windows  not  excepted.  It  also  seems  cer- 
tain that  excesses  in  living  of  all  kinds  favoured  the  inroads  of  the 
disease,  as  also  did  exposure  and  fatigue.  All  observers  have  testified 
to  the  frequency  of  the  disease  and  to  its  heavy  mortality  in  the  alcoholic 
particularly,  and  also  in  the  overworked  and  harassed. 

A  large  section  of  the  public,  in  addition  to  common  sense  hygiene 
of  this  sort,  applied  itself  to  various  drugs  and  inhalations  in  the  hope 
of  warding  off  an  attack.  Quinine  was  in  most  frequent  demand  in- 
ternally, and  eucalyptus  as  an  inhalation ;  but  it  cannot  be  said  that 
either  quinine  or  salicin  in  the  one  way,  or  inhalation  in  the  other, 
showed  any  positive  success. 

We  are  as  yet  in  ignorance  how  long  the  influenzal  poison  retains  its 
vitality,  but  common  prudence  suggests  that  infected  rooms  and  clothing 
should  be  well  disinfected  after  they  have  been  contaminated. 

Treatment.  —  There  is  no  specific  yet  at  hand  for  this  disease.  This 
is  quite  certain  from  the  number  of  drugs  that  have  been  regarded  as 
almost  infallible  by  one  observer  and  another.  All  are  agreed,  however, 
that  mildness  of  attack  and  speedy  recovery  are  best  insured  by  taking 
at  once  to  bed,  and  that  it  is  the  worst  folly  to  struggle  on  with  work 
and  to  attempt  to  fight  the  disease,  —  a  plan  that,  although  some  came 
through  successfully,  was  nevertheless  the  cause  of  the  loss  of  many 
lives. 

To  go  to  bed,  to  take  plenty  of  light  liquid  nourishment  and  some 
liquor  ammoniae  acetatis  every  few  hours,  was  sufficient  in  most  eases  to 
induce  a  quick  recovery.  Other  remedies  largely  in  request  were  salicy- 
late of  soda  in  ten  grain  doses  ever^^  three  or  four  hours,  antipyrine,  alone 
or  combined  with  the  former,  phenacetin  and  quinine.  Upon  a  review 
of  the  whole  epidemic,  there  appears  in  these  drugs  nothing  of  a  specific 
effect  in  cutting  short  the  disease  ;  but  in  many  cases,  by  their  sudorific 
action  and  in  the  control  that  these  drugs  have  over  the  temperature, 
they  were  productive  of  relief,  and  made  for  the  return  of  health.  For 
the  rest  it  is  necessary  to  combat  symptoms  as  may  seem  best :  the  cough 
perhaps  most  readily  with  opium  in  some  form ;  the  aches  and  pains 
perhaps  in  a  similar  manner ;  and  for  the  long-lasting  after  effects  some 
of  the  many  good  nerve  tonics,  and  the  judicious  use  of  alcohol,  have 
been  upon  the  whole  the  most  successful. 


DIPHTHERrA  701 


For  most  of  the  statements  in  the  foregoing  article  I  have  appealed, 
in  the  first  instance,  to  my  own  experience.  But  in  the  preparation 
of  the  article  I  have  frequently  referred  to  Dr.  Theophilus  Thomson's 
Annals  of  Influenza  iti  Great  Britain  from  1510-1837;  to  the  Report  to 
the  Privy  Council  on  Influenza  by  Dr.  Parsons ;  to  the  Further  Rejjort 
and  Papers  on  Epidemic  Influenza,  1889-92,  by  the  same  gentleman ; 
to  Dr.  Klein's  report  in  this  latter  volume  ;  to  a  Monograph  on  Influenza 
by  Dr.  Althaus ;  and  to  Dr.  Creighton's  recently  published  History  of 
Epidemics  in  Britain. 

The  literature  of  influenza  scattered  over  the  periodicals  of  the  last 
few  years  is  very  voluminous ;  this  also  has  been  consulted  as  much 
as  possible,  but  the  task  has  been  rendered  incomparably  lighter  by 
such  recent  publications  as  those  I  have  specially  mentioned,  containing 
as  they  practically  do  all  the  information  that  is  to  be  obtained  upon 
epidemic  influenza. 

J.    F.    GOODHART. 

REFERENCES 

1.  Althaus.  On  Influenza,  p.  44.  —  2.  Brit.  Med.  Journ.  13th  June  1871.— 3. 
Bruce  Low  in  Report  to  the  Privy  Council  by  Dr.  Parsons,  p.  61.  —  4.  Lancet,  1893, 
vol.  ii.  p.  222,  "The  Nervous  Sequelae  of  Influenza." —.5.  Creighton.  History  of 
Epidemics  iyi  Britain,  vol.  ii.  p.  348.  —  6.  Report  on  the  Influenza  Epidemic,  1889-90,  p. 
14.  —  7.  Further  Report  and  Papers  on  Epidemic  Influenza,  1889-92.  —  8.  Guy's  Hos- 
pital Gazette,  1894,  p.  183. — 9.  Report  to  the  Local  Government  Board  on  the  Influenza 
Epidemic  of  1889-90.  — 10.  Annals  of  Influenza  and  Epidemic  Catarrhal  Fevers  in 
Great  Britain  from  1510  to  1S37.  Sydenham  Society,  1852. — 11.  Louis  Ha  yne.  Practi- 
tioner, vol.  liii.  No.  4. 

J.  F.  G. 


DIPHTHEEIA^ 


DiPHTHERiTis  and  Diphtheria  are  names  which  were  invented  by  Bre- 
tonneau/  in  1821,  to  denote  a  certain  kind  of  specific  inflammation 
(phlegmasie  specifique).  In  his  endeavours  to  distinguish  diphtheria  from 
other  diseases  he  was  compelled  to  rely  altogether  upon  observations  made 
at  the  bedside  and  post-mortem  table ;  nor  has  any  other  means  of  dis- 
crimination been  possible  until  within  the  last  few  years.  Yet  the 
clinical  definition  has  never  been  adequate  to  its  intention,  and,  in 
respect  of  some  cases  of  sore  throat  attended  by  the  formation  of  false 
membranes,  it  has  always  been  doubtful  hitherto  whether  they  are  to  be 
deemed  diphtheritic  or  not.     At  one  time  it  seemed  probable  that  an 

1  The  history  of  diplitheria  being  beyond  the  scope  of  this  essay,  the  reader  may  be 
referred  to  tlie  works  (1,  2,  I'.)  mentir)ned  at  the  end  of  it. 

2  "  11  me  soit  permis  de  dcsij^ner  cette  phlegmasie  par  la  d(?nomination  de  DIPH- 
THl'lRITE,  dei-ivf?  deAi*0KPA,  pdlis,  exuvium,  vest.is  coviacea"  (4),  p.  41.  (^v\>eepirrii 
and  U(l>eei>iat  have  the  same  meaning:  qui  geBtat  pelliceam  sen  coriaceam  tuuicam.) 


702  SYSTEM  OF  MEDICINE 

adequate  definition,  based  upon  the  essential  cause  of  the  disease  (the 
very  ens  diplitherioi),  could  at  length  be  propounded ;  that  diphtheria 
might  be  taken  to  signify  disease  due  to  infection  by  the  bacillus 
of  Klebs.^  But  now  we  are  told  that  the  bacillus  of  Klebs  and  Loftier 
is  not  found  in  some  of  the  cases  which  we  have  been  accustomed 
to  call  diphtheritic,  and  that  certain  micrococci  have  the  power  of 
setting  up  a  pellicular  inflammation.  So,  if  we  continue  to  use  the 
word  diphtheria  in  the  sense  of  ]3retonneau,  we  must  distinguish  several 
kinds  of  that  disease  (bacillary,  micrococcal  and  so  forth) ;  or  if  we 
restrict  the  use  of  the  word  to  those  cases  in  which  the  bacillus  is 
found,  we  must  invent  new  words  to  signify  the  other  forms  of  pellic- 
ular sore  throat.  It  would  probably  be  the  better  course  not  to  diminish 
the  extent  of  meaning  of  the  word  diphtheria,  and  still  to  use  it  as  Bre- 
tonneau  used  it,  but  in  a  generic  sense.  However,  the  popular  tendency 
seems  to  be  strongly  in  the  other  direction,  that  is  to  say,  to  confine  the 
name  to  those  cases  in  which  the  bacillus  is  found.  Moreover,  causes 
seldom  operate  singly  and  simply ;  and  even  that  diphtheria  Avhich  is 
characterised  by  the  presence  of  the  aforesaid  bacillus,  is  so  complicated 
by  the  action  or  co-operation  of  other  morbific  microbes,  that  diphtheria 
is  seldom  or  never  due  to  a  simple  infection.  Nor  has  skill  in  bacterio- 
logical research  yet  come  to  be  a  usual  accomplishment  of  medical  men; 
hence  the  uncertainty  concerning  the  nature  of  some  kinds  of  sore  throat, 
which  has  always  prevailed,  is  far  from  wholly  dispelled.  Indeed,  for 
practising  physicians,  the  main  note  of  diphtheria  is  still  found  in  the 
presence,  not  of  special  microbes  and  morbid  poisons,  but  of  false 
membranes  upon  certain  mucous  surfaces  or  upon  abraded  skin ;  it 
being  well  understood  that  false  membranes  are  not  quite  peculiar 
to  diphtheria,  even  when  that  word  is  used  in  its  most  extensive  sense: 
the  mucous  surfaces  referred  to  are  those  of  the  throat,  nose,  and 
windpipe  —  not  to  speak  of  surfaces  seldom  affected,  such  as  those  of 
the  stomach,  conjunctiva  and  vulva.  Definitions  of  this  kind,  though 
rude  and  inadequate,  serve  useful  purposes  until  wrought  out  into  a  full 
description  of  the  disease.  g_  q._ 

Etiology  and  Prophylaxis.  —  There  is  much  to  justify  Oertel's  asser- 
tion that  diphtheria  is  "  one  of  the  oldest  epidemic  diseases  of  the  human 
race."  A  disease,  in  description  like  diphtheria,  has  prevailed  from 
time  to  time  in  various  parts  of  England.  It  occurred,  mainly  in  a 
sporadic  form,  at  intervals  during  the  earlier  half  of  the  present  century ; 
it  assumed  an  epidemic  form  when  the  "Boulogne  sore-throat"  occurred 
on  the  French  coast ;  and  from  1855  onwards  the  disease  has  been  more 

1  In  a  bnok  cnlled  Scrntinium.  physico-mpdicum  contac/iof^s  lids  quie  dlcititr  Pestis,  by 
Athanasius  Kircher,  published  in  lfi59,  will  be  found  a  remarkable  exposition  of  the  doctrine 
that  contagious  diseases  are  dependent  upon  livina:  particles,  con  tagia  viva,  semin  a  animata. 
He  frequently  refers  to  male  in  canna  (diphtheria)  as  a  kind  of  pestilence.  Pestilential 
"effluvium  est  animata  foetura  vermium.  Sunt  autem  hi  vermicnli  pestis  propagatores 
tam  exigui,  tam  tenues  et  subfiles,  nt  omnem  sensus  captum  eludant,  nee  non  nisi  exquisi- 
tissimo  smicroscopio  sub  sensum  cadant,  atomos  diceres." 


DIPHTHERIA  703 


or  less  continuously  present  in  this  country.  Until  recent  days  available 
statistics  of  diphtheria  in  England  and  Wales  have  been  limited  to  fatal 
attacks ;  and  most  of  the  data,  especially  the  earlier  ones,  are  more  or  less 
imperfect  by  reason  of  faulty  diagnosis  and  faulty  nomenclature.  But, 
such  as  they  are,  they  show  that  during  the  three  decennial  periods, 
1861-70,  1871-80,  and  1881-90,  the  rates  of  mortality  from  diphtheria 
per  million  living  were  187, 121,  and  163  respectively.  The  increase  of 
the  rate  of  mortality  from  diphtheria  indicated  in  1881-90  has  been  more 
than  maintained.  In  the  eighteen  years  1871-88,  the  mean  of  the 
annual  diphtheria  death-rates  per  million  living  in  England  and  Wales 
had  been  137,  the  rate  hardly  ever  exceeding  160;  but  for  the  five 
years  1889-93  the  mean  of  the  rates  has  been  216,  the  rates  for  1892 
and  1893  being  the  highest  ever  recorded,  namely,  222  and  318  re- 
spectively. Indeed,  examination  of  the  mortality  returns  shows  that 
we  are  face  to  face  with  the  fact  that  for  a  period  of  some  twenty  years 
there  has  been  in  England  an  increasing  mortality  from  diphtheria, 
and  that  this  increase  has  been  specially  marked  during  the  more  recent 
years  of  that  period.  To  some  extent  this  increase  may  be  set  down 
to  improved  diagnosis,  and  better  methods  for  the  certification  of 
deaths;  but  no  such  explanation  can  account  for  an  addition  to  the 
death-roll  which,  to  use  the  description  of  the  Registrar-G-eneral,  must 
be  regarded  as  "formidable."  In  studying  the  etiology  of  diphtheria 
account  will  be  taken  of  this  growing  mortality  from  the  disease :  the 
more  because  there  is  ample  evidence  to  show  that  diphtheria  has  not 
merely  increased  in  fatality  —  whilst  the  total  amount  of  sickness  from 
that  cause  remains  much  as  before  —  but  that  the  increase  in  the  number 
of  diphtheria  deaths  has  gone  hand  in  hand  with  a  wider  diffusion  of  the 
disease  throughout  the  country. 

It  may  be  convenient  at  this  stage  definitely  to  formulate  certain 
propositions  respecting  dijihtheria  which  I  consider  to  be  demonstrated. 
It  does  not  fall  to  me  to  give  proof  of  their  truth ;  but  in  that  which 
follows  they  must  be  constantly  borne  in  mind  by  any  one  seeking  to 
apprehend  the  etiology  of  the  disease. 

1.  Diphtheria  is  a  specific  infectious  disease,  primarily  and  preferen- 
tially affecting  mucous  surfaces,  notably  the  upper  portion  of  the  res- 
piratory and  alimentary  mucous  tracts ;  also,  but  more  rarely,  affecting 
abraded  surfaces  of  the  skin. 

2.  Diphtheria  appears  first  as  a  local  disease,  the  part  attacked  being 
the  seat  of  an  inflammatory  process  characterised  by  the  formation  of  a 
false  membranous  deposit.  The  system  as  a  whole  is  secondarily  affected, 
the  general  disease  being  a  sequence  of  the  local  one. 

3.  Local  diphtheria  results  from  the  receiDtion  at  a  particular  point 
of  the  mucous  membrane  and  the  subsequent  development  there  of  a 
definite  micro-organism  —  the  Klebs-Loffler  bacillus  diphtheria'.  This 
micro-organism,  which  is  vegetable  rather  than  animal  in  its  nature 
must  therefore  be  regarded  as  the  particulate  and  essential  cause  of  the 
local  disease.     The  general  symptoms  of  diphtheria,  on  the  other  hand, 


704  SYSTEM   OF  MEDICINE 

are  largely  due  to  absorption  into  the  system  of  a  cliemical  poison  or 
toxin,  a  result  of  the  life-processes  of  the  bacillus. 

4.  Diphtheria,  or  a  disease  ejusdevi  generis,  is  found  in  certain  of 
the  lower  animals,  and  can  be  communicated  to  them  from  the  human 
subject. 

Consideration  of  the  factors  which  favour  diphtheria  will  involve 
reference  to  much  that  is  still  obscure;  but  our  present  knowledge  of 
the  etiology  of  the  disease  may  best  be  set  out  by  considering  the  char- 
acter of  the  evidence  on  which  certain  conditions  have  been  regarded  as 
disposing  to  this  disease. 

Topography,  Soil,  etc.  —  It  has  been  shown  by  Dr.  Longstaff  that, 
during  the  twenty-six  years  1855-80,  the  greatest  incidence  of  death 
from  disease  registered  as  diphtheria  in  this  country  took  place  on  our 
eastern  coast,  namely,  in  Lincolnshire,  Norfolk,  Sussex,  and  North  Yorks ; 
that  next  in  order  came  East  York,  Extra-Metropolitan  Kent,  and  Essex, 
counties  which  are  also  on  our  eastern  coast,  together  Avith  AVales  and 
certain  counties  within  or  bordering  upon  the  Midlands ;  whereas  the 
smallest  death-rates  from  disease  thus  registered  Avere  recorded  in  Lan- 
cashire, Devon,  and  Somerset  on  the  one  hand,  and  in  inland  counties 
such  as  Bucks,  Herts,  Northaoipton,  Leicester,  and  Gloucester  on  the 
other.  These  data  in  themselves,  apart  from  other  considerations, 
afford  no  sufficient  indication  that  one  or  other  portion  of  England  is 
especially  liable  to  fatal  diphtheria;  but  when  they  are  considered  in 
connection  with  conditions  of  soil,  surface,  aspect  and  rainfall,  there  is 
some  ground  for  believing  that  areas  which  favour  retention  in  the  soil 
of  wetness  and  of  dead  organic  matter,  and  are  exposed  to  the  influence 
of  cold  wet  winds,  do  tend  to  the  fostering  and  fatality  of  diphtheria. 
But  that  there  are  other  conditions  of  equal  if  not  of  greater  importance 
is  unquestionable;  indeed,  there  are  already  indications  that  the  locali- 
sation of  the  diphtheria  mortality,  which  Dr.  Longstaff  referred  to  as 
holding  good  up  to  1880,  has,  by  reason  of  other  and  more  potent 
influences,  undergone  modification  since  that  date. 

Season.  —  It  is  generally  admitted  that,  although  diphtheria  is  now 
never  absent  from  this  country,  season  exerts  a  marked  influence  on  its 
behaviour.  Taking  this  country  as  a  whole,  the  death  records  over  a 
series  of  years  show  that  the  second  quarter  of  the  year  exhibits  the 
smallest  number  of  fatal  attacks ;  that  there  is  some  increase  in  the  third 
quarter ;  that  a  very  substantial  addition  to  the  number  of  deaths  takes 
place  in  the  fourth  quarter,  when  the  rate  of  mortality  is  at  its  highest; 
and  that  during  the  first  quarter  of  the  year,  which  ranks  second  as 
regards  amount  of  death,  a  diminution  in  mortality  sets  in.  Thus, 
during  the  twenty-four  years  1870-93,  the  average  annual  number  of 
deaths  registered  as  diphtheria  in  England  and  Wales  was  distributed 
as  follows:  1st  quarter  1000,  2nd  quarter  819,  3rd  quarter  847,  4th 
quarter  1192.  But,  judging  from  available  material  concerning  attack, 
non-fatal  and  fatal,  it  would  appear  that  the  increase  in  the  mortality  at 
the  beginning  of  the  fourth  quarter  is  due  to  increase  of  attacks  in 


DIPHTHERIA 


705 


September ;  and  that  a  not  inconsiderable  amount  of  death  registered 
in  the  first  quarter  of  the  year  relates  to  attacks  which  date  from 
the  latter  part  of  the  preceding  quarter.  In  short,  an  increase  of 
diphtheria  commonly  begins  about  the  second  or  third  week  in  Sep- 
tember; the  increase  goes  on  augmenting  through  October  and  the 
greater  part  of  November,  and  a  decline  in  its  amount  usually  sets  in 
not  later  than  mid-December.  According  to  Mr.  W.  H.  Power,  October 
and  November  constitute  "the  well-known  season  of  normal  extra 
activity  of  diphtheria."  There  is  a  second  tendency  to  exacerbation,  on 
a  much  smaller  scale,  in  the  spring,  commonly  about  the  end  of  March 
or  the  beginning  of  April ;  after  this  the  disease  gradually  falls  to  its 
minimum  in  June,  July,  or  even  in  early  August. 

Sex  and  Age.  —  There  is  some  excess  of  diphtheria  in  the  female  sex, 
but  it  would  appear  to  be  largely  due  to  the  greater  opiDortunities  of  infec- 
tion in  girls  and  women  than  in  the  case  of  males.  The  excess  in  females 
commences  at  the  age  when  little  girls  begin  to  tend  the  baby  and 
.  younger  children,  whilst  their  brothers  are  occupied  out  of  doors  ;  and 
it  is  maintained  throughout  that  period  of  life  when  women  and  mothers 
are  engaged  in  house  duties  and  in  caring  for  the  sick.  Amongst 
females  also  habits,  such  as  that  of  kissing,  prevail  to  an  extent 
which  may  account  for  some  excess  of  a  disease  that  is  often  conveyed 
from  mouth  to  mouth.  At  the  extremes  of  life  the  rate  of  diphtheria 
death  in  females  does  not  exceed  that  in  males. 

The  influence  of  age  on  diphtheria  is  very  marked,  whether 
death  or  attack  be  in  question.  By  far  the  largest  rate  of  mortality 
takes  place  during  the  first  five  years  of  life,  and  especially  during 
the  age-period  2  to  5  years ;  the  period  5  to  10  years  ranks  next, 
and  it  is  not  till  after  the  termination  of  the  period  10  to  15  years 
that  any  substantial  diminution  sets  in.  In  adult  life  and  in  old  age  the 
diphtheria  death-rate  is  comparatively  insignificant.  With  regard  to  the 
comparative  immunity  of  infants  under  one  year  of  age  from  death  by 
diphtheria,  it  has  been  pointed  out  by  Dr.  D.  A.  Gresswell,  now  chief 
health  officer  to  the  Victorian  Government,  that  infants  at  times  suffer 
from  diphtheria  deposits  in  the  fauces  without  obvious  inconvenience,  and 
that  this  may  be  due  to  the  rudimentary  character  of  the  tonsils  at 
that  age.  Speaking  generally,  and  including  non-fatal  with  fatal  attacks, 
it  may  be  asserted  there  is  a  special  incident  of  diphtheria  on  the  age- 
period  3  to  12  years.  Now  it  will  be  at  once  remembered  that  the  age 
3  to  12  years  is  precisely  that  during  which  children  are  in  attendance 
at  the  elementary  schools. 

School  Influence.  — The  influence  of  school  attendance  on  the  diffusion 
of  diphtheria  was  noted  almost  as  soon  as  skilled  inquiry  into  the  circum- 
stances of  this  disease  was  instituted.  This  was  pointed  out  by  Mr.  W.  H. 
Power  in  1870,  and  in  the  following  year  I  had  an  opportunity  of  study- 
ing the  matter  during  a  maintained  prevalence  of  diphtheria  at  Cogges- 
hall  in  Essex.  It  was  found  practicable  to  divide  tlie  928  children  in 
the  village  into  age-groups,  and  then  to  ascertain  within  each  group  the 

VOL.  I  2  z 


7o6  SYSTEM   OF  MEDICINE 

relative  amount  of  diphtlieria  in  those  who  attended  school,  and  iii  those 
who  did  not.  Under  three  years  of  age  school  attendance  was  not  found 
to  have  materially  influenced  the  number  of  attacks;  but  in  the  age- 
period  3  to  12  years  the  incidence  of  the  disease  was  not  far  from 
50  per  cent  greater  on  school  attendants  than  on  others ;  and  in  the 
age-period  12  to  15  years  the  school  attendants  suffered  nearly  three 
times  more  than  those  who  were  not  at  school.  The  same  result  was 
noted  by  other  observers ;  and,  quite  apart  from  age  susceptibility,  it 
soon  became  evident  that,  there  were  certain  circumstances  associated 
with  school  attendance  which  promoted  diphtheria.  Indeed,  this  is 
now  so  generally  accepted  that  restrictions  in  school  attendance  often 
form  one  of  the  earliest,  if  not  the  chief  of  the  measures  adopted  by 
local  authorities  to  prevent  the  diffusion  of  the  disease.  But  as 
the  subject  was  more  carefully  studied,  it  became  evident  that  the 
influence  of  school  attendance  was  by  no  means  the  simple  affair 
of  personal  infection  under  circumstances  especially  favourable  to  the 
transfer  of  infection  from  one  child  to  another ;  and  another  stage  was 
reached  when  Mr.  W.  H.  Power  investigated  a  maintained  prevalence  of 
diphtheria  at  Firbright  in  Surrey.  School  attendances  were  recognised 
there  as  serving  to  diffuse  the  malady  amongst  a  somewhat  scattered 
population ;  indeed,  in  hitherto  uninfected  households,  children  between 
three  and  twelve  years  of  age,  who  at  a  given  period  were  attending 
school,  became  affected  five  or  six  times  as  numerously  as  children  of  the 
same  age  who  at  the  same  period  were  not  attending  school.  Hence,  it 
was  deemed  desirable  to  close  the  schools  on  several  occasions.  It  was 
also  seen  that  attacks  of  "  sore  throat,"  which  did  not  present  the  typical 
signs  of  diphtheria,  and  seemed  ofte^n  but  trivial  in  their  character, 
served  as  links  between  the  more  marked  outbreaks  of  the  disease. 
Hence,  besides  resort  to  measures  of  disinfection  at  the  school-house 
and  in  invaded  houses,  sustained  medical  effort  was  made  to  eliminate 
from  the  school,  on  the  occasion  of  each  of  its  reopenings,  all  cases  of 
sore  throat,  however  mild.  Thus  it  came  about  that  comparison  was 
possible  between  nine  alternating  periods  of  school  work  and  school  clos- 
ure, —  the  intervals  of  closure  lasting  generally  for  some  six  weeks,  and 
school  operations  not  being  recommenced  until  all  signs  of  sore  throat 
had  disappeared  amongst  the  scholars.  "  While  the  school  remained 
open,"  writes  Mr.  Power,  '■'•  in  the  early  months  of  the  year,  the  rate  of 
attack  in  children  aged  from  three  to  twelve,  presiimably  susceptible  of 
dinhtheria,  but  not  having  the  disease  at  home,  was  16'6  per  cent  of  those 
who  were  at  school,  and  3-8  per  cent  of  those  who  were  not.  The  next  time 
the  school  was  opened  the  respective  rates  were  4-8  and  0-0 ;  the  third 
time,  7-1  and  2-5 ;  and  on  the  November  (the  last)  occasion,  4-1  and  0-0." 
The  numbers  on  which  the  percentages  are  based  were  admittedly  not 
large,  but  it  is  claimed  for  them  that  the  indication  which  they  furnish  is 
too  uniform  to  be  mistaken.  A  newly-observed  phase  of  school  operations 
seemed  here  to  have  been  at  work;  the  bringing  together  of  the  school 
children  operating  again  and  again  so  as  to  give  a  serious  specific  quality 


DIPHTHERIA  707 

to  throat  ailments  whicli  either  appeared  very  trivial  or  were  altogether 
unrecognised;  and  this  with  remarkable  and  even  startling  suddenness. 
Similar  experiences  were  soon  recorded  by  other  observers;  and  definite 
'■'■  explosions  "  of  diphtheria  have  been  by  no  means  uncommonly  recorded 
in  connection  with  school  attendances.  School  influence  has  also  operated 
in  another  way,  and  this  especially  at  those  seasons  when  diphtheria  is 
least  prone  to  show  itself  in  recognisable  form.  At  such  seasons  the 
unexpected  occurrence  of  one  or  more  severe  attacks  of  the  disease  has 
led  to  the  idea  that  the  infection  might  possibly  be  lingering  amongst 
the  school  children,  and  under  such  circumstances  both  other  observers 
and  I  myself,  as  the  result  of  personal  examination  of  the  throats  of 
pupils  and  pupil  teachers  in  elementary  schools,  have  found  an  unex- 
pected and  exceptional  amount  of  throat  sickness,  the  true  nature  of 
which  has  been  revealed  by  the  detection  of  cases  of  diphtheritic  paraly- 
sis amongst  some  of  those  who  admitted  such  antecedent  throat  or  nasal 
symptoms  as  are  common  in  mild  attacks  of  diphtheria. 

Whilst  dealing  with  this  subject  I  would  refer  to  a  communication  I 
addressed  to  the  Epidemiological  Society  of  London  in  April  1878,  in 
which,  from  certain  of  my  own  investigations  into  outbreaks  of  diph- 
theria, 1  drew  the  conclusion  that  under  certain  circumstances  the 
property  of  infectiveness  appeared  to  be  a  matter  of  progressive  devel- 
opment, and  that  throat  illness  which  under  one  set  of  conditions  might 
remain  practically  non-infective,  might  under  others  become  specifically 
infective  and,  in  their  transmission,  acquire  characteristics  not  to  be  dis- 
tinguished from  that  which  is  clinically  knovfn  as  diphtheria.  This  view 
has  since  been  accepted  by  a  number  of  medical  officers  of  health  and 
other  observers ;  but  it  has  seemed  insufficient  to  account  for  the  explo- 
sive character  of  some  of  the  outbreaks  which  have  occurred  in  connec- 
tion with  elementary  schools.  On  this  latter  point  I  would  venture  to 
observe  that  a  micro-organism  possessing  in  small  degree  the  property  of 
infectiveness  might,  under  one  set  of  conditions  of  throat,  season,  and  so 
forth,  require  repeated  transferences  and  transplantations  from  throat  to 
throat  before  any  considerable  modification  of  its  morbific  qualities  was 
brought  about ;  whereas  under  other  conditions  of  "  throat  culture  "  the 
stages  in  question  might  be  reached  at  so  rapid  a  rate  as  even  to  account 
for  occurrences  such  as  those  met  with  at  Pirbright. 

In,  a  former  work  on  the  subject  of  diphtheria  I  have  summarised 
the  methods  in  which  school  influence  appears  to  be  operative  for  mis- 
chief much  as  follows:  —  1st,  It  brings  together  those  members  of  the 
community  who  are,  by  reason  of  age,  most  susceptible  to  diphtheria; 
2nd,  The  children  thus  brought  together  are  placed,  and  remain  for  many 
hours  of  t?ie  day,  in  exceptionally  close  relation  to  each  other;  3rd,  The 
closer  the  aggregation  and  the  greater  the  hindrance  to  free  movement  of 
air,  the  greater  the  risk;  4th,  Faulty  sanitary  conditions  of  the  school- 
house  and  its  surroundings,  and  such  other  conditions  as  tend  to  a  con- 
dition of  general  ill  health,  in  so  far  as  they  induce  sore  throat,  favour 
the   reception  of  any  imported  diphtheria  infection;    5th,  There  are 


7o8  SYSTEM  OF  MEDICINE 

ample  grounds  for  believing  that  the  aggregation  of  children  in  ele- 
mentary schools  constitutes  one  of  the  conditions  under  which  a  form 
of  disease  of  particular  potency  for  spread  and  for  death  may  be  manufac- 
tured; 6th,  The  practices  of  kissing  and  of  transferring  sweetmeats  from 
mouth  to  mouth  —  practices  more  common  among  girls  than  boys  —  the 
joint  use  of  drinking  cups  and  the  like  must  assist  in  the  diifusion  of 
diphtheria  amongst  school-fellows. 

Amongst  the  more  recent  contributors  to  the  etiology  of  diphtheria 
in  connection  with  school  influence  is  Mr.  Shirley  Murphy.  He  has 
pointed  out  (13)  that  in  the  metropolis  there  Avas  during  the  ordinary 
late  summer  holiday  period  of  1893  a  sudden  drop  in  the  number  of 
notifications  of  diphtheria ;  and  he  adds  "  the  whole  of  the  holiday 
depression  is  due  to  diminished  prevalence  at  the  school-age  period  of 
life."  Mr.  Murphy  does  not  regard  statistics  for  so  limited  a  period  as 
conclusive ;  but  he  notes  that,  at  least,  they  harmonise  with  other  obser- 
vations, and  indicate  the  need  for  further  inquiry  into  the  influence  of 
elementary  schools  on  the  prevalence  of  epidemic  disease. 

Direct  Infection  from  Person  to  Person.  —  Incidentally  this  has  been 
referred  to  more  than  once  already.  It  is  probably  by  far  the  most 
common  cause  of  diphtheria,  and  as  the  fauces  and  respiratory  tracts  of 
the  sick  and  healthy  respectively  are  closely  brought  together,  so  is 
reception  of  the  poison  by  this  means  the  more  likely  to  result.  Young 
nurses  who  carry  about  in  their  arms  little  children  suffering  from 
diphtheria ;  relations  and  others  who  kiss  persons  suffering  from  diph- 
theria, whether  in  a  recognised  form  or  not,  and  children  who  during 
school  attendances  are  packed  closely  together,  and  thus  run  risk  of 
inhaling  the  throat  or  nasal  emanations  of  school-mates  having  mild 
forms  of  diphtheria,  —  these  are  the  sort  of  people  who  run  most  risk 
from  diphtheria  by  direct  infection. 

Fomites. — The  infection  of  diphtheria  has  long  been  supposed  to 
attach  itself  both  to  premises  and  to  articles  of  bedding,  clothing  and  the 
like ;  and  there  are  indications  to  show  that  in  so  far  as  premises  are 
concerned,  the  faculty  of  the  diphtheria  organism  for  retaining  its  vitality 
is  distinctly  enhanced  by  conditions  leading  to  dampness  —  especially 
dampness  of  site.  Growths  of  ordinary  mould  in  premises  may  often 
indicate  such  dampness.  In  a  number  of  instances  the  evidence  of  the 
communication  of  diphtheria  by  means  of  the  bedding  and  clothing  of  the 
sick  is  such  that  no  doubt  can  remain  of  the  spread  of  the  disease  in  this 
way.  Again  and  again  the  distribution  of  such  articles  amongst  relations 
and  others  has  been  followed  by  diphtheria  amongst  their  recipients, 
and  this  under  circumstances  of  time,  and  of  previous  immunity  from 
any  throat  affection,  that  must  remove  all  doubt  as  to  the  relation  be- 
tween the  two  events.  To  name  one  instance  only,  I  have  known  the 
despatch  of  a  pillow  from  an  infected  house  to  another  locality  altogether 
free  from  any  throat  affections  to  be  followed  within  a  few  days  by  the 
onset  of  fatal  diphtheria  amongst  the  members  of  the  recipient  family. 

Milk  Diplitheria.  —  One  of  the  most  important  discoveries  of  modern 


DIPHTHERIA  709 

times  in  connection  with  the  etiology  of  diphtheria  is  the  relation  of  this 
disease  to  the  consumption  of  milk ;  and  it  is  not  saying  too  much  to  assert 
that  many  occurrences  of  diphtheria  which  might  otherwise  have  been 
set  down  to  other  or  to  altogether  unknown  causes,  have  received  their 
explanation  since  the  dissemination  of  diphtheria  by  the  agency  of  milk 
was  first  demonstrated  by  Mr.  W.  H.  Power  in  1878  (14).  Since  that 
date  many  outbreaks  have  been  traced  with  the  greatest  certainty  to 
milk,  —  the  disease  not  only  having  followed  the  distribution  of  a  certain 
milk-supply  again  and  again,  even  when  carried  to  widely  different  and 
distant  localities,  but  having  been  limited  at  the  onset  of  the  outbreaks  in 
those  special  localities  exclusively  to  persons  using  the  milk  in  question. 

In  certain  instances  the  infection  of  milk  by  means  of  the  diphtheria 
contagium  must  be  attributed  to  the  exposure  of  milk  to  infection  derived 
from  antecedent  diphtheria  in  the  human  subject.  It  is  needless  to  dis- 
cuss at  any  length  the  means  by  which  milk  can  thus  become  infected. 
Wherever  the  throat  emanations  go,  and  whether  aerially  or  by  means  of 
material  adherent  to  the  hands  and  clothes  of  others,  there  will  be  risk 
of  infection  ;  hence  milk  may  become  specifically  contaminated  whenever 
the  air  of  the  sick  chamber  has  access  to  it,  or  where  persons  in  attend- 
ance on  the  sick  take  part  in  any  dairy  processes.  In  like  manner  milk 
may  become  infected  with  the  diphtheria  poison  when  persons  who  are 
engaged  either  in  the  dairy  farm  or  the  milk  shop,  or  who  are  occupied 
in  any  way  in  the  collection  and  distribution  of  milk,  are  themselves 
suffering  from  diphtheria  in  however  mild  a  form.  And  it  has  been 
shown  by  Dr.  Klein  that  milk,  once  inoculated  with  the  diphtheria  bacil- 
lus, serves  as  an  excellent  multiplying  ground  for  the  organism  even  at 
such  ordinary  temperatures  as  18°-20°  C.  (64-4°-68°  F.). 

But  the  more  we  learn  of  milk  as  a  vehicle  of  diphtheria,  the  more 
probable  does  it  become  that  the  infection  is  much  more  frequently 
derived  from  the  cow  herself  than  from  repeated  specific  contamination 
by  the  human  subject.  Thus  it  has  happened  that  milk  from  a  certain 
dairy,  whatever  the  locality  in  which  it  has  been  distributed,  has  served 
to  convey  and  to  keep  on  conveying  diphtheria  to  the  retail  customers ; 
and  this  although  all  suspicion  of  antecedent  diphtheria  or  ''  sore-throat " 
amongst  the  dairy  hands  could  be  eliminated  with  a  degree  of  certainty 
leaving  little  or  nothing  to  be  desired.  And  this  has  happened  when  the 
milk,  which  was  obviously  conveying  the  infection,  was  derived  from 
two  different  dairies  situated  at  a  distance  from  each  other,  and  having 
little  or  nothing  in  common  except  the  transference  of  cows  from  one 
to  the  other  establishment.  So  strongly  has  the  evidence  in  such  cases 
pointed  to  the  cow  herself,  that  Mr.  W.  H.  Power  felt  compelled  to 
consider  (as  he  wrote  now  some  seventeen  years  ago)  whether  there  might 
not  have  been  "  risk  of  specific  fouling  of  milk  by  particular  cows  suf- 
fering from  specific  disease,  whether  recognised  or  not "  (15).  Later  it 
became  possible  to  trace  the  milk  which  conveyed  diphtheria  in  very 
definite  manner  to  certain  cow-houses  in  which  one  or  more  cows  — 
notably  those  which  had  recently  calved  —  had  suffered  from  an  ail- 


7IO  SYSTEM   OF  MEDICINE 

ment  which,  is  certainly  infective  from  one  cow  to  another,  and  is  asso- 
ciated with  certain  definite  symptoms,  including  a  rise  of  temperature 
and  a  form  of  eruption  on  the  udder  and  teats  which,  when  seen  in  its 
later  stages,  has  hitherto  been  commonly  regarded  by  cow-keepers  as 
"  chapped  teats."  This  eruption  usually  begins  in  the  form  of  vesicles, 
which  rapidly  pass  into  pustules  and  scabs,  or  crusted  ulcers.  At  a  next 
stage  in  the  inquiry  it  was  found  that  a  similar  disease  could  be  pro- 
duced in  the  cow  by  inoculating  the  animal  with  sub-cultures  of  the 
diphtheria  bacillus ;  and  when  this  was  done  the  material  derived  from 
the  induced  vesicles  and  pustules  Avere  in  turn  found  to  contain  the 
same  bacillus,  which  could  be  unmistakably  demonstrated  by  cover-glass 
specimens  and  by  culture.  And,  further,  the  milk  of  cows  thus  inocu- 
lated was  found  to  contain  the  diphtheria  bacillus  in  abundance. 

In  a  number  of  outbreaks  of  that  which  may  now  without  question 
be  called  "  milk  diphtheria,"  it  has  been  found  that  the  different  incidence 
of  the  disease  on  individuals  has  come  to  depend,  among  other  things,  on 
their  opportunities  for  consuming  the  milk  in  question.  Thus  well-to- 
do  persons,  largely  using  raw  milk  in  their  families,  have  suffered  out  of 
all  proportion  to  their  poorer  neighbours,  who  could  only  atford  a  small 
supply,  to  be  used  in  their  tea.  And,  further,  it  has  been  found  that 
stored  milk,  in  the  form  of  cream  and  still  more  so  of  skim-milk,  has  been 
more  potent  for  mischief  than  fresh  milk  —  the  storage  of  milk,  as,  for 
example,  when  set  for  cream,  giving  opportunity  for  the  development 
and*  multiplication  in  it  of  the  contained  specific  organisms. 

Diphtlieria  in  the  Lower  Animals.  —  But  the  cow  is  not  the  only  one 
of  the  lower  animals  which  is  capable  of  serving  as  a  medium  for  the 
distribution  of  diphtheria,  nor  the  only  one  to  which  the  disease  can  be 
communicated  from  man.  Different  animals,  including  pigeons,  turkeys, 
and  cats,  have  been  referred  to  in  this  connection ;  but,  whether  the  mat- 
ter be  studied  from  a  bacteriological  or  etiological  point  of  view,  it  will 
probably  be  admitted  that  the  case  of  one  animal  only  is  altogether  free 
from  doubt  in  this  connection,  namely,  that  of  the  cat.  There  are  a 
number  of  instances  in  which  human  diphtheria  has  followed  on  similar 
disease  in  cats ;  and,  on  the  other  hand,  evidence  has  appeared  that  cats 
have  contracted  diphtheria  from  the  human  subject.  Dr.  Bruce  Low,  in 
reporting  to  the  Local  Government  Board  on  an  epidemic  of  diphtheria 
in  Enfield,  expresses  the  opinion  that  a  disease  resembling  diphtheria 
which  he  met  with  in  the  cat  was  in  all  probability  first  contracted  from 
human  diphtheria,  then  communicated  from  cat  to  cat,  and  then  trans- 
ferred again  from  the  cat  to  the  human  subject. 

Writing  in  1889,  Dr.  Klein  (16)  says  "that  cats  are  really  subject  to 
an  infectious  disease  occurring  in  association  with  human  diphtheria  " ; 
and,  further,  that  "this  disease  casually  occurring  in  the  cat  is  very 
similar  to  the  malady  artificially  producible  in  that  animal  by  inoculating 
it  with  human  diphtheria."  We  must,  therefore,  recognise  the  fact  that 
diphtheria  in  the  human  subject  may  have  its  origin  in  disease  of  a  like 
sort  in  at  least  one  animal  common  in  oiir  households,  namely,  the  cat. 


DIPHTHERIA 


711 


Tlie  Influence  of  Sanitary  Circumstances.  — Few  questions  relating  to 
the  etiology  of  diphtheria  have  led  to  more  discussion  than  that  which 
is  concerned  with  determining  the  influence,  if  any,  of  faulty  sanitary 
circumstances  on  the  causation  of  this  disease.  The  extremes  of  opin- 
ion are  best  illustrated  by  two  classes  of  contentions.  First,  there  are 
those  who,  having  to  deal  with  diphtheria,  find  that  in  the  locality  or 
house  where  it  prevails  there  are  certain  more  or  less  obvious  faulty 
sanitary  conditions ;  and  these  persons  are  content  to  regard  the  coinci- 
dence as  cause  and  effect :  secondly,  there  are  those  who,  often  meeting 
with  diphtheria  where  there  is  no  history  of  exposure  to  faulty  sanitary 
conditions,  have  become  convinced  that  the  disease  can  in  no  way  have 
relation  to  such  conditions.  The  truth  lies,  I  believe,  somewhere  between 
these  two  extremes. 

In  considering  this  question  it  should  be  remembered,  in  the  first 
place,  that  the  quarter  of  a  century  beginning  about  the  year  1870  has 
been  a  period  in  which  unexampled  progress  has  been  made  in  England 
and  Wales  in  improving  the  sanitary  circumstances  under  which  the 
people  are  living,  whether  of  water-supply,  sev/erage  and  drainage,  the 
disposal  of  refuse  and  excreta,  or  dwelling  accommodation.  It  has  also 
been  a  period  in  which  the  general  mortality  from  all  causes  in  this 
country  has  diminished  from  the  mean  annual  rate,  for  the  first  five  years 
of  that  period,  of  22  per  thousand  living,  to  one  of  19  for  the  latest  five 
years  of  that  period  for  which  we  have  mortality  returns  ;  in  which 
the  corresponding  rate  from  the  seven  principal  zymotic  diseases, 
including  diphtheria,  has  fallen  from  4-8  to  2-5;  and  in  which  the 
rate  of  mortality  from  enteric  fever  —  a  disease  known  to  be  intimately 
associated  with  bad  sanitary  circumstances  affecting  water-supply,  sew- 
erage and  drainage,  and  so  forth  —  has  fallen  from  0-37  to  0*17  per 
thousand.  But  during  this  same  period  of  sanitary  progress,  associated 
as  it  has  been  with  a  substantial  diminution  in  the  amount  of  death  from 
the  several  causes  specified,  the  corresponding  death-rate  from  diphtheria 
in  England  and  Wales  has  gone  up  from  042  to  049,  an  increase  of  63 
per  cent ;  and  in  London  and  the  large  cities  the  increase  has  been  even 
greater — it  has,  indeed,  more  than  trebled.  From  these  facts  it  would  at 
least  appear  that  the  removal  of  ordinary  faulty  sanitary  circumstances 
has  not  only  not  been  followed  by  diminution  in  diphtheria,  but  that 
precisely  the  reverse  has  taken  place.  In  the  second  place,  so  far  as  I  can 
learn,  it  has  hitherto  been  found  impossible  by  skilled  observers  —  includ- 
ing the  medical  inspectors  of  the  Local  Government  Board,  many  leading 
medical  officers  of  health,  and  distinguished  foreign  epidemiologists,  such 
as  Professor  Fodor  —  to  identify  the  use  of  polluted  water-supplies  as  a 
cause  of  diphtheria.  In  the  third  place,  it  is  certain  that  in  the  vast 
majoi'ity  of  cases  diphtheiia  is  due  either  to  infection  from  an  antecedent 
case,  whether  in  school  or  elsewhere,  or  to  infection  conveyed  through 
milk ;  and  that  consequently  the  balance  attributable  to  faulty  sanitary 
circumstances  cannot  be  a  large  one.  The  advocates,  however,  of  general 
insanitary  conditions  as  a  cause  of  diphtheria  lay  special  stress  on  the 


712  SYSTEM  OF  MEDICINE 

influence  of  faulty  sewers  and  drains,  and  of  collections  of  offensive 
refuse,  garbage,  and  the  like ;  it  is  indeed  to  effluvia  from  such  sources 
that  they  are  disposed  to  attribute  diphtheria.  Their  contention,  there- 
fore, requires  further  examination. 

Diphtheria,  as  already  stated,  is  due  to  the  operations  of  a  specific 
bacillus,  but  this  organism  has  never  to  my  knowledge  been  discovered 
in  "  sewer  air."  Indeed,  such  experiments  as  have  been  made  in  this 
direction  have  resulted  in  failure.  Moreover,  it  is  contended  (17)  that 
the  micro-organisms  found  in  sewer  emanations  are  related  rather  to  those 
commonly  found  in  the  outer  air  —  being  in  the  main  moulds  and  micro- 
cocci —  than  to  the  micro-organisms  found  in  the  sewage.  And  further 
when,  in  such  outbreaks  of  diphtheria  as  I  have  investigated,  some  obvious 
defect  leading  to  pollution  of  respired  air  by  sewer  or  drain  emanations 
was  regarded  as  the  cause  of  the  disease,  I  have  in  almost  every  instance 
found  it  not  only  impossible  to  eliminate  other  and  better  established 
sources  of  infection,  but  also  that  some  alternative  sources  of  infection 
were  generally  found  to  have  had  obvious  causal  relation  to  the  disease. 

But  after  all  has  been  said  in  this  direction  there  remains  a  residuum 
of  cases  which  cannot  so  easily  be  disposed  of.  These  cases  are,  in  my 
experience,  usually  limited  to  single  attacks,  to  attacks  in  single  house- 
holds, or  on  occasion  to  a  small  group  of  persons  having  opportunity  of 
infection  from  the  earlier  cases. 

In  dealing  etiologically  with  such  cases,  it  is  impossible  to  ignore  the 
fact  that  exposure  to  certain  foul  emanations  is  in  certain  persons  often 
followed  by  sore  throat;  and  it  must  be  admitted  that  such  sore  throat, 
as  also  the  common  "  household  sore  throat,"  have  infective  qualities, 
although  as  yet  these  affections  have  not  been  identified  with  any  par- 
ticular organism.  Some  persons  are  extremely  intolerant  of  these  and 
other  morbific  conditions  —  such  as  damp,  cold,  etc.  —  and  when  exposed 
to  them  suffer  from  sore  throat ;  and  it  is  often  among  such  persons  that 
diphtheria  may  occur  almost  immediately  after  exposure  to  one  or  other 
of  the  emanations  referred  to.  Now  a  sore  throat,  however  induced, 
is  peculiarly  favourable  to  the  reception  and  subsequent  local  multi- 
plication of  the  diphtheria  organism.  Children  subject  to  chronic  sore 
throats  have  often  been  found  specially  liable  to  contract  diphtheria; 
and  it  is  also  matter  of  common  observation,  that  convalescents  from 
diseases,  such  as  scarlet  fever  and  measles  —  diseases  in  which  the 
fauces  may  be  denuded  of  their  epithelial  coating  —  are  especially 
liable  to  contract  diphtheria;  whereas  there  is  no  corresponding  liability 
on  the  part  of  diphtheria  convalescents  to  contract  scarlet  fever  or 
measles.  In  short,  a  morbid  condition  of  the  fauces  affords  a  soil  favour- 
able to  the  lodgment  and  maintenance  of  the  diphtheria  contagiura  —  the 
process  being  one  of  "aerial-inoculation."  Another  explanation  of  the 
relation  between  exposure  to  foul  emanations  and  an  attack  of  diphtheria 
is,  that  where  diphtheria  has  assumed  an  obscure  and  chronic  form  — 
the  local  manifestations  being  mainly  nasal  or  exceptionally  mild  — 
exposure  to  drain  emanations,  to  cold,  and  damp  ai^d  like  conditions,  has 


DIPHTHERIA  713 


almost  certainly  a  tendency  to  induce  and  to  accelerate  the  occurrence 
of  those  recrudescing  attacks  of  diphtheria  which  are  so  fertile  a  source 
of  the  spread  of  the  disease  to  healthy  persons  who  associate  with  diph- 
theria convalescents. 

But  these  explanations  do  not  cover  a  number  of  cases  in  which  it 
is,  at  least,  certain  that  diphtheria  prevails  coUcurrently  with  oppor- 
tunities for  exposure  to  drain  and  other  like  emanations ;  and  some 
observers,  who  do  not  assert  that  the  diphtheria  organism  is  itself  con- 
veyed by  means  of  sewer  air,  contend  that  there  are  circumstances  under 
which  sore  throats,  which  in  their  early  stages  lack  specific  character- 
istics, do  definitely  acquire  them  at  a  later  date.  When  I  first  suggested 
that  the  theory  of  the  "  progressive  development  of  the  property  of  in- 
fectiveness  "  was  necessary  to  the  explanation  of  many  occurrences  of 
diphtheria,  I  was  inclined  to  assume  that  some  substantial  lapse  of  time 
was  an  essential  element  in  the  process.  But  some  observers,  including 
the  late  Dr.  David  Page,  medical  inspector  to  the  Local  Government 
Board,  Dr.  Fosbroke,  county  health  officer  for  Worcestershire,  and  Dr. 
Jacob,  medical  officer  of  health  for  Mid-Surrey,  have  recorded  instances 
which  seem  to  indicate  that  the  process  may  begin  and  be  completed 
during  the  stages  of  a  single  outbreak  of  very  limited  duration.  Thus 
Dr.  Jacob  records  "  an  outbreak  of  diphtheria  which  was  preceded  for  a 
month  by  a  series  of  ordinary  sore  throats,"  and  "  gradually  worked  up, 
so  to  speak,  to  the  genuine  characteristic  form  of  the  disease."  How 
far  the  sore  throats  in  question  may,  on  the  one  hand,  have  been  attacks 
of  true  but  unrecognised  diphtheria  from  the  onset,  or  how  far,  on  the 
other  hand,  such  process  of  development  as  I  have  indicated  may  take 
place  in  a  single  individual,  owing  to  the  accelerating  influence  of  foul 
emanations  having  special  characteristics,  I  am  unable  to  say ;  but  I  am 
bound  to  admit  that,  bacteriologically  considered,  we  have  as  yet  no 
proof  that  such  development  does  occur. 

In  brief  I  would  observe :  —  First,  that  the  only  available  vital 
statistics  as  to  diphtheria  do  not  support  the  contention  that  this  disease 
and  its  increase  in  this  country  are  related  to  faulty  sanitary  circum- 
stances ;  second,  that  the  operation  of  that  which  is  included  in  the  term 
"  school  influence  "  does  account  to  a  very  important  extent  for  the  in- 
crease in  question ;  third,  that  much  diphtheria  which  in  former  times 
would  undoubtedly  have  been  assigned  to  faulty  sanitary  circumstances 
is  now  found  to  be  communicated  to  man  through  the  agency  of  milk  ; 
fourth,  that  there  are  good  reasons  for  believing  that  sore  throats,  v/hich 
are  induced  by  exposure  to  conditions  such  as  drain  emanations,  render 
people  especially  susceptil)le  to  the  influence  of  the  diphtheria  contagion ; 
and,  fifth,  that  amongst  the  residuum  of  attacks  there  remain  a  number 
in  which  there  is,  in  appearance  at  least,  a  connection  between  exposure 
to  foul  emanations  and  diphtheria,  and  that  some  of  these  cases  may 
possibly  be  instances  in  which  a  process  of  development,  even  in  the 
same  person,  leads  from  a  minor  affection  up  to  a  major  and  definitely 
specific  disease. 


714  SYSTEM   OF  MEDICINE 

JSTo  attempt  can  properly  be  made  to  divide  the  causes  of  diphtheria 
into  definite  groups.  In  one  sense  there  is  but  one  cause  of  diphtheria, 
namely,  the  ojjerations  of  the  bacillus  diphtheriae,  and  the  direct  in- 
fluence of  this  organism  has  been  indicated  in  each  of  the  sets  of  circum- 
stances referred  to.  This  is  equally  the  case  whether  the  organism  be 
in  a  state  of  specific  activity  at  the  moment  of  its  reception,  or  whether, 
as  has  been  suggested,  it  be  in  a  form  requiring  time  and  circumstance 
for  development  of  its  specific  potency.  The  real  difference  between 
the  several  sets  of  conditions  concerned  in  diphtheria  is  as  follows :  — 
Some  involve  conditions  such  as  age,  antecedent  sore  throat,  dampness 
of  soil,  etc.,  which  appear  to  favour  the  opportunities  for  mischief  of 
any  chance  diphtheria  bacilli  which  may  be  received  on  the  fauces  or 
other  surface ;  the  others,  such  as  direct  infection  from  an  antecedent 
case,  infected  milk,  etc.,  involve  the  reception  of  the  infection  in  such 
form,  quality,  and  quantity,  as  practically  to  ensure  the  production  of 
diphtheria  even  Avhere  some  of  those  conditions,  regarded  as  favouring 
diphtheria,  may  be  absent.  Study  of  the  operations  of  both  sets  of  con- 
ditions will  indicate  the  means  of  prevention. 

In  the  prophylaxis  or  prevention  of  diphtheria  we  have  to  consider 
both  the  general  measures  which  may  diminish  the  chance  of  contract- 
ing the  disease,  and  also  the  more  immediate  and  active  steps  which 
should  be  adopted  to  prevent  its  spread  when  the  disease  is  actually 
prevalent. 

It  is  well  to  remember,  and  this  especially  as  regards  families  who 
tend  to  suffer  from  "sore  throat,"  that  Avhilst  the  broad  geological 
features  of  a  district  have  not  been  observed  to  have  any  special  in- 
fluence on  the  development  and  diffusion  of  diphtheria,  yet  residence  in 
localities  exposed  to  cold  wet  winds,  and  on  sites  characterised  by  con- 
stantly recurring  dampness  of  soil  and  retention  of  organic  debris  and 
other  refuse,  is,  if  possible,  to  be  avoided.  It  is  a  matter  of  almost  equal 
importance  to  secure  the  influence  of  sunlight  and  movement  of  air 
about  the  residences  of  families  and  persons  who  are  regarded  as  ex- 
ceptionally susceptible  to  diphtheria.  These  are  points  to  be  especially 
borne  in  mind  in  the  case  of  old-fashioned  and  well-timbered  country 
places.  The  adoption  of  general  measures  of  sanitation,  and  especially 
the  removal  of  those  conditions  of  drainage,  and  disposal  of  refuse, 
which  are  believed  to  have  some  relation  to  the  production  of  sore 
throat,  should  always  be  insisted  on. 

Avoidance  of  infection  through  the  agency  of  milk  can  only  be 
ensured  by  habitiial  abstention  from  the  use  of  any  milk  that  has  not 
been  previously  scalded  or  otherwise  cooked.  Fortunately  we  know 
that  exposure  of  the  diphtheria  bacilli  to  a  temperature  of  C0°  C. 
(140°  F.)  for  five  minutes  suffices  to  destroy  their  vitality.  Eecent 
scalding,  therefore,  gives  ample  protection  against  diphtheria  through 
the  agency  of  milk,  and  indirectly  will  tend  to  prevent  infection 
from  other  contagia,  such  as  those  of  scarlet  fever,  enteric  fever,  and 
tuberculosis. 


DIPHTHERIA  715 

Ailing  domestic  animals,  notably  cats,  should  be  avoided.  The  evi- 
dence of  the  communication  of  diphtheria  from  the  latter  to  man  does 
not  admit  of  doubt. 

Diphtheria  being  a  highly  infectious  disease,  easily  communicated 
from  person  to  jjerson,  and  this  at  distances  the  limit  of  which  cannot 
as  yet  be  stated,  the  immediate  isolation  of  the  infected  person  should 
always  be  attempted.  The  most  effectual  form  of  isolation  consists  in 
the  removal  of  the  individual  to  an  isolation  hospital ;  but  where  this 
is  not  practicable  the  nearest  available  approach  to  isolation  should  be 
secured.  Thus,  the  removal  of  a  patient  to  the  upper  story  of  a  house, 
when  that  story  can  be  exclusively  reserved  for  the  patient  and  the 
necessary  nurse  and  attendant,  may  suffice,  provided  strict  precautions 
are  taken  to  maintain  the  isolation.  The  apartment  of  the  patient  should 
be  well  ventilated ;  aerial  communication  between  it  and  the  remainder 
of  the  house  may  properly  be  hindered  by  the  suspension,  across  the 
doorways  of  the  infected  apartments,  of  sheets  which  are  kept  con- 
stantly wet  Avith  some  disinfecting  fluid,  the  wetness  of  the  sheet  being 
an  essential  point  to  bear  in  mind ;  sputa  should  be  destroyed  by  lire  or 
by  boiling ;  lint,  rags,  and  the  like,  used  in  connection  with  discharges 
from  the  throat,  nose,  etc.,  should  be  burned  in  the  apartment ;  all  china, 
glass,  spoons,  and  such  articles  used  in  connection  Vv^ith  the  patient's 
meals  should  be  placed  in  boiling  water  before  they  are  cleaned ;  and  all 
communication  with  the  remainder  of  the  household  should  be  avoided 
as  far  as  possible.  The  need  for  stringency  in  these  matters  is  often 
even  greater  during  convalescence,  for  this  is  precisely  the  time  when 
there  is  a  tendency  to  relax  them.  Members  of  the  family  who  are  at 
the  susceptible  ages  should,  if  practicable,  be  sent  away  from  the  house. 
On  the  termination  of  the  illness  all  apartments  and  articles  liable  to 
retain  infection  should  be  dealt  with  (12)  by  such  measures  as  lime- 
washing,  stripping  of  paper,  disinfection,  etc.  The  question  as  to 
when  freedom  from  infection  in  a  convalescent  may  be  regarded  as 
complete,  will  be  referred  to  in  connection  with  the  next  measure. 

This  measure  has  to  do  with  the  control  of  school  attendances. 
Schools  of  all  descriptions  must  always  be  looked  upon  as  affording 
exceptional  facilities  for  the  diffusion  of  diphtheria.  Hence,  in  boarding- 
schools,  for  example,  all  forms  of  sore  throat  should  be  dealt  with  as  if 
infective ;  and  if,  after  the  effectual  isolation  of  a  few  first  cases,  the 
disease  still  shows  a  tendency  to  spread,  the  school  should  be  broken  up 
at  once,  and  measures  of  cleansing  and  disinfection  resorted  to.  Early 
bacteriological  examination  of  material  scraped  from  the  fauces  or  nos- 
trils will  materially  aid  in  a  definite  conclusion  as  to  the  need  of  such 
action ;  but  even  when  bacteriological  evidence  is  negative,  the  mere  fact 
that  "  sore  throat "  is  spreading  should  have  great  weight  in  forming  a 
decision  on  measures  of  prevention.  As  regards  the  circumstances 
under  which  reassembly  of  scholars  in  boarding-schools  may  be  allowed, 
usefid  information  may  be  obtained  from  the  pnblicatioia  of  Codes  of 
Rules  by  the  Medical  Officers  of  Schools  Association  (18).     The  advance 


716  SYSTEM  OF  MEDICINE 

of  bacteriological  investigations  is  also  certain  to  come  to  the  aid  of 
those  who  are  concerned  in  arriving  at  a  decision  in  this  matter.  In 
day  schools,  and  notably  in  our  elementary  schools,  early  attacks  of 
diphtheria  have  hitherto  been  apt  to  be  overlooked ;  and  it  has  not  been 
until  the  attendance  at  schools  began  to  diminish  by  reason  of  sickness 
that  the  matter  received  attention.  This  should  not  be  wherever  the 
operation  of  the  Infectious  Disease  (Notification)  Act  is  adopted.  The 
existence  of  a  case  of  diphtheria  in  a  household  should  in  itself  be  a 
reason  why  no  member  of  that  household  should  be  allowed  to  attend 
school.  If,  notwithstanding  the  exclusion  of  children  so  circumstanced, 
cases  of  diphtheria  continue  to  manifest  themselves,  and  especially  if 
first  attacks  in  individual  households  are  found  to  occur  amongst  chil- 
dren attending  school,  it  may  become  necessary  to  close  the  schools  for 
a  time.  The  exclusion  from  school  of  scholars  from  infected  houses  or 
localities,  or  the  actual  closure  of  elementary  schools,  are  matters  in  which 
sanitary  authorities,  acting  under  the  advice  of  their  health  officers,  are 
vested  with  considerable  compulsory  powers  under  the  Education  Code. 
It  has  already  been  shown  that  the  reopening  of  schools  after  closure 
has  often  been  the  means  of  leading  to  a  recrudescence  of  the  disease, 
and  to  the  development  of  a  special  potency  in  the  infection.  The 
recrudescences  must  now  be  regarded  as  mainly  due  to  the  fact  that  the 
bacillus  diphtheriae  is  retained  about  the  fauces  of  convalescents  for  a 
much  longer  period  than  was  formerly  thought  at  all  probable.  Accord- 
ing to  experiments  made  in  the  case  of  diphtheria  convalescents,  it  has 
been  found  that  the  specific  bacillus  of  the  disease  may  exist  in  scrap- 
ings from  the  fauces  in  a  state  of  vitality,  as  shown  by  cultivation,  for 
several  weeks  at  least  after  all  disappearance  of  local  indications  of  any 
throat  affection.  Bacteriological  examination  of  such  material  in  each 
individual  case  is  necessary  where  the  utmost  procurable  certainty  is 
desired.  Where  such  investigation  is,  for  one  or  another  reason,  im- 
practicable, it  may  be  stated  that  under  no  circumstances  should  a 
child  be  allowed  to  return  to  school  from  a  household  in  which  there 
has  been  diphtheria  until  at  least  two  weeks  have  elapsed  since  the  last 
indication  of  throat-mischief  in  any  one  of  the  family  concerned. 

Whenever  diphtheria  or  sore  throat  of  an  infective  type  are  at  all 
prevalent  in  schools  or  elsewhere,  precautions  should  be  taken  to  avoid 
the  common  use  of  drinking-cups  and  other  like  articles  ;  kissing  among 
children  should  also  be  avoided. 

Whilst  this  article  is  passing  through  the  press  the  question  of  the 
value  of  anti-toxins  is  under  investigation  and  discussion.  It  is  claimed 
that  the  serum  of  horses  which  have  been  inoculated  with  diphtheria 
organisms,  or  with  the  chemical  products  of  those  organisms,  is  able, 
when  injected  into  the  human  subject,  to  confer  on  man  an  immunity 
against  diphtheria  infection.  As  yet  the  use  of  this  diphtheria  anti- 
toxin has  been  almost  exclusively  limited  to  the  treatment  of  individual 
cases  of  the  disease,  a  matter  with  which  this  article  is  not  concerned. 
But  Dr.  Klein  has  made  some  preliminary  experiments  in  this  country 


DIPHTHERIA  717 

which  go  to  show  that  guinea-pigs  which  have  been  rendered  immune 
against  diphtheria,  by  the  injection  of  the  prepared  horse  serum, — 
inoculations  which  would  otherwise  have  been  fatal  to  them,  —  succumb 
to  fresh  inoculations  of  the  same  diphtheria  material  after  the  lapse  of  a 
week  or  two.  These  experiments  confirm  very  similar  ones  by  Behring 
and  Roux.  It  is  not  pretended  that  this  is  the  limit  of  immunity  that 
can  be  conferred  on  the  guinea-pig,  neither  has  it  been  practicable 
hitherto  to  determine  definitely  to  what  extent  such  immunity,  if  any, 
can  be  conferred  on  the  human  subject.  Protective  inoculations  of 
ordinary  doses  of  serum  seem  hitherto  to  be  effective  only  for  about 
three  weeks.  There  appear  to  be  grounds,  however,  for  believing  that, 
in  so  far  as  the  guinea-pig  is  concerned,  the  use  of  larger  doses  of  the 
serum  would  be  followed  by  extension  of  the  period  of  protection. 
But  for  the  moment  the  indications  suggest  that  any  such  immunity 
is  likely  to  be  evanescent,  that  such  utility  as  it  possesses  may  be  limited 
to  the  protection  of  individuals  who  have  just  incurred,  or  must  run 
risk,  of  exposure  to  the  infection  of  diphtheria;  and  that  prolongation 
of  such  risk  may  call  for  repetition  of  the  injection  of  the  material  which 
confers  such  immunity.  -^_  ._^^^^^^  ^^^^^^_ 


Bacteriology  and  Pathology  of  Diphtheria 

There  are  but  few  infective  diseases  the  bacteriology  of  which  has 
been  so  completely  worked  out  as  in  the  case  of  diphtheria.  Although 
Klebs,  in  1883,  had  described  a  special  bacillus  observed  by  him  in  diph- 
theritic membranes,  Lof&er  was  the  first  Avho  succeeded  not  only  in 
separating  it  by  growth  in  artificial  media,  but  also  in  producing  in 
animals  by  means  of  inoculations  distinct  lesions,  said  by  him  to  resem- 
ble diphtheria.  After  its  discoverers,  the  bacillus  is  generally  called  the 
Klebs-Loffier  bacillus.  Loffier's  observations  were  soon  confirmed  by 
others,  notably  by  Roux  and  Yersin  in  Prance,  and  Dr.  Klein  in  Eng- 
land ;  but  the  final  proof  of  the  specificity  of  the  B.  diphtheria  we  owe 
more  especially  to  the  researches  of  Dr.  Sidney  Martin. 

The  Klebs-Loffler  bacillus  is  found  in  every  case  of  diphtheria;  and 
from  the  results  of  investigations  made,  we  may  say,  all  over  the  world, 
we  must  refuse  to  call  any  lesion  diphtheria,  unless  it  is  associated  with 
that  bacillus;  conversely,  any  morbid  process  accompanied  by  this 
organism  is  diphtheria.  Formerly,  when  physicians  relied  for  their 
diagnosis  merely  on  inspection  of  the  affected  parts,  or  on  certain  symp- 
toms and  signs,  cases  were  excluded  because  they  did  not  conform  to  the 
accepted  clinical  "type";  and  the  absence  of  gangrene,  necrosis,  or  mem- 
brane was  almost  sufficient  for  a  denial  of  the  existence  of  diphtheria. 
Bacteriology  has  taught  us  that  we  must  alter  our  views,  and  include 
under  diphtheria  many  cases  which,  according  to  the  older  conception, 
would  not  have  been  called  diphtheria.  At  the  present  time  we  frequently 
hear  that  typical  bacilli  have  been  discovered  in  cases  which  clinically 


7i8  SYSTEM   OF  MEDICINE 

are  not  diphtheria:  our  clinical  notions  must  then  be  amended  and  our 
position  reconsidered.  On  the  other  hand,  but  a  few  years  ago  many 
forms  of  tonsillitis  and  laryngitis  were  diagnosed  as  diphtheria,  which 
now  by  means  of  an  adequate  examination  are  readily  excluded.  We 
possess,  then,  in- this  organism  of  Klebs-LofEer,  a  certain  test,  with  the 
help  of  which  in  competent  hands  it  is  easy  to  decide  the  true  nature  of 
a  suspicious  case ;  and  the  vexed  discussion  as  to  the  identity  or  non- 
identity  of  croup  and  diphtheria  ceases  henceforth.  In  tubercle  and  in 
diphtheria  the  bacillus  asserts  itself  with  an  authority  which  must  put 
aside  any  preconceived  notions. 

The  Diphtheria  Bacillus.  —  This  organism  is  extremely  polymorphic, 
and  this  character  greatly  facilitates  dia.gnosis.  Two  varieties  may  be 
conveniently  described,  the  long  and  the  short  variety  —  (a)  Long  forms  : 
Tiiese  are  perhaps  to  the  beginner  the  most  characteristic  forms.  They 
are  generally  clubbed  at  one  or  other  end,  and  are  distinctly  curved  or/- 
shaped,  and  frequently,  when  stained,  they  have  a  granular  or  segmented 
appearance,  as  they  do  not  take  up  the  dye  uniformly.  These  clubbed 
forms  are  regarded  by  many  as  degeneration  or  involution  forms;  but  we 
shall  see  that  this  idea  is  probably  erroneous,  since  they  are  best  marked 
in  young  growths.  (6)  Short  forms :  These  occur,  as  a  rule,  as  straight 
or  slightly  curved  rods,  not  uniform  in  thickness,  but  generally  slightly 
swollen  at  one  end,  or  swollen  in  the  middle  with  pointed  ends. 

It  is,  however,  not  advisable  to  be  too  strict  in  this  division  of  the 
bacilli  into  types  according  to  their  size  because,  although  we  may  find 
growths  in  which  all  the  bacilli  are  long  and  clubbed,  or  short  and  straight, 
yet  they  do  frequently  vary  in  size  and  shape  in  the  same  culture,  and  on 
transferring  a  long  form  from  tube  to  tube  it  often  changes  in  appearance 
from  the  long  to  the  short  form,  and  conversely.  It  has  also  been  stated 
that  cases  presenting  the  long  forms  are  more  virulent  than  those  pre- 
senting the  short  form.  This,  however,  is  misleading  and  erroneous. 
After  an  extensive  examination,  I  can  say  confidently  that  it  is  futile  to 
base  a  prognosis  on  the  type  of  organism  present.  Some  of  the  worst 
cases  that  I  have  seen  were  associated  with  the  short  variety  exclusively, 
while  many  less  serious  cases  exhibited  long  forms  only.  Again,  I  have 
found  colonies  of  the  long  and  the  shoit  lorm  side  by  side  on  the  same 
agar-agar  surface. 

In  all  cases  the  grouping  of  the  diphtheria  bacilli  is  characteristic. 
They  never  form  chains  or  threads,  but  are  generally  arranged  in  irregu- 
lar clusters,  which  in  structure  have  been  aptly  compared  to  the  irregular 
Chinese  characters  which  are  built  up  of  lines  set  unsymmetrically  and 
at  various  angles.  The  bacilli  possess  no  spores,  and  stain  well  with 
Gram's  method  anfl.  with  ordinary  aniline  dyes. 

Artificial  Cultivation.  —  The  media  best  suited  for  artificial  cultivation 
are  serum  or  serum  agar-agar,  glycerine  agar-agar,  gelatine  and  broth, 
(a)  On  the  surface  of  gelatine  the  growth  appears  slowly,  and  consists  at 
first  of  a  series  of  small  isolated  punctiform  colonies,  which  gradually  fuse, 
and  form  a  thick,  opaque,  uneven  white  or  yellowish  streak  which  is  char- 


DIPHTHERIA  719 


acteristic  and  easily  recognised  by  those  familiar  with  the  diphtheria 
bacillus.  The  middle  of  the  streak  is  thick  and  prominent,  while  at  the 
margins  the  growth  is  thinner  and  expands  in  an  irregular,  uneven  out- 
line. (6)  On  the  surface  of  agar-agar  or  serum  the  separate  colonies  when 
typical  are  round  and  whitish,  with  a  thick,  yellowish  brown  raised  centre. 
Lateral  expansion  as  a  rule  is  slow,  but  varies  greatly ;  and  in  some  cases 
the  growth  is  entirely  made  up  of  minute  dotlike  colonies,  (c)  Growth  in 
alkaline  broth  is  rapid,  the  liquid  becoming  turbid  within  twenty-four 
hours  at  the  body  temperature.  The  reaction  of  the  culture  medium  at 
first  becomes  acid,  but  later  it  is  once  more  alkaline. 

The  bacilli  thus  artificially  cultivated  present  the  characters  of 
type  and  grouping  described  above;  they  may  appear  either  as  long 
or  short  forms,  clubbed,  curved  or  straight.  They  do  not  move  and 
they  possess  no  flagella.  It  is  in  young  cultures  on  serum  or  agar- 
agar  especially  that  the  peculiar  clubbed  and  branched  forms  may  be 
observed;  so  that  we  cannot  regard  these  as  degeneration  forms,  but 
with  Dr.  Klein  may  seek  in  them  a  clue  to  the  ancestral  history 
of  the  bacillus,  inasmuch  as  they  point  to  a  mycelial  origin.  An 
attempt  has  been  made  to  distinguish  two  types  according  to  the  size 
of  the  individual  colonies  on  the  surface  of  agar-agar ;  some  diph- 
theria bacilli  grow  always  in  large  colonies,  and  others  grow  always  in 
small  colonies.  But  this,  again,  is  no  distinctive  character,  since  large 
colonies  on  subcultivation  will  frequently  appear  as  small  ones,  and 
conversely ;  to  a  certain  extent  the  smallness  of  the  colonies  seems  to 
depend  on  the  closeness  and  crowding  together  of  the  colonies. 

Bacteriological  Diagnosis. — Having  shortly  described  the  most  lead- 
ing characteristics  of  the  Klebs-Lof&er  bacillus,  it  is  well  here  to  give  as 
shortly  a  few  directions  as  to  the  method  to  be  pursued  when  a  bacterio- 
logical examination  has  to  be  made  for  diagnostic  purposes:  —  (a)  If  a 
piece  of  membrane  is  available,  it  should  first  be  washed  in  several  changes 
of  sterile  physiological  salt  solution;  then  a  small  piece  is  removed  with 
a  strong  platinum  loop,  or  the  platinum  needle  is  dug  into  the  substance 
of  the  membrane.-.  With  the  latter  thus  charged,  a  series  of  serum  or 
seram  agar-agar  tubes  are  now  streaked,  three  parallel  streaks  being 
made  on  each,  passing  from  one  tube  to  the  other  without  recharging 
the  needle,  so  that  in  the  last  tube  the  insemination  is  scantiest.  The 
tubes  are  now  incubated  at  38'5°  C.  and  examined  next  morning; 
suspicious  colonies  are  selected,  and  traces  thereof  removed  with 
the  jjlatinum  wire,  and  transferred  to  a  drop  of  broth  on  a  slide.  The 
organisms  may  be  examined  stained  or  unstained ;  but  it  seems  to  me  that 
in  an  unstained  condition  the  bacilli  are  more  easily,  and  certainly  more 
speedily  recognised,  (b)  If  membrane  be  unobtainable,  the  platinum  loop 
must  be  passed  over  or  pushed  into  the  affected  part,  if  it  be  acces- 
siVile,  and  with  the  charged  wire  tubes  must  be  inoculated  in  the  manner 
already  described.  This  is  easy  enough  when  the  fauces,  nose,  or  conjunc- 
tiva are  affected,  but  what  is  to  be  done  in  laryngeal  diphtheria  ?  Ex- 
perience shows  that  in  most  of  these  cases  the  bacilli  may  be  readily 


720  SYSTEM  OF  MEDICINE 

obtained  from  the  pharyngeal  or  faucial  —  not  tonsillar  —  secretions,  and 
from  these  tubes  should  be  prepared. 

For  the  purpose  of  diagnosis  a  medium  must  be  chosen  which,  while 
specially  favourable  to  the  development  of  the  Klebs-Loffler  bacillus,  has 
a  retarding  influence  over  the  organisms  generally  associated  Avith  the  lat- 
ter, such  as  streptococci,  staphylococci,  and  the  bacterium  coli  commune. 
From  practical  experience  I  should  recommend  an  agar-agar  prepared 
from  ascitic,  pleuritic,  or  hydrocele  fluid  containing  2  per  cent  of  a  10 
per  cent  solution  of  caustic  potash,  with  5  per  cent  glycerine  and  1  per 
cent  grape  sugar.  It  is  more  easily  obtained  and  prepared  than  serum 
or  serum  agar-agar,  since  the  above  exudations  are  always  within  easy 
reach.  The  selective  power  of  this  medium  towards  the  diphtheria 
bacillus  is  truly  remarkable,  and  its  inhibitory  action  over  other  organ- 
isms quite  as  striking. 

It  must  be  remembered  that  membranes,  produced  by  other  bacteria 
besides  the  diphtheria  bacilli,  may  appear  in  the  throat,  and  that  in 
many  cases  the  clinical  phenomena  prove  to  be  of  but  little  assistance;  a 
careful  bacteriological  examination  is  therefore  required.  In  scarlatina 
especially  membranous  sore  throat  is  common;  it  may  be  caused  by 
pyogenetic  cocci,  especially  streptococci,  or  it  may  be  due  to  the  Klebs- 
Loffler  bacillus.  Hench  and  Heubner  on  clinical  grounds,  and  others 
guided  by  bacteriological  investigations,  state  that  the  scarlatinal  angina 
appearing  concurrently  with  scarlet  fever  is  not  true  diphtheria,  while  the 
membranous  inflammation  following  some  time  after  scarlet  fever  is  true 
diphtheria.  This  statement,  which  is  also  supported  by  Dr.  Klein,  is  only 
true  in  a  general  way,  and  must  not  be  taken  too  literally  ;  the  rule  is 
one  to  which  there  are  numerous  exceptions :  nevertheless  it  is  a  useful 
rule,  as  it  assists  us  materially  in  the  early  diagnosis  of  scarlet  fever. 
Sore  throats  may  appear  in  other  infective  fevers,  and  should  always  be 
subjected  to  a  careful  bacteriological  examination ;  for  in  several  cases 
of  typhoid  fever  and  measles,  for  instance,  diphtheria  bacilli  have  been 
found,  and  it  has  been  stated  that  the  palsy  which  occasionally  appears 
in  or  after  enteric  fever  is  actually  due  to  diphtheria  intoxication. 

As  a  rule,  there  is  no  difficulty  for  the  experienced  eye  to  recognise 
the  diphtheria  bacilli  either  on  the  surface  of  the  nutrient  medium  as  a 
colony  or  on  the  microscopic  slide.  Occasionally,  however,  there  is  some 
or  even  great  hesitation  before  an  opinion  is  hazarded.  For  bacilli  do 
occur  in  healthy  and  non-diphtheritic  sore  throats  which  closely  resem- 
ble the  Klebs-Loffler  organism,  but  yet  are  not  entitled  to  this  name. 
These  have  been  named  "  pseudo-diphtheria  bacilli."  The  name  pseudo- 
diphtheria  bacillus  apparently  includes  several  varieties  and  species,  and 
must  be  used  with  caution.  At  present  there  are  at  least  two  views  and 
over  half  a  dozen  different  descriptions  of  the  alleged  pseudo-diphtheria 
bacillus.  Some  observers  give  this  name  to  organisms  which  bear  a 
superficial  resemblance  to  Loffler's  bacillus,  but  which  any  critical  bacteri- 
ologist would  not  and.could  not  confound  with  it ;  others  use  the  term  for 
organisms  which  morphologically  cannot  be  distinguished  from  the  typical 


DIPHTHERIA 


J2l 


diphtheria  bacillus,  but  which  differ  from  it  in  so  far  as  they  fail  to  evince 
any  pathogenetic  properties  when  tested  on  guinea-pigs.  This  is  not  the 
place  for  the  discussion  of  this  question,  but  I  think  that  we  may  fairly 
deny  the  claim  of  the  former  group  to  the  title  pseudo-diphtheria  bacillus, 
just  as  we  deny  the  claim  of  the  bacillus  coli  communis  to  pose  as  a  pseudo- 
typhoid  bacillus.  Whether,  however,  the  virulence  test  is  satisfactory 
and  exclusive  is  a  doubtful  matter :  on  the  face  of  it,  it  seems  a  weak  reed 
to  rest  upon  and,  until  stronger  evidence  is  forthcoming,  it  is  safer  to 
regard  with  great  suspicion  any  bacillus  which  not  merely  resembles  the 
diphtheria  bacillus,  but  agrees  with  it  in  every  point  except  that  of  viru- 
lence ;  and  this  the  more  since  Roux  and  Yersin  have  asserted  that  on  one 
and  the  same  agar-agar  or  serum  surface  we  may  find  virulent  and  non- 
virulent  forms  side  by  side,  and  also  since  it  is  easy  to  deprive  the  true 
bacillus  of  its  virulence.  The  French  writers,  in  fact,  consider  that  the 
so-called  pseudo-diphtheria  bacillus  is  a  form  of  the  true  Klebs-Loffler 
bacillus,  the  virulence  of  which  has  become  attenuated. 

Pathogenetic  Properties. — We  must  now  briefly  consider  the  evidence  on 
which  the  specific  relation  between  diphtheritic  processes  and  the  Klebs- 
Loffler  bacillus  has  been  established.  (1)  If  we  except  the  cat,  spontaneous 
diphtheria  is  not  found  in  animals  ;  the  diphtheria-like  lesions  occurring 
in  them  are  due  to  organisms  other  than  the  Klebs-Loffler  bacillus.  In 
the  cat,  however,  a  disease  characterised  by  broncho-pneumonia,  kidney 
disorder,  and  ophthalmia  is  described :  in  the  consolidated  areas  of  the 
lung  Dr.  Klein  discovered  the  diphtheria  bacillus  in  considerable  num- 
bers ;  and  on  artificial  inoculation  local  diphtheritic  changes  were  pro- 
duced. Hence  Dr.  Klein  concludes  that  cats  are  susceptible  to  human 
diphtheria,  and  that  in  them  a  disease  occurs,  centred  chiefly  in  the  lungs, 
which  is  akin  to  the  infection  in  man.  Those  who  are  acquainted  with 
Klein's  researches  in  this  matter  can  hardly  question  the  truth  of  his 
conclusions  ;  and  since  we  are  gradually  recognising  that  the  diphtheria 
bacillus  is  capable  of  producing  non-membranous  lesions,  and  that,  when 
it  finds  access  to  the  lungs,  it  may  lead  to  pronounced  broncho-pneumonia, 
they  gain  considerably  in  significance.  However  this  may  be,  inocula- 
tion of  the  conjunctiva  or  of  the  buccal  mucous  membrane  of  the  cat  with 
diphtheritic  material  is  followed  by  changes  closely  resembling  human 
diphtheria.  Loffler,  Welch,  and  others  succeeded  in  producing  mem- 
branous inflammation  in  guinea-pigs  by  vigorously  inoculating  the  vaginal 
mucosa;  and  in  rabbits  by  treating  the  conjunctiva  or  tracheal  mucous 
membrane  in  a  similar  manner.  In  some  instances  paralysis  followed 
the  inoculation. 

Subcutaneous  injection  of  virulent  diphtheria  bacilli,  whether  of  fresh 
broth  cultures  or.of  gelatine  cultures  suspended  in  broth,  leads  to  death  of 
tlie  guinea-pigs  in  from  eighteen  to  seventy-two  hours.  The  first  changes 
to  be  noticed  are  swelling  at  the  seat  of  inoculation  —  due  to  round  cell 
infiltration,  ojrlema  and  exudation;  also,  as  a  rule,  considerable  local 
necrosis,  and  degenerative  changesof  the  heart  and  the  voluntary  muscles. 
PVom  the  seat  of  inoculation  diphtheria  bacilli  can  easily  be  recovered, 

VOL.  1  3  a 


722  SYSTEM  OF  MEDICINE 

and  occasionally  also  from  the  blood  and  from  more  distant  organs, 
as  for  instance  the  lymphatic  glands,  spleen  and  liver.  The  guinea-pig, 
being  highly  susceptible,  is  the  animal  generally  used  for  these  experi- 
ments :  if  it  be  inoculated  in  a  hind  extremity  with  a  small  quantity  of 
virulent  material  there  appears  first  a  distinct  fibrinous  exudation,  sur- 
rounded by  more  or  less  extensive  haemorrhagic  oedema ;  the  lymphatic 
glands  in  the  neighbourhood  soon  swell ;  the  exudation  becomes  more 
marked,  necrotic  changes  take  place,  and  the  animal  gradually  wastes 
and  dies,  showing,  besides  the  local  lesions,  haemorrhagic  redness  of  the 
suprarenal  capsules,  pleural  exudation,  and  degenerative  changes  in  the 
muscles  and  nerves.  Occasionally  death  is  delayed  even  in  these  highly 
susceptible  animals,  and  then  paresis  or  even  complete  paralysis  of  the 
extremities  shows  itself,  and  the  nerves  show  advanced  degeneration. 

(2)  The  most  striking  morbid,  phenomenon  in  the  course  of  human 
diphtheria  is  the  loss  of  muscular  power  which  accompanies  or  follows  the 
acute  disease.  When  it  was  shown  that  even  these  characteristic  symp- 
toms could  be  reproduced  in  the  animal  by  artificial  infection,  doubt  as 
to  the  specific  action  of  the  Ivlebs-Lofiler  bacillus  could  scarcely  persist 
any  longer.  Eoux  and  Yersin  demonstrated  that  the  inoculation  of  the 
poisonous  products  precipitated  from  broth  cultures  is  followed  by  pare- 
sis, a  point  which  has  received  general  confirmation.  Dr.  S.  Martin  has 
elaborated  this  question  still  further,  and  has  demonstrated,  so  far  as 
it  is  possible,  the  chemical  and  physiological  identity  between  the  toxins 
produced  in  artificial  growths  and  the  toxins  produced  in  the  human  body. 
Their  inoculation  into  the  animal  is  followed  by  the  same  results;  namely, 
by  paresis,  primary  nerve  degeneration,  fatty  degeneration  of  the  cardiac 
and  SKeletal  muscles,  and  respiratory  disorder.  The  agreement  in  almost 
all  points  is  so  close  that  none  but  those  who  refuse  to  accept  the  con- 
clusions obtained  through  animal  experiments  will  deny  that  in  the 
Klebs-Loftier  bacillus  we  have  the  specific  cause  of  diphtheria. 

(3)  The  last  vestige  of  doubt  miist  be  removed  by  the  triumphant 
results  of  treatment  with  antitoxin.  The  serum  of  an  animal  protected 
against  the  diphtheria  bacillus  cures  diphtheria  in  man.  As  this  action 
is  specific,  it  follows  that  the  animal  which  gave  the  serum  Avas  protected 
against  an  infection  equivalent  to  diphtheria ;  that  is,  that  the  Klebs- 
Loffler  bacillus  is  the  immediate  cause  of  diphtheria. 

Tiie  Pathology  of  Diplitlieritic  Infection.  —  It  may  be  said,  with  some 
degree  of  truth,  that  the  diphtheria  bacillus  is  found  only  in  the  affected 
area  and  its  neighbourhood ;  so  that  the  chief  symptoms  of  the  disease 
are  due  to  intoxication  by  the  poisons  locally  manufactured  at  the  seat 
of  infection.  Until  recently,  and  especially  in  this  country,  this  was 
accepted  almost  as  a  law  ;  recent  researches,  however,  show  that  we  must 
modify  our  views  somewhat,  for  it  has  been  demonstrated  that  after  death 
the  bacilli  may  be  traced  in  certain  viscera  and  organs  not  in  direct 
communication  with  the  diseased  tissues.  In  the  membranes,  or  at  the 
primary  seat  of  infection,  they  occur  in  largest  numbers,  and  here  the 
toxin  is  most  copious ;  in  distant  parts  the  organisms,  when  present, 


DIPHTHERIA  723 

are  generally  scanty  and  the  poison  more  diluted.  Hence,  with  due 
reservations,  the  original  statement  may  be  allowed  to  stand,  and  we 
may  look  to  the  seat  of  infection  as  the  source  of  all  the  trouble.  At  the 
same  time,  however,  we  must  keep  in  mind  that  the  bacilli  may  escape, 
and  do  escape  oftener  than  is  generally  imagined,  into  the  blood  or  more 
distant  organs ;  this  is  true  especially  of  those  cases  which  end  fatally, 
and  on  them  most  of  our  pathological  observations  are  based.  This 
question,  which  here  can  only  be  considered  in  all  brevity,  has  been 
more  fully  discussed  by  myself  and  Mr.  J.  W:  W.  Stephens  at  a  recent 
meeting  of  the  Pathological  Society.  The  bacilli  may  escape  from  the 
seat  of  infection  along  various  paths:  (a)  by  transference  of  the  con- 
taginm  to  other  parts  of  the  body,  as,  for  instance,  cutaneous  infections 
during  the  course  of  diphtheria;  (h)  by  direct  extension  of  the  diph- 
theritic process  (with  or  without  membranes)  along  the  open  passages 
in  communication  with  the  seat  of  infection,  that  is,  for  example,  from 
the  tonsils  or  larynx  upwards  to  the  nose,  eyes,  and  ear,  and  downwards 
to  the  trachea,  bronchi,  bronchioles  and  lung  alveoli,  oesophagus,  stomach 
and  intestines ;  (c)  by  extension  along  the  lymphatic  channels  into  the 
cervical,  submaxillary,  or  bronchial  glands ;  (d)  through  the  circulati6n 
into  the  spleen,  liver,  kidney.  ISTow  it  is  evident  that  the  first  and  second 
conditions  cannot  influence  the  generally-accepted  notion  of  a  local  infec- 
tion, for  in  the  one  case  we  have  an  accidental  additional  lesion,  and  in 
the  other  merely  an  increased  area  of  infection  by  continuity ;  but  the 
other  two  conditions,  if  they  occur  frequently,  would  compel  us  to  change 
our  views.  At  present  we  do  not  possess  sufficient  information  as  to  how 
often  distant  glands  and  distant  organs  contain  diphtheria  bacilli ;  but 
from  the  observations  of  others  and  ourselves  it  is  certain  that  in  the 
spleen,  for  instance,  they  may  be  found,  at  anj^  rate  in  fatal  cases,  com- 
paratively often.  Thus  Frosch,  Kolisko  and  Paltauf,  Booker,  Wright  and 
Stokes,  collectively  discovered  them  there  pretty  often,  and  in  twelve 
consecutive  post-mortem  examinations  we  obtained  positive  results  in 
nine  cases ;  hence  it  can  no  longer  be  doubted  that  an  escape  into  the 
circulation  does  occur  in  lethal  cases,  and  especially  when  a  tracheotomy 
has  been  performed.  Nevertheless  for  the  present  and  in  a  general  way 
we  may  regard  diphtheria  as  primarily  a  local  infection,  the  bacilli  being 
found  in  enormous  numbers  at  the  seat  of  lesion,  whence  the  deadly 
poison  or  poisons  secreted  or  manufactured  by  them  pass  into  the  system. 
To  the  pathologist,  then,  the  toxic  substances  are  of  the  utmost  im- 
portance, and  to  them  we  must  now  turn  our  attention.  Eoux  and 
Yersin  first  demonstrated  that  by  injection  of  the  toxic  products  of  the 
diphtheria  bacilli  into  susceptible  animals  the  nervous  lesions  so  char- 
acteristic of  the  human  disease  may  readily  be  induced  in  such  animals. 
This  observation  was  followed  up  and  confirmed  by  Brieger  and  Frankel, 
and  more  especially  by  Sidney  Martin  in  this  country.  Allusion  has 
already  been  made  to  this  inquiry  in  the  general  article  on  Infection. 
Youx  and  Yersin  obtained  the  toxin  by  precipitation  with  alcohol  and 
Ijhosphate  of  lime,  and  therefore  inclined  to  the  belief  that  this  substance 


724  SYSTEM   OF  MEDICINE 

is  a  ferment,  or,  more  correctly  speaking,  an  enzyme ;  while  Brieger  and 
Frankel  saw  in  it  a  toxalbumin,  or  rather  a  mixture  of  toxalbumins.  Dr. 
Martin's  view  has  already  been  explained,  but  may  here  be  once  more 
briefly  repeated,  since  his  experiments  were  more  thorough  than  those 
of  his  predecessors. 

He  separated  from  the  blood,  spleen  and  other  viscera  of  children  dead 
of  diphtheria,  albumoses  (chiefly  deutero-albumose)  and  an  organic  acid ; 
the  former  being  always  present  in  far  greater  quantity  than  the  acid. 
Subcutaneously  injected  into  guinea-pigs,  the  albumoses  produced  local 
oedema  and  slight  irregularity  of  the  body  temperature.  When,  however, 
they  were  intravenously  injected  into  rabbits,  the  result  was  fever,  or  a 
lowering  of  the  temperature,  loss  of  coagulability  of  the  blood,  paralysis 
of  the  hind  legs,  coma  and  death.  Oft-repeated  intravenous  injections 
of  small  doses  were  followed  by  fever  (variable  in  degree),  paresis  (a 
constant  effect),  respiratory  disturbances,  loss  of  weight  and  diarrhoea. 
The  fever  may  last  a  long  time,  the  paresis  may  appear  suddenly  and 
rapidly,  buo  its  progress  is  slow,  and  the  loss  of  weight  is  always  tardy. 
The  paresis  is  best  seen  in  the  extremities,  but  affects  also  the  trunk 
muscles.  There  is  no  visible  atrophy  of  the  muscles  and  no  loss  of  the 
knee-jerk.  On  examining  the  animals  after  death  bacilli  were  not  found, 
so  that  the  lesions  were  due  to  the  chemical  substances ;  that  is  to  say 
were  truly  intoxicative.  The  organic  acid,  like  the  albumoses,  is  a  nerve 
poison,  but  not  nearly  so  toxic.  From  diphtheritic  membranes  fibrin, 
hetero-albumose,  traces  of  proto-  and  deutero-albumoses,  and  of  organic 
acid  were  obtained;  but  the  membrane  extract  consisted  of  proteid  sub- 
stances with  minute  traces  of  albumoses,  which  extracts,  when  adminis- 
tered to  rabbits,  produced  fever,  paresis  and  death.  It  is  thus  seen  that 
the  membranes  contain  proteid  substances  which  are  not  albumoses,  but 
have,  nevertheless,  the  same  action ;  they  are,  however,  far  more  viru- 
lent than  the  albumoses.  From  pure  cultures  of  the  Klebs-Loffler  bacillus 
the  same  albumoses  and  organic  acid  were  obtained,  and  these  displayed 
the  same  physiological  action  as  the  tissue  substances.  Dr.  Martin  con- 
cludes that  the  bacillus  diphtherise  produces  the  same  substances  in  the 
culture  media  as  in  the  tissues,  that  these  have  the  same  action  when 
injected  into  an  animal  body,  and  that  undoubtedly  the  bacillus  of  the 
Klebs-Lofl&er  is  the  immediate  cause  of  diphtheria.  Since  the  membrane 
extract  contains  no  albumoses  worth  mentioning,  and  yet  is  extremely 
toxic,  it  is  possible  that  in  them  a  ferment-like  substance  is  formed  which, 
absorbed  by  the  tissues,  splits  them  up  by  virtue  of  its  digestive  action  into 
toxic  albumoses  and  an  organic  acid ;  and  that  the  albumoses  thus  manu- 
factured will  produce  the  characteristic  lesions  in  the  animal  organism. 

This  ferment-like  body  or  enzyme  corresponds  to  that  obtained  by 
Roux  and  Yersin,  and  is  formed  in  and  secreted  by  the  bacilli  themselves. 
Martin  explains  the  pathological  process  in  this  manner.  Since  the 
infection  is  primarily  a  local  one,  the  organism  at  the  primary  seat  of 
lesion  secretes  a  potent  proteolytic  enzyme  which  enters  the  tissues  and 
blood,  and  wherever  it  comes  in  contact  with  them,  digests  them ;  the 


DIPHTHERIA  725 


products  of  this  digestion  are  toxic  albumoses  and  the  organic  acid, 

substances  which  are  diffusible  and,  on  being  absorbed,  lead  to  the 
morbid  changes  and  disturbances  which  belong  to  the  diphtheritic  infec- 
tion. We  have  already  shortly  criticised  this  view,  and  we  found  that, 
tempting  though  it  may  seem,  it  cannot  be  accepted  in  the  form  in 
which  Martin  offers  it  (see  p.  524).  Besides  the  reasons  given  there, 
Martin  has  not  taken  into  consideration  that  in  fatal  cases  of  diphtheria 
the  bacilli  are  frequently  found  in  the  lungs,  spleen,  and  other  organs ; 
and  therefore  it  seems  far  more  probable  that  the  toxin  is  secreted  di- 
rectly by  the  bacilli  than  produced  by  intermediary  fermentative  proc- 
esses. The  spleen  contains  toxins  because  they  have  been  absorbed, 
and  often  for  the  further  reason  that  bacilli  have  found  their  way  there ; 
and  since  the  bacilli  are  vastly  more  numerous  in  the  membrane  than  in 
the  spleen,  we  find  a  poison  of  lesser  virulence  in  the  spleen.  The  albu- 
moses may  be  merely  contaminations  which  happen  to  come  down  with 
the  reagents  which  precipitate  the  true  toxin;  the  latter  is  a  direct  cellu- 
lar product  of  the  organisms  —  according  to  Gamaleia  a  nucleo-albumin 
—  which  is  absorbed  by  the  tissues,  blood  and  lymph.  There  is  no  evi- 
dence that  the  process  of  intoxication  is  an  indirect  one,  the  bacterial 
cell  forming  an  enzyme,  the  enzyme  producing  albumoses,  and  the  latter 
inducing  the  intoxication ;  on  the  contrary  we  may  assume  that  the  bac- 
terial cell  secretes  its  toxin,  whatever  its  nature  may  be,  and  that  the 
latter  is  absorbed  as  a  direct  tissue  poison. 

Whatever  view  we  take  of  the  nature  of  the  poison  or  of  the  process 
of  intoxication,  the  laboratory  has  conclusively  demonstrated  that  the 
Klebs-Loffler  bacillus  is  the  cause  —  the  specific  cause  of  diphtheria: 
whether  we  inoculate  the  animal  with  the  living  germs  or  with  the  toxic 
products,  all  the  characteristic  symptoms  and  lesions  of  diphtheria  can 
easily  be  reproduced  by  carefully  thought  out  experiments. 

There  is,  however,  another  point  to  be  considered  briefly,  namely, 
"  mixed  infection."  But  rarely  on  examining  diphtheritic  membranes  do 
we  find  pure  growths  of  Loffler's  bacillus ;  as  a  rule  the  latter  is  associated 
with  various  streptococci  and  staphylococci,  many  of  which  belong  to  the 
group  of  pyococci.  Is  their  presence  of  significance  ?  Foreign  observers, 
especially  Boux,  Martin,  and  others,  assert  that  such  an  association  is 
most  unfavourable,  while  Messrs.  Washbourn,  Goodall,  and  Card  do  not 
consider  the  association  with  streptococci  on  a  single  bacteriological 
examination  as  evidence  of  unfavourable  import ;  in  fact,  they  incline 
rather  to  the  opposite  conclusion.  Personal  observation  made  at  St.  Bar- 
tholomew's Hospital,  where  as  a  rule  only  serious  cases  are  admitted,  lead 
me  to  believe  that  the  presence  of  streptococci  in  itself  does  not  influence 
the  prognosis ;  indeed  that,  as  a  matter  of  fact,  they  are  rarely  found 
absent,  whether  the  cases  be  mild  or  serious,  if  a  series  of  cultivations 
(two  or  three  tubes)  be  made  in  every  case.  There  can  be  no  doubt, 
however,  that  secondary  septic  complications,  such  as  suppurating 
glands,  suppurative  otitis  media,  septicaemia  and  pyaemia,  may  be  pro- 
duced by  these  organisms.    Most  so-called  septic  and  huimorrhagic  forms 


726  SYSTEM  OF  MEDICINE 

of  diphtheria  are  caused  by  secondary  pyococcal  infection.  It  is,  how- 
ever, a  mistake  to  consider  all  swollen  and  inflamed  glands,  and  all  forms 
of  lung  affections  such  as  broncho-pneumonia  or  otitis  media,  as  being 
exclusively  caused  by  these  pyogenetic  organisms.  In  the  cervical  and 
bronchial  glands  the  Klebs-Lotiler  bacillus  is  frequently  found ;  so  it  is 
also  in  the  lungs  after  death,  and  occasionally  in  the  middle  ear.  Never- 
theless it  is  of  the  utmost  importance  to  keep  in  mind  the  possibility  of 
a  secondary  infection  since,  when  we  come  to  treatment,  we  cannot  ex- 
pect a  serum  which  specifically  counteracts  the  diphtheritic  process  to 
be  potent  also  against  the  pyococcal  infections.  For  this  reason  the  em- 
ployment of  an  antistreptococcal  serum  has  been  suggested,  and  in 
France  this  plan  has  already  been  adopted.  Hgemorrhagic  diphtheria 
seems  to  be  generally  due  to  secondary  infection,  for  in  two  or  three 
cases  examined  personally,  or  in  conjunction  with  Mr.  J.  W.  W.  Stephens, 
I  found  pyococci  (pneumococci  and  streptococci)  in  the  blood  and  organs  ; 
in  a  third  case,  however,  the  diphtheria  bacillus  existed  in  the  spleen. 
The  mortality  of  this  kind  of  diphtheria  is  always  high,  in  spite  of  the 
antitoxin  now  used ;  and  we  can  readily  explain  the  failure  of  the  new 
remedy  if  it  be  a  fact  that  most  forms  of  hsemorrhagic  diphtheria  are 
due  to  secondary  infection  or  are  true  septicaemia.  Broncho-pneumonia 
has  also  been  generally  attributed  to  streptococci ;  but  my  own  observa- 
tions and  those  of  Wright,  Frosch,  Stephens  and  others,  tend  to  prove 
that  in  most  cases  we  have  a  true  diphtheritic  infection  in  the  lungs ;  and 
in  almost  all  fatal  cases,  especially  if  the  process  were  laryngeal,  or  if 
tracheotomy  had  been  performed,  the  Klebs-Loffler  bacillus  can  be  found 
in  the  lung.  This  point  is  worthy  of  the  fullest  consideration,  since  it 
shows  the  necessity  of  active  and  energetic  antitoxin  treatment  in  such 
cases ;  in  these  the  area  of  toxin  production  must  be  enormous,  and,  as 
the  lungs  are  extremely  vascular,  absorption  thence  must  indeed  be  great. 

Although  I  feel  tempted  to  say  a  few  words  on  cutaneous  and 
ophthalmic  diphtheria,  in  order  not  to  extend  this  article  too  much,  I 
must  now  pass  on  to  the  morbid  anatomy  of  diphtheritic  processes. 

Morbid  Anatomy  of  Diphtheria.  —  (a)  Membrane  :  The  presence  of 
true  or  false  membranes  Avas  formerl}^  considered  the  characteristic  of 
diphtheria,  but,  as  we  have  already  seen,  it  is  by  no  means  essential.  If, 
for  instance,  we  regard  the  process  as  it  occurs  in  the  tonsils  and  fauces, 
we  may  have  extensive  membranes,  or  small  patches  or  mere  powdery 
flakes ;  or  again  we  may  find  an  entire  absence  of  membranous  exudation. 
There  may  be  mere  redness  or  oedematous  swelling,  or  there  may  be  a 
gangrenous  or  necrotic  lesion.  Yet  since  the  membrane  must,  for  the 
present  at  least,  remain  an  important  clinical  diagnostic  factor,  a  few  lines 
must  be  devoted  to  its  description.  These  membranes  consist  mainly  of 
fibrin,  and  are  either  coherent  patches  or  small  whitish  fiocculi ;  they 
maybe  firmly  or  loosely  adherent.  In  most  cases  the  surface  epithelium 
is  shed  in  part  before  the  deposition  of  fibrin  begins ;  but  membranes 
may  also  appear  in,  over  and  even  under  the  intact  epithelium.  When 
fully  formed  they  consist  of  filaments  of  fibrin,  which  form  a  network 


DIPHTHERIA  727 


enclosing  within  its  meshes  leucocytes,  red  corpuscles,  and  bacteria. 
The  thickness  and  size  of  the  fibrin  filaments  varies  considerably  and, 
if  the  membranes  are  firm,  lamination  is  often  seen.  When  detached 
they  leave  a  reddened  surface  behind  which,  as  for  instance  occasionally 
on  the  tonsils,  may  be  in  a  state  of  ulceration ;  a  second  membrane  may 
quickly  develop  on  the  denuded  surface.  Formerly  distinctions  were 
drawn  between  diphtheritic  and  croupous  membranes  —  true  and  false 
membranes:  there  is,  however,  no  reason  why  we  should  adhere  to 
this  more  or  less  artificial  division.  Dr.  Klein,  in  his  report  to  the 
Local  Government  Board  for  1891  and  1892,  pp.  126,  127,  summarises 
the  more  recent  views  tersely,  and  his  words  may  be  quoted  with  ad- 
vantage :  —  "  True  diphtheritic  change  of  mucous  membrane  is  regarded 
as  involving  exudation  into  the  mucosa  itself  —  a  condition  resulting, 
under  engorgement  and  stasis  in  the  vessels  of  the  mucosa,  in  complete 
necrosis  of  that  tissue.  In  this  latter  circumstance  the  mucosa  becomes 
in  effect  diphtheritic  membrane ;  its  superficial  part  contains  leucocytes, 
its  middle  or  main  part  is  a  reticulated  fibrinous  necrosed  tissue,  while 
its  deeper  part,  that  in  contact  with  the  inflamed  but  still  living  portion 
of  the  mucous  membrane,  contains,  like  this  latter,  leucocytes.  Most 
text-books  now  represent  the  above  anatomical  conditions  as  differentiat- 
ing croupous  and  diphtheritic  change  of  mucous  membrane." 

So  far  as  diphtheria  is  concerned,  we  have  first,  when  membranes 
appear,  a  superficial  exudation  into  the  epithelial  surface,  with  fibrin  for- 
mation and  degeneration  of  the  epithelium  itself.  Now  the  necrosed  epi- 
thelium gradually  disappears,  in  part  or  entirely ;  and  the  underlying 
connective  tissue  or  tonsillar  tissue  becomes  covered  by  a  fibrinous  layer 
containing  dead  epithelial  cells,  leucocytes,  and  the  like,  which  gradually 
extends  into  the  deeper  strata  of  the  mucous  membrane  or  tonsil.  Fresh 
layers  of  fibrin  may  be  added  until  perhaps  a  thick  membrane  is  formed. 
In  the  superficial  lay ers,which  generally  are  the  oldest,  cocci  may  be  found ; 
while  in  the  deeper  and  younger  layers  we  often  find  the  diphtheria  bacilli 
unmixed  with  other  organisms.  Often  enough,  however,  the  diphtheria 
bacilli  are  found  in  any  part  of  the  membrane.  The  tissue  below  the 
membrane  is  in  a  state  of  inflammation,  showing  collections  of  leucocytes, 
or  fibrinous  exudation  and  haemorrhages,  and,  according  to  my  own  obser- 
vations, may  be  invaded  by  the  bacilli.  Healing  as  a  rule  takes  place  with- 
out scarring,  unless  the  tissue  defect  were  so  serious  as  to  lead  to  destruc- 
tion of  the  mucosa.  It  is  interesting  to  remark  that  the  diphtheria  bacilli, 
even  in  fatal  cases,  are  frequently  found  in  the  leucocytes,  which  may  be 
almost  over-distended  by  the  engulfed  organisms.  With  the  disappear- 
ance of  the  membrane  the  bacilli  also  generally.disappear.  In  many  cases, 
by  means  of  careful  test-tube  experiments  as  the  cases  progress  towards 
recovery,  a  steady  diminution  in  the  number  of  the  specific  organisms  can 
be  demonstrated.  Exceptions  to  this  rule,  however,  are  numerous,  for 
even  after  apparent  recovery  the  bacilli  may  linger  in  the  throat  for 
weeks.  In  such  cases  they  may  be  impaired  in  virulence,  in  others  there 
is  no  attenuation.     These  observations  show  the  necessity  of  examining 


728  SYSTEM  OF  MEDICINE 

the  throats  of  patients  who  have  been  treated  in  hospitals  before  dismiss- 
ing them ;  such  patients  must  not  be  discharged  until  the  bacilli  have  com- 
pletely disappeared,  since  otherwise  they  may  become  sources  of  infection. 

Membranes  may  be  seen  in  the  mucous  membrane  of  the  soft  palate 
and  its  pillars,  the  tonsil,  fauces,  and  pharynx,  and  the  larynx;  and  may 
extend  also  into,  or  appear  primarily  in  the  nose,  conjunctiva,  trachea, 
and  bronchi :  more  rarely  they  extend  into  the  oesoj)hagus,  or  appear  in 
the  stomach  and  intestines.  In  cutaneous  diphtheria  membranes  also 
generally  cover  the  sores.  When  the  process  extends  into  the  bronchi  a 
diphtheritic  broncho-pneumonia  follows,  as  a  rule ;  and  we  often  observe, 
in  the  alveoli  a  fibrinous  network  enclosing  the  bacilli:  as  I  have  said 
there  can  be  no  doubt  that  diphtheritic  broncho-piaeumonia  or  capillary 
bronchitis  is  much  commoner  than  is  generally  believed.  A  curious  and 
important  pathological  condition  is  the  so-called  rhinitis  fibrinosa,  where 
we  find  membranous  casts  on  the  nasal  mucosa.  Clinically  such  cases  are 
not  diphtheria,  but  pathologically  and  bacteriologically  they  are  so ;  in  the 
cases  personally  examined  I  obtained,  as  others  did,  large  numbers  of  vir- 
ulent diphtheria  bacilli.  These  chronic  fibrinous  inflammations  constitute 
what  might  be  called '' chronic  diphtheria," — not  dangerous,  perhaps,  to 
the  individual,  but  deserving  the  fullest  attention  as  a  source  of  infection. 

Besides  the  local  changes  in  the  parts  mentioned,  morbid  appearances 
may  be  found,  (a)  in  the  lymphatic  glands,  (6)  the  spleen,  (c)  kidneys, 
(d)  heart,  and  (e)  in  the  nervous  system.  The  glands,  especially  the 
cervical  or  bronchial  according  to  the  seat  of  affection,  are  swollen, 
inflamed,  or  even  in  a  suppurative  condition.  The  spleen  is  frequently 
enlarged  and  injected  or  congested, though  rarely  soft;  the  kidneys  are 
generally  pale  and  cloudy,  and  microscopically  they  may  show  evidence 
of  epithelial  necrosis,  fatty  degeneration,  or  even  of  actual  nephritis. 
The  muscular  tissue  of  the  heart  may  be  in  a  condition  of  fatty  degen- 
eration, which  varies  to  a  greater  or  lesser  degree,  but  is  frequently 
absent.  Of  greatest  interest  are  the  nervous  changes  which  have  been 
more  carefully  studied  by  Dejerine,  Gorabault,  Meyer,  and  Sidney  Martin. 
The  paralysis  following  diphtheria  is  due  to  a  parenchymatous  degen- 
eration in  the  peripheral  nerves ;  so  that  the  expression  "  peripheral 
neuritis  "  in  this  connection  is  unjustifiable.  The  white  substance  of 
the  medullated  fibres  is  broken  up  and  attenuated,  or  may  disappear 
altogether ;  the  primitive  sheath  remains  intact,  and  the  axis  cylinders 
are  frequently  ruptured.  If  this  be  the  case,  the  nerve  fibres  below  the 
rupture  undergo  the  Wallerian  degeneration,  the  white  substance  break- 
ing up  along  the  whole  course  of  the  fibre,  and  the  axis  cylinder  also 
degenerating.  The  different  branches  of  the  same  nerve  are  affected  to 
a  varying  degree,  so  that  there  are  generally  fibres  intact  Avhich  can 
still  innervate  the  muscle  if  a  motor  nerve  be  affected.  This  explains 
why  during  life  the  paralysis  is  as  a  rule  partial  and  not  complete. 

The  sensory  and  motor  nerves  may  suffer  alike,  and  so  may  also  the 
sympathetic  nerves ;  except  that  in  the  latter  case  we  find  changes  only 
in  the  axis  cylinders,  there  being  no  visible  medulla.     Some  observers 


DIPHTHERIA  729 


have  described  changes  in  the  cells  ^of  the  anterior  cornu  of  the  spinal 
cord,  or  have  ascribed  the  nervous  changes  to  a  mild  form  of  poliomyelitis. 
Martin,  in  the  observation  from  which  I  have  amply  quoted,  considers 
them  all  to  be  essentially  peripheral,  and  has  never  detected  lesions  in 
the  ganglia  or  central  nervous  system.  This  matter  is  still  under 
discussion,  and  cannot  be  considered  as  finally  settled.  Meyer  has 
described  an  increase  of  nuclei  of  the  nerve  fibres,  and  also  nodular 
swellings  of  the  nerves  formed  of  cellular  elements;  but  according  to 
Martin  these  changes  probably  only  indicate  an  attempt  5-t  repair  of 
the  nerve. 

The  distribution  of  the  nerve  lesions  will  be  considered  in  the  clinical 
portion  of  this  article,  and  I  may  conclude  by  mentioning  that,  necessarily, 
the  muscle  supplied  by  the  diseased  nerves  are  also  degenerated  to 
a  degree  proportional  to  the  nerve  lesion.  The  muscular  fibres  may 
present  advanced  fatty  degeneration  to  such  an  extent  that  all  fibres  are 
affected ;  or  fatty  fibres  may  be  mixed  with  normal  ones,  or  parts  of  a 
fibre  only  may  be  fatty.  It  seems  that  the  diphtheria  poisons  are  special 
nerve  poisons,  for  Martin  has  shown  in  man  that  even  during  the  course 
of  an  acute  attack  which  lasted  only  five  days  nerve  degenerations  may 
appear. 

The  same  observer  further  states  that  fatty  degeneration  of  the 
cardiac  muscle  is  observed  chiefly  in  fatal  cases  of  diphtheritic  palsy  or 
in  cases  which  die  in  syncope;  hence  the  signs  of  cardiac  failure  in 
diphtheria  are  due  to  a  direct  influence  of  the  diphtheria  toxins  on  the 
cardiac  muscle :  this  is  the  more  probable  as  the  heart  of  the  experi- 
mental animal  is  easily  affected  by  these  poisons. 

In  discussing  the  pathology  of  diphtheria  I  cannot  conclude 
without  saying  a  few  words  on  the  haemic  changes,  that  is,  on  the 
increase  or  decrease  of  the  number  of  leucocytes  and  on  the  possible 
import  of  these  conditions.  Most  writers  are  agreed  that  diphtheria  is 
accompanied  by  a  marked  leucocytosis  which  increases  as  the  disease 
progresses,  and  again  diminishes  during  convalescence,  disappearing  soon 
after  the  membrane.  This  leucocytosis  is  of  the  ordinary  febrile  type, 
affecting  chiefly  the  "multinuclear,  neutrophile  "  (finely  granular  oxy- 
phile)  corpuscles.  Gabritschewsky  states  that  this  increase  in  the  num- 
ber of  leucocytes  is  greatest  in  fatal  cases,  and  believes  that  a  progressive 
leucocytosis  implies  a  bad  prognosis.  After  antitoxin  injections  the 
leucocytosis  steadily  diminishes  as  it  does  in  convalescence,  and  the 
haemocytometer  is  therefore,  according  to  him,  a  useful  means  of  gauging 
the  success  of  treatment.  Dr.  Ewing  does  not  consider  the  high 
leucocytosis  to  be  necessarily  an  unfavourable  sign,  for  it  may  mean 
merely  a  pronounced  reaction ;  but  he  agrees  with  others  that  in  fatal  cases 
there  is  leucocytosis  till  death ;  in  mild  cases  the  leucocytosis  is  but  slight, 
and  the  leucocytosis  steadily  decreases  in  favourable  cases.  Dr.  Morse, 
on  the  other  hand,  does  not  think  that  the  examination  of  the  blood  is 
of  value  in  prognosis,  because,  although  fatal  cases  generally  have  a  well- 
marked  leucocytosis,  it  is  not  always  present,  and  even  in  the  mildest 


730  SYSTEM   OF  MEDICLVE 


cases  is  often  very  pronounced.  Judging  from  personal  observations 
made  at  St.  Bartholomew's  Hospital  in  conjunction  with  Mr.  E.  L.  Lloyd, 
I  agree  with  this  writer  on  the  prognostic  value  of  the  leucocytosis  in 
diphtheria.  The  daily  counts  made  in  a  series  of  cases  show  that  — 
(1)  broadly  speaking,  a  high  leucocytosis  signifies  a  good  reaction,  and 
was  present  in  those  which  recovered;  (2)  a  low  leucocytosis  at  the 
height  of  the  disease,  before  antitoxin  has  been  injected,  accompanies 
most,  if  not  all  the  fatal  cases ;  (3)  the  high  leucocytosis  of  well  reacting 
cases,  after  and  during  antitoxin  treatment,  steadily  diminishes,  the  num- 
ber of  cells  decreasing  by  50  per  cent  in  three  to  four  days.  Dr.  Wald- 
stein  states  that  when  during  convalescence  the  leucocytosis  declines, 
the  number  of  "  neutrophile  "  cells  falls  rapidly,  while  the  uninuclear  or 
lymphocytic  elements  increase ;  in  the  lymphocytosis  he  sees  a  prognos- 
tic sign  of  great  value,  so  much  so  that  he  recommends  subcutaneous 
injections  of  pilocarpin,  in  order  to  raise  artificially  the  number  and  ratio 
of  the  lymphocytes. 

Artificial  Immu)dti/.  — Guinea-pigs,  which  are  highly  susceptible  ani- 
mals, can  be  protected  against  an  infection  with  the  Klebs-Loffler  bacillus 
in  various  ways:  (1)  by  means  of  subcutaneous  injections  of  broth  cult- 
ures sterilised  by  heat  or  attenuated  by  adding  trichloride  of  iodine ;  (2) 
by  means  of  prophylactic  injections  of  hydrogen  peroxide  ;  (3)  by  a 
successful  cure  of  an  experimental  infection  ;  (4)  by  means  of  Behring's 
combined  method,  which  consists  in  the  administration  first  of  attenuated 
cultures,  followed  by  that  of  fully  virulent  ones  or  of  strong  toxin ;  (5) 
by  rpeans  of  feeding  with  diphtheria  toxin.  The  serum  of  a  highly 
protected  animal,  as  mentioned  elsewhere  [see  art.  "Immunity"],  when 
injected  into  a  guinea-pig  in  a  normal  state,  possesses  the  remarkable 
property  of  rendering  it  immune;  and,  when  injected  into  one  already 
suffering  from  the  effects  of  a  diphtheritic  lesion,  of  curing  it.  This  gives 
us  the  6th  method  of  artificial  protection,  namely,  the  injection  of  protec- 
tive serum  or  antitoxin,  and  on  it  is  founded  the  serum  treatment  of 
diphtheria  to  be  discussed  presently :  its  principle  has  already  been  fully 
considered  [see  art.  "  Serum  Therapeutics  "].  To  obtain  a  good  and  active 
serum  horses  may  be  injected  with  toxins,  gradually  increasing  in  dose 
and  virulence,  or  with  the  bacteria  themselves,  beginning  with  their  dead 
bodies  and  gradually  proceeding  to  large  doses  of  living  bacilli ;  or  these 
two  methods  may  be  combined  in  order  to  obtain  a  serum  which  is  both 
strongly  antitoxic  and  highly  protective.  The  immunity  which  this  se- 
rum is  capable  of  conferring  on  animals  is  of  comparatively  short  duration 
(one  to  two  weeks,  and  at  most  ten  Aveeks) ;  and  when  used  on  man  is  so 
slight  as  to  be  of  little  value  for  prophylactic  purposes.  Thus  in  a  case 
under  my  own  observation,  a  child  acquired  true  diphtheria  within  two 
weeks  after  a  copious  administration  of  the  antitoxin,  which  had  been 
given  for  an  angina  erroneously  diagnosed  as  diphtheria.  Its  curative 
value,  however,  as  we  shall  see,  cannot  be  questioned. 


A.  A.  Kakthack. 


DIPHTHERIA  731 

Order  of  Development  of  Diphtheria 

The  first  result  of  diphtheritic  infection  is  local.  The  infected  part 
inflames,  and  it  is  in  and  upon  the  inflamed  surface  that  the  morbific 
microbes  increase  and  multiply.  Infection  of  the  deeper  tissues  and  of 
the  whole  body  is  chiefly  due  to  absorption  of  soluble  venom  from  the 
place  where  the  growth  of  microbes  is  proceeding.  Thus  diphtheria 
may  be  compared  Avith  syphilis :  the  primary  pellicular  inflammation  of 
the  one  and  the  primary  sore  of  the  other  being  strictly  analogous ;  from 
the  primary  lesion  the  secondary  infection  of  the  whole  body  proceeds 
in  both  cases.  This  close  analogy  was  discerned  by  Bretonneau  (5),  and 
the  most  recent  and  complete  experiments  upon  the  lower  animals  have 
confirmed  the  accuracy  of  his  opinion. 

Omitting  for  the  moment  consideration  of  the  nasal  passages,  the 
primary  seat  of  infection  is  seldom  any  other  than  the  fauces  or  the 
larynx.  Hence  two  chief  forms  of  diphtheria.  The  symptoms  and 
whole  appearance  of  the  disease  differ  so  much  according  to  the  part 
first  affected,  that  many  years  elapsed  before  physicians  universally 
accepted  Bretonneau's  doctrine  of  the  essential  identity  of  faucial  diph- 
theria and  membranous  croup. ^  The  question  cannot  now  be  said  to 
exist,  bacteriological  researches  having  finally  decided  it  in  favour  of 
Bretonneau. 

Simple  and  Malignant  DiiMheria.  —  From  the  time  of  Aretaeus  a  dis- 
tinction has  been  made  between  mild  (or  simple)  and  pestilential  (or 
malignant)  diphtheria.  Simple  diphtheria  is  that  which  is  characterised 
chiefly  by  the  local  affection;  malignant  is  that  in  which  the  toxsemia 
predominates :  the  blood,  and  through  it  the  whole  body,  is  poisoned  by 
venom  prepared  at  the  primary  local  lesion. 


A.   Diphtheritic  Sore  Throat  (Angina  faucium) 

In  the  following  pages  diphtheria  will  be  described  analytically, 
symptom  by  symptom,  yet  not  without  reference  to  the  association  and 
succession  of  symptoms.  A  general  description  of  the  disease  must 
always  be  more  or  less  imaginary,  and  can  never  tally  with  actual 
experience  and  matter  of  fact  —  so  many  are  the  symptoms  of  diphtheria, 
and  so  infinitely  varied  is  the  manner  in  which  they  are  associated.^ 

1  "  You  have  not  forgotten  the  celebrated  Concovrs,  ordered  by  the  Emperor  (Napoleon 
I.)  at  the  deatli  of  the  young  i)rince,  his  nephew,  nor  the  division  of  the  great  prize  between 
Jurino  of  Geneva  and  All)ers  of  Bremen,  authors  of  Memoirs,  in  which  they  both  declare 
that  angina  maligna  is  a  distinct  and  opposite  disease  from  croup.    No  matter !  "  (4)  p.  179. 

2  "  Some  such  descriptions,  when  they  have  conveyed  the  truth  with  great  force  and 
faithfulness,  liave  been  r(!garded  with  the  same  sort  of  pleasure  with  which  we  look  upon 
a  well-drawn  picture.  But,  after  all,  they  are  moi-e  pleasing  than  profital)le.  P(;rfection 
in  this  kind  was  reached  ages  ago,  yet  we  go  on  describing  what  has  been  better  described 
before,  and  are  venturing  with  rash  hands  still  to  retouch  the  masterpieces  of  Ai'etajus." 
—  P.  M.  Latham,  Din.  of  llaart,  vol.  i.  p.  lOU. 


732  SYSTEM   OF  MEDICINE 


I.  Prodroma.  —  The  first  symptoms  of  disease  relate  either  to  the 
fauces  or  to  infection  of  the  blood ;  the  diphtheria  is  manifested  first  in 
the  throat  or  not.  Symptoms  which  are  due  to  infection  of  the  blood, 
and  precede  the  pellicular  affection  of  the  fauces,  are  called  prodroma 
or  premonitory  symptoms. 

i.  Fever,  which  is  probably  an  early  symptom  in  all  cases,  in  some 
is  the  very  earliest,  preceding  any  signs  of  local  disease.  The  onset  is 
sometimes  gradual  and  insidious,  sometimes  sudden  and  marked  by  chil- 
liness, not  enough  to  cause  shivering.  The  temperature  seldom  rises 
above  103°.  Premonitory  fever  is  of  uncertain  duration,  seldom  lasting 
more  than  a  day  or  two. 

ii.  Fever  will  be  accompanied  by  its  usual  concomitants  —  drowsi- 
ness, giddiness,  peevishness,  aching  and  pains  in  the  limbs  and  back ; 
the  frequency  of  the  pulse  will  be  increased,  the  digestion  disordered. 
The  digestive  disorder,  indicated  by  vomiting,  disgust  for  food,  head- 
ache, weariness  and  low  spirits,  will  sometimes  last  fully  four  days  be 
fore  the  sore  throat  begins,  and  may  be  (perhaps  with  reason)  attributed 
to  "biliousness." 

iii.  Spontaneous  lassitude  is,  in  some  patients,  the  most  marked  pre- 
monitory symptom  —  a  great  sense  of  weakness  and  weariness,  lasting 
about  four-and-twenty  hours  before  the  throat  becomes  sore.  When  the 
lassitude  exists,  as  it  may,  nearly  a  week  before  the  onset  of  sore  throat, 
it  lies  open  to  question  whether  the  lassitude  is  to  be  attributed  to  the 
diphtheria  or  to  some  other  form  of  blood  poisoning  (such  as  bilious- 
ness) ;  whether,  in  other  Avords,  the  specific  invasion  (or  prodromal) 
period  of  diphtheria  can  last  so  long. 

II.  The  Sore  Throat.  —  In  most  cases  the  disease  is  first  manifested 
in  the  throat  or  neighbouring  parts,  and  by  one  or  more  of  the  following 
symptoms :  — 

i.  Soreness  of  the  throat,  especially  felt  on  swallowing,  and  some- 
times causing  cough.  In  young  children  the  sore  throat  is  indicated  by 
disinclination  to  swallow.  But  the  soreness  is  sometimes  very  slight, 
and  may  not  be  complained  of  even  when  examination  shows  that  false 
membranes  have  already  formed  upon  the  fauces. 

ii.  Noise  in  breathing,  snoring,  breathing  with  mouth  open,  change 
in  quality  of  voice  —  all  due  to  swelling  of  fauces. 

iii.  Coryza,  sneezing,  nose-bleeding  —  due  to  simultaneous  affection 
of  nasal  fossae. 

iv.  Swelling  of  neck  on  one  side  or  on  both ;  enlargement  of  lym- 
phatic glands  at  angles  of  lower  jaw:  pain  felt  in  neck,  especially  on 
movement. 

V.  Visible  appearances  in  the  throat;  these  demand  much  more 
close  attention :  they  are  of  four  kinds,  appearance  before  occurrence  of 
false  membrane,  false  membrane,  swelling,  and  muco-purulent  secretion. 

1.  Inflamed  Throat  before  Formation  of  False  Membrane.  — When  an 
opportunity  is  afforded  for  examining  the  fauces  before  the  appearance  of 
false  membrane,  they  are  seen  to  be  swollen,  sometimes  pale  and  glisten- 


DIPHTHERIA  733 


ing,  or  sometimes  reddish.  There  are  no  signs  by  which  the  naked  eye 
can  distinguish  diphtlieritic  inflammation  (before  the  appearance  of  false 
membrane)  from  other  kinds  of  inflammation.  Upon  this  inflamed  sur- 
face false  membrane  appears  sooner  or  later.  In  some  cases  it  is  formed 
very  rapidly,  for  however  soon  the  throat  be  examined  after  the  first 
signs  of  local  disease  false  membrane  is  seen.  On  the  other  hand  sev- 
eral days  may  elapse  before  the  angina  becomes  pellicular. 

The  diphtheritic  affection  of  the  throat  does  not  always  result  in  for- 
mation of  false  membrane,  and  this  non-pellicular  angina  constitutes  one 
form  of  latent  diphtheria. 

2.  False  Membranes. — The  first  appearance  of  false  membrane  is 
as  one  or  several  small  whitish  specks  or  patches.  Although  there  is  no 
part  of  the  throat  where  they  may  not  first  appear,  they  are  especially 
apt  to  begin  upon  the  tonsil  or  nvula.  The  margins  of  the  mouth  of 
the  tonsillar  crypts  are  often  first  affected,  a  point  which  will  be  alluded 
to  hereafter  with  reference  to  the  diagnosis  of  false  membranes  which 
are  diphtheritic  from  those  which  are  not.  The  diphtheritic  membrane 
differs  much  in  different  cases  in  respect  of  — 

(a)  Texture ;  being  firm,  tough,  and  coherent,  or  soft,  loose,  and 
friable. 

(6)  Thickness ;  at  first,  being  thin,  the  membrane  is  transparent, 
opaline,  afterwards  quite  opaque. 

(c)  Extent ;  by  which  the  activity  of  the  disease,  so  far  as  the  throat 
alone  is  concerned,  is  to  be  judged  of  chiefly.  But  at  first  it  cannot  be 
said  what  the  final  extent  of  membrane  may  be ;  a  very  small  pellicle 
may  be  the  beginning  of  very  extensive  disease.  Rapid  extension  is  a 
sign  of  virulence  :  in  forty-eight  hours  from  the  beginning  of  exudation 
the  whole  soft  palate,  uvula,  tonsils  and  pharynx  may  be  invaded,  not 
to  speak  of  the  posterior  nares,  root  of  tongue,  larynx,  and  even  other 
parts,  of  less  importance,  to  be  named  hereafter  as  occasional  seats  of 
diphtheritic  disease. 

(d)  Adhesion  to  the  tissues  beneath,  that  is  to  say,  to  the  mucosa; 
the  membrane  is  sometimes  very  adherent,  sometimes  it  can  be  removed 
by  a  soft  brush  with  ease.  The  mucosa  is  left  very  slightly  abraded 
and  looking  almost  natural,  or  it  is  swollen,  ragged,  and  bleeding.  A 
new  false  membrane  is  formed  upon  the  raw  surface,  and  sometimes 
very  rapidly,  within  two  or  three  hours. 

(e)  Rapid  decomposition  of  the  false  membrane  sometimes  occurs, 
and  indicates  a  bad  form  of  disease.  The  whitish  colour  is  lost  and  the 
membrane  tends  to  become  blackish;  the  smell  of  the  breath  is  most 
offensive  :  putrid  sore  throat. 

These  differences  in  the  false  membrane  are  believed  to  represent, 
to  a  great  extent,  differences  in  the  relative  abundance  or  activity 
of  the  several  microbes  growing  in  the  exudation  —  whether  specific 
bacilli,  divers  ijyogenetic  micrococci,  or  common  putrefactive  microbes. 
It  is  said  that  when  the  specific  bacillus  is  the  prevailing  microbe  the 
false  membrane  is  tough,  coherent,  and  not  prone  to  decomposition ; 


734  SYSTEM   OF  MEDICINE 

the  puriform  discharge  from  the  affected  part  is  scanty;  when  the  false 
membrane  is  carefully  removed,  the  mucosa  beneath  seems  not  to  be 
much  affected  and  does  not  bleed.  When  streptococci  are  found  alone, 
or  are  largely  mingled  with  the  bacilli,  the  exudation  is  softer,  more 
pulpy,  more  prone  to  decomposition  and  to  be  attended  by  an  abundant 
puriform  discharge ;  removal  of  the  false  membrane  exposes  a  swollen, 
raw  and  bleeding  mucosa. 

3.  Swelling  of  parts  beneath  false  membrane  is  usually  proportionate  to 
the  activity  of  the  local  disease.  Swelling  of  the  fauces  sometimes  be- 
comes so  great  in  two  or  three  days  that  the  uvula  is  pushed  back  and 
invisible,  even  the  tonsils  cannot  be  distinguished,  and  the  isthmus  fau- 
cium  is  reduced  to  a  narrow  vertical  slit  in  the  middle  line.  In  conse- 
quence of  this  inflammatory  swelling,  the  soft  palate  may  be  not  less 
than  three-quarters  of  an  inch  thick,  firm  and  tough. 

4.  Mucopurulent  Secretion.  —  Abundant  puriform  discharge  from  the 
fauces  occurs  in  severe  cases  so  as  to  interfere  greatly  with  examination. 
The  secretion  is  sometimes  offensive  to  smell.  If  a  similar  discharge 
(watery  at  first,  afterwards  more  purulent)  occur  from  the  nostrils  or 
ears,  it  may  be  assumed  that  the  nasal  fossae  or  tympana  are  invaded, 
and  the  disease  so  much  the  more  serious,  because  more  extensive.  The 
discharge  from  the  nostril  is  acrid,  and  excoriates  the  upper  lip  in  a 
manner  quite  comparable  to  the  effect  of  the  vesicating  virus  of  can- 
tharides,  as  Bretonneau  pointed  out.  No  doubt  this  diphtheritic  fluid 
is  also  a  powerful  irritant  to  the  mucous  membranes  with  Avhich  it  comes 
into  contact,  and  thus  prepares  the  way  for  the  growth  of  false  mem- 
brane. Cutaneous  erysipelas  sometimes  starts  from  the  point  where 
these  irritating  discharges  reach  the  surface  of  the  body  —  a  complica- 
tion especially  apt  to  occur  in  diphtheritic  otorrhoea. 

6.  False  Membrane  cast  off. — After  the  false  membrane  has  ceased 
to  grow  it  is  soon  cast  off,  either  as  coherent  flakes  and  shreds,  or  soft 
pulpy  material.  The  mucosa  beneath  is  left  at  first  somewhat  reddened 
and  perhaps  swollen.  Mere  excessive  redness  soon  passes  away,  swell- 
ing less  quickly. 

Ulceration  of  the  mucosa  will  follow  but  seldom  upon  the  false  mem- 
brane being  thrown  off.  The  ulcers  may  be  deep,  and  on  both  sides  of 
the  throat,  quite  like  the  ulcers  of  scarlatina  anginosa ;  the  tonsil  will 
sometimes  be  destroyed  so  as  to  leave  a  ragged  cavity ;  the  soft  palate  and 
uvula  may  be  extensively  ulcerated  or  sloughy ;  the  mucous  membrane 
about  the  epiglottis  and  ary-epiglottic  folds  may  suffer  in  like  manner. 

6.  Relapse.  —  After  the  false  membrane  has  been  cast  off,  but  before 
the  patient  has  recovered  from  the  whole  disease,  a  renewed  exudation 
upon  the  fauces  may  occur,  and  the  relapse  will  aggravate  the  disease 
in  all  respects.  Recurrence  of  diphtheria,  after  complete  recovery  from 
a  former  attack,  is  mentioned  elsewhere. 

III.  Affection  of  Lymphatic  Structures  in  Neck. — Swelling  of  the 
lymphatic  glands  at  the  angle  of  the  loAver  jaw  is  usually  the  first  sign  of 
poisonous  infection  spreading  beyond  the  fauces.    This  is  the  case  even  if 


DIPHTHERIA  735 


the  glandular  swelling  precede  the  appearance  of  false  membranes  on  the 
fauces,  in  which  case  the  mucous  membrane  of  the  throat  is  infected  by 
microbes,  although  they  have  not  gone  on  to  the  formation  of  false  mem- 
brane ;  or,  as  sometimes  happens,  false  membrane  may  have  been  formed 
in  some  situation  where  it  is  not  visible ;  for  example,  on  the  back  of  the 
soft  palate.  But  it  is  seldom  that  lymphadenitis  precedes  visible  pellicles 
on  the  fauces. 

The  degree  of  the  glandular  swelling  is  proportionate  to  the  virulence 
of  the  angina  faucium,  but  not  always  proportionate  to  the  malignity  of 
the  disease ;  or,  in  other  words,  the  most  malignant  form  of  diphtheria, 
which  kills  the  patient  by  intense  toxaemia,  is  not  by  any  means  always 
accompanied  by  much  affection  of  the  fauces  or  swelling  of  the  neck. 
In  bad  cases  swelling  of  the  connective  tissue  aroiuid  the  glands  occurs  ; 
it  may  be  to  so  great  an  extent  as  to  deform  the  whole  neck  from  ears 
to  collar-bones,  to  render  the  enlarged  glands  hardly  perceptible,  and  even 
to  involve  the  cheeks  and  vipper  part  of  the  chest.  This  external  swell- 
ing is  sometimes  tender  to  touch,  sometimes  not;  it  does  not  pit  upon 
pressure ;  the  skin  is  either  pale  or  reddened.  Erysipelatous  redness  of 
the  skin  over  the  swelling  will  sometimes  give  rise  to  an  appearance 
closely  resembling  that  of  an  abscess.  Great  swelling  of  the  neck  is 
sometimes  associated  with  very  great  swelling  of  the  fauces ;  in  this 
case  the  false  membrane  is  often  thin  and  delicate,  the  disease  show- 
ing itself  chiefly  as  swelling.  Much  coryza,  with  irritant  discharge,  is 
common.  The  malignant  swelling  occurs  rapidly;  it  may  be  great  on 
the  third  day  of  disease ;  and  death,  mainly  from  dysphagia  and  dysp- 
ncea,  may  ensue  on  the  fourth  day.  The  dyspnoea  is  sometimes  par- 
ticularly great,  the  frequency  of  respirations  being  nearly  one  hundred 
a  minute ;  post-mortem  the  lungs  are  excessively  inflated  with  air,  and 
yet  without  any  false  membrane  in  the  air-passages. 

The  external  swelling  is  useful  as  a  prognostic  sign ;  if  the  pellicular 
formation  be  not  extensive,  much  affection  of  the  glands  and  cellular 
membrane  of  the  neck  indicates  a  virulent  form  of  disease.  It  is  said 
that  the  virus  of  bacillus  diplitheriae  does  not  cause  more  than  a  very 
moderate  degree  of  lymphatic  glandular  swelling,  and  little  or  no  infil- 
tration of  the  cellular  tissue,  and  that  the  severer  form  of  affection  of 
the  neck  (cynanche  cellularis)  is  due  to  the  virus  of  micrococci. 

Suppuration  of  the  lymphatic  glands,  or  around  them,  is  uncommon. 
The  more  virulent  forms  of  the  disease  are  fatal  too  soon  for  suppuration 
to  occur.  In  cases  which  end  in  recovery,  if  there  be  any  suppuration, 
it  is  slow  and  scanty. 

IV.  Some  rarer  local  lesions,  that  is  of  the  mouth  and  salivary  glands, 
attending  diphtheritic  angina  faucium. 

(o.)  The  parotid  and  submaxillary  salivary  glands  sometimes  suffer 
in  diphtheria,  y)robably  in  consequence  of  inflammation  spreading  from  the 
mouth.  The  submaxillary  glands  especially  may  be  felt  to  be  distinctly 
enlarged,  and  the  parotid  swelling,  in  rare  cases,  is  sufficient  to  resemble 
the  swelling  of  mumps. 


736  SYSTEM   OF  MEDICINE 


(b)  The  mouth  does  not  suffer  severely;  the  tongue  is  furred  more 
or  less ;  the  gums  are  somewhat  swollen,  and  either  pale  or  red,  with  a 
very  thin  film  of  fur  upon  them ;  sometimes  they  bleed  a  little,  but 
nothing  like  the  "  scorbutic  gangrene  "  described  by  Bretonneau  is  ever 
seen  in  England  at  the  present  day  (4),  (6).  Small  herpetic  aphthae  are 
sometimes  present,  and  now  and  then  a  patch  of  false  membrane  upon 
the  lip  or  cheek. 

The  signs  of  diphtheria,  which  has  spread  from  the  throat  to  the  nose 
or  larynx,  Avill  be  described  under  the  heads  of  nasal  diphtheria  and 
diphtheritic  croup.  The  laryngeal  affection,  when  it  supervenes  upon 
disease  beginning  in  the  fauces,  usually  begins  within  three  or  four  days 
from  the  onset  of  the  angina  faucium,  and  seldom  after  a  week  or  eight 
days.  Post-mortem,  laryngeal  false  membranes  are  seldom  found  to  be 
continuous  with  those  in  the  pharynx.  If  the  diphtheritic  angina  be  of 
a  malignant  type  the  supervention  of  croup  does  not  obviously  change 
the  aspect  of  the  case ;  the  patient  dies  just  the  same  from  debility  and 
not  from  suffocation. 

V.  Temperature  of  the  Body.  —  Diphtheria,  at  its  onset  at  least,  is 
probably  always  a  febrile  disease.  The  fever  follows  no  constant  type 
or  course  ;  as  a  sort  of  rough  rule,  it  may  be  said  that  the  fever  of  the 
onset  falls  on  the  second  or  third  day,  and  that  a  moderate  rise  of  tem- 
perature continues  a  few  days  longer.  The  temperature  seldom  rises 
above  103°  or  10-l-°,  even  at  the  beginning  of  the  disease ;  when  the  sore 
throat  is  at  its  height,  temperatures  about  101°  are  more  common. 
Diphtheria  is  not  a  very  febrile  disease,  and  the  slighter  forms  are 
more  febrile  than  the  severer.  Indeed,  in  bad  cases  the  temperature 
is  not  only  not  raised,  but  is  even  depressed,  temperatures  between  97° 
and  98°  being  common ;  in  the  most  malignant  cases  a  temperature  of 
96°  in  the  rectum  has  been  observed. 

The  cause  of  such  algidity  is  uncertain ;  it  has  been  attributed  to 
degenerative  change  in  the  muscular  walls  of  the  heart,  but  a  more  prob- 
able cause  would  seem  to  be  the  generation  of  a  febrifuge  poison  ;  in- 
deed, the  worst  cases  of  diphtheria  and  of  perforative  peritonitis  resemble 
each  other  much  in  this  respect  of  algidity. 

VI.  Albuminuria.  —  The  urine,  if  it  be  often  and  carefully  examined, 
will  be  found  in  very  many  cases  to  contain  albumin.  This  albuminuria 
depends  upon  nephritis,  which  is  in  turn  probably  due  to  a  soluble  poison 
circulating  in  the  blood. 

Albumin  first  appears  in  the  urine  at  any  period  of  the  disease  before 
the  tenth  day,  seldom  later.  Albuminuria  will  sometimes  come  on  co- 
piously, and  for  the  first  time,  after  the  throat  has  seemed  to  have  been 
free  from  disease  for  several  days.  If  the  patient  survive  albuminuria 
seldom  lasts  long,  even  if  it  have  been  great.  In  a  few  cases  it  may 
persist  for  some  weeks  after  all  other  symptoms  of  disease  have  passed 
away.  Now  and  then  albumin  seems  likely  to  be  permanently  present 
in  the  urine,  though  Avhether  the  albuminuria  is  really  permanent,  or 
whether  in  such  cases  the  patient's  kidneys  were  certainly  sound  before 


DIPHTHERIA  737 


the  attack  of  diphtheria,  speaking  from  my  own  experience,  I  cannot 
be  sure. 

The  amount  of  albumin  affords  no  trustworthy  prognostic  sign. 
The  urine  may  be  highly  albuminous  one  day,  and  two  or  three  days 
afterwards  contain  the  merest  trace  of  albumin.  Other  things  being 
equal,  a  case  with  albuminuria  is  more  serious  than  a  case  without  it; 
more  patients  die  who  have  albuminuria  than  those  who  have  it  not,  yet 
patients  will  die  who  have  never  had  it,  and  patients  will  easily  recover 
whose  urine  for  a  short  time  has  been  highly  albuminous. 

If  the  nephritis  be  severe  the  urine  is  scanty  and  very  albuminous ; 
casts  and  corpuscles  are  found  by  the  microscope  :  casts  hyaline,  granular, 
and  corpuscular;  corpuscles  having  the  characters  for  the  most  part  of 
leucocytes,  bat  some  probably  being  renal  epithelium ;  a  few  red  blood 
disks  are  seen.  The  urine  is  seldom  or  never  smoky  or  bloody.  Com- 
plete suppression  of  urine  is  observed  at  the  end  of  life  in  cases  which 
prove  fatal  by  vomiting  and  heart  failure. 

Dropsy  occurs  very  seldom,  if  ever.  Symptoms  which  can  without 
doubt  be  attributed  to  uraemia  are  not  met  with. 

VII.  Haemorrhages  and  Changes  in  the  Blood.  —  In  some  cases  of 
malignant  diphtheria  the  affection  of  the  blood  is  so  profound  that  during 
life  the  lips  and  even  the  whole  surface  of  the  body  are  of  a  slaty  gray 
colour,  quite  apart  from  any  dyspnoea  or  mere  respiratory  lividity.  The 
blood  itself  is  of  a  dirty  brown  colour,  which  has  been  compared  to  prune 
juice  or  Spanish  liquorice ;  but  microscopical  examination  detects  nothing 
amiss.  Spectroscopic  examinations  have  not  been  made,  and  the  nature 
of  the  very  obvious  change  which  the  blood  undergoes  is  but  ill  under- 
stood. 

Haemorrhagic  tendency  shows  itself  now  and  then ;  whether  dependent 
upon  changes  in  the  blood  or  blood-vessels,  or  both,  remains  unknown. 
Small  specks  or  larger  blotches  of  extravasated  blood  appear  in  the  skin, 
mucous  membranes,  serous  membranes  and  retinae.  Free  bleeding  from 
the  mucous  membranes  occurs,  especially  from  the  nose,  but  also  from 
the  throat,  stomach,  and  bowels ;  the  bleeding  may  prove  fatal,  either 
very  speedily  or  more  slowly.  Haematuria  is  a  very  uncommon  event 
even  in  haemorrhagic  diphtheria.  The  spleen  is  sometimes  enlarged  as 
in  purpura,  and  sometimes  not.  Haemorrhage,  even  when  too  scanty 
to  be  the  cause  of  death,  will  do  much  towards  increasing  the  weakness 
of  the  patient;  such  cases  are  always  to  be  deemed  serious. 

The  haemorrhagic  tendency  bears  no  proportion  to  the  affection  of  the 
throat;  indeed,  the  latter  may  be  so  slight  that  the  diphtheritic  character 
of  the  disease  shall  be  wholly  overlooked,  and  the  death  of  the  patient 
be  certified  as  due  to  purpura  haemorrhagica. 

Cerebral  haemorrhage  of  the  same  nature  is  a  cause,  but  a  very  un- 
common cause  of  hemiplegia. 

VIII.  Failure  of  Heart.  —  In  diphtheria  tho  function  of  the  heart  is 
more  apt  to  fail  than  in  any  other  virulent  disease  which  we  meet  with 
in  our  country.     This   primary  debility  of  the   heart   (vital  debility, 

VOL.   r  3  b 


738  SYSTEM   OF  MEDICINE 

lipothymia),  not  due  to  exhaustion  of  tlie  powers  of  the  whole  body,  but 
to  a  peculiar  operation  of  morbid  poison  upon  the  heart  itself,  Avhich  is 
selected  as  it  were  for  this  effect,  constitutes  the  primary  or  protopathic 
malignity  of  the  older  writers  (Stoll,  for  example) — the  word  malignity 
being  used  in  a  much  more  restricted  sense  than  that  referred  to  on  page 
731.  The  cause  of  the  heart  failure  is  degeneration  of  its  muscular 
walls  (myocarditis)  ;  when  degeneration  is  not  found  after  death  (if  this 
ever  be  the  case)  the  heart  failure  must  be  attributed  to  paralysis  of  the* 
cardiac  branches  of  the  par  vagum. 

A  sign  of  this  affection  of  the  heart  is  found  in  the  pulse,  which  be- 
comes small  and  weak ;  it  is  often  irregidar  also,  in  some  cases  it  is  very 
frequent,  in  others  very  infrequent.  The  temperature  of  the  body  falls 
even  as  low  as  95-5°  in  the  rectum ;  the  skin  and  limbs  ai'e  cold.  The 
iirst  sound  of  the  heart  is  weak  or  quite  inaudible,  sometimes  a  systolic 
murmur  at  apex  or  base  springs  up.  Unpleasant  fluttering  or  palpitation 
of  the  heart  may  be  complained  of,  and  the  weakened  pulmonary  circula- 
tion may  be  indicated  by  shortness  of  breath.  The  face  becomes  remark- 
ably pale.  The  patient  is  sensible  of  great  muscular  weakness,  is  very 
shiggish,  dislikes  to  be  moved,  and  even  takes  food  unwillingly. 

These  symptoms  often  come  on  gradually,  the  patient's  heart  steadily 
becoming  weaker  and  weaker ;  patients  of  this  kind  may  lie  a  week  or 
ten  days  in  a  state  of  prostration.  But  the  symptoms  sometimes  set  in 
suddenly,  all  at  once  faintness  (lipothymia,  collapse)  occurs,  attended  by 
a  marked  change  (which  cannot  be  described)  in  the  look  of  the  patient's 
face,  and  by  the  aforesaid  sigTis  of  heart  failure.  The  patient  may 
die  suddenly  and  unexpectedly,  but  usually  he  lingers  for  some  hours 
in  a  state  of  extreme  prostration,  consciousness  is  retained  to  the  end, 
and  the  power  of  the  voluntary  movements  is  in  remarkable  contrast 
with  the  weakness  of  the  heart  muscle. 

failure  of  the  heart  is  usually  met  with  during  the  height  of  the 
diphtheritic  disease,  say  at  any  time  between  the  fourth  and  fourteenth 
day.  A  slight  affection  of  the  throat  may  be  followed  by  serious  disorder 
of  the  heart.  When  the  heart  fails  later  it  is  especially  associated  with 
paralytic  symptoms.^ 

Signs  of  dilatation  of  the  heart  and  a  systolic  murmur  sometimes 
occur  during  convalescence,  and  may  be  expected  to  disappear  Avhen  the 
health  of  the  patient  is  fully  restored.  If  endocarditis  and  pericarditis 
ever  occur  as  a  result  of  diphtheria  they  are  probably  dependent  upon 
micrococci. 

IX.  Vomiting.  —  Another  serious  symptom,  and  one  often  associated 
with  cardiac  failure,  is  a  tendency  to  vomit.  The  cause  of  it  is  not 
always  the  same.     But  whatever  it  be,  repeated  vomiting  is  a  dangerous 

1  Rabot  and  Philippe  (7)  describe  an  interstitial  myocarditis  which  occurs  dnrins:  con- 
valescence from  diphtheria,  when  the  patient  has  been  allowed  to  get  up,  and  thinks  him- 
self to  be  well.  Tliis  form  of  disease  must  be  uncommon.  [I  remember  such  a  case  in 
the  private  practice  of  the  late  Dr.  Fuller.  The  patient,  a  young  man,  convalescent  at 
the  seaside,  rose  quickly  from  a  sofa  and  fell  back  dead.  The  autopsy  revealed  "  degen- 
erated heart."  —  Ed.] 


DIPHTHERIA 


739 


symptom;  most  of  such  patients  die  in  a  state  of  heart  failure  and 
algidity  within  a  few  hours  or  a  few  days. 

In  very  rare  cases  vomiting  is  a  sign  of  diphtheria  of  the  stomach. 

In  most  cases  vomiting  is  associated  with  affection  of  the  kidneys. 
Sometimes  the  urine  is  highly  albuminous  and  scanty,  or  even  completely 
suppressed;  the  diminished  secretion  is  probably  in  greater  part  de- 
pendent upon  the  vomiting.  Sometimes  the  quantity  of  albumin  in 
the  urine  is  small ;  sometimes  the  renal  affection  is  manifested  more  by 
corpuscles  and  casts  in  the  urine  than  by  much  albumin.  The  patient 
retains  consciousness.     Convulsions  in  rare  cases  precede  death. 

Now  and  then  vomiting  occurs  late  in  the  disease,  in  the  course  of 
paralysis,  four  or  five  weeks  from  the  onset  of  the  diphtheria. 

X.  Paralysis.  —  The  period  at  which  paralysis  occurs  in  the  course 
of  diphtheria  is  uncertain,  and  very  variable.  Palsy  sometimes  sets  in 
while  the  primary  disease  (the  formation  of  false  membrane)  is  progress- 
ing, say  as  early  as  the  fourth  day.  On  the  other  hand,  as  much  time 
as  ten  weeks  may  intervene  between  the  onset  of  the  diphtheria  and  of 
the  palsy.  The  mean  interval,  computed  from  many  cases,  is  three  or 
four  weeks.  More  often  than  not  paralysis  may  be  called  a  sequel 
of  diphtheria ;  that  is  to  say,  a  period  of  convalescence  intervenes  be- 
tween the  primary  disease  and  the  paralysis. 

Palsy  may  be  consequent  upon  any  form  of  diphtheria,  yet  diphtheria 
which  is  mainly  or  altogether  laryngeal  is  seldom  followed  by  palsy ; 
indeed,  few  patients  survive  the  primitive  disease.  The  patellar  tendon 
reflex  is  lost  in  some  cases  of  diphtheritic  croup,  and  this  symptom  may 
be  regarded  as  akin  to  palsy.  Some  of  the  cases  in  which  the  tube 
cannot  be  removed  after  tracheotomy  are  probably  of  the  nature  of 
laryngeal  palsy.  Anything  like  extensive  paralysis  after  diphtheritic 
croup  must  be  most  uncommon. 

Diphtheria  of  the  fauces  is  by  far  the  commonest  primitive  lesion, 
indeed,  there  is  seldom  any  other.  About  one-tenth  of  all  cases  of 
diphtheritic  sore  throat  are  attended  by  paralysis  sooner  or  later.  It 
mostly  begins  after  the  second  week  of  the  angina ;  it  may  occur  much 
sooner,  as  mentioned  above;  seldom  later  than  the  seventh  week. 
(Paralysis  after  nasal  diphtheria  is  referred  to  further  on.) 

The  usual  course  of  the  palsy  is  this,  that  it  gradually  increases 
until  the  patient  dies,  or  until  the  disease  begins  to  decline  as  gradually 
as  it  arose.     In  the  latter  case  recovery  is  complete. 

There  is  no  proportion  between  the  severity  of  the  primary  disease 
and  of  the  palsy  ;  or  at  least  paralysis  often  ensues  when  the  primitive 
diphtheria  has  been  very  slight.  Indeed,  in  some  cases  the  sore  throat 
altogether  escapes  observation,  the  paralysis  being  the  first  evidence  of 
diphtheria. 

The  fauces,  and  especially  the  soft  palate,  usually  suffer  first.  The 
signs  of  palsy  of  the  soft  palate  are  two:  the  voice  becomes  nasal,  and 
drinks  are  apt  to  return  through  the  nose;  moreovei',  the  patient  can 
hardly  blow  out  a  candle,  inflate  the  cheeks,  suck  or  gargle.     The  palate 


740 


SYSTEM   OF  MEDICINE 


will  be  seen  to  have  lost  its  arching,  and  to  hang  straighter  than  natural 
on  both  sides.  The  sensibility  of  the  mucous  membrane  and  the  reflex 
movements  are  more  or  less  diminished.  These  signs  are  sometimes 
more  marked  on  the  one  side  of  the  palate  than  on  the  other;  or  they  may 
even  be  present  on  one  side  alone.  Palsy,  insensibility  and  abolished 
reflex  by  no  means  always  concur :  one  or  more  of  these  symptoms  may 
be  absent ;  for  instance,  the  reflex  may  be  lost  though  sensibility  is  re- 
tained. Paralysis  of  the  lowest  constrictor  of  the  pharynx  is  indicated 
by  entry  of  food  into  the  glottis,  causing  choking  and  cough. 

Paralysis  is  often  coniined  to  the  fauces  and  spreads  no  farther; 
in  this  case  it  will  last  ten  days  or  a  fortnight  and  then  begin  gradually 
to  disappear.  The  fauces  sometimes  escape  even  though  the  limbs  and 
trunk  are  severely  affected.  Sometimes  paralysis  diminishes  in  the 
fauces  as  it  increases  in  the  limbs. 

Paralysis  of  the  rima  glottidis  is  indicated  by  weakened  voice  and 
inefiicient  cough,  both  dependent  upon  imperfect  closure  of  the  glottis. 
Together  with  the  paralysis  go  insensibility  and  deficient  reflex  of  the 
epiglottis  and  interior  of  the  larynx.  Hence  great  danger  of  pneumo- 
nia from  entry  of  food  into  the  windpipe ;  great  danger  of  suffocating 
bronchitis  also,  from  deficient  expectoration.  Recovery  from  laryngeal 
palsy  is  possible. 

Paralysis  of  the  limbs  affects  the  legs  before  the  arms ;  indeed  the 
arms  often  escape.  When  the  patient  is  able  to  walk  at  all  the  gait  is 
staggering:  at  last  he  becomes  unable  to  stand,  or  even  to  move  the 
legs  in  bed.  Palsy  of  the  limbs  usually  takes  about  seven  weeks  to 
reach  its  height.  The  muscles  tend  to  waste,  and  sometimes  waste 
greatly ;  partly  in  consequence  of  the  nerve  disease,  but  partly  in  some 
cases  from  insufiicient  feeding.  Tlie  electrical  reactions  of  the  nerve- 
trunks  are  normal.  The  excitability  of  the  muscles  to  faradisation  is 
diminished  or  even  wholly  lost ;  voluntary  power  is  sometimes  much  les- 
sened while  faradic  excitability  remains  normal;  in  some  instances  faradic 
excitability  will  go  on  diminishing,  while  voluntary  power  is  increasing. 
The  degree  of  galvanic  excitability  of  the  muscles  is  uncertaiii ;  it  is 
often  diminished  or  slow,  may  possibly  be  increased  for  a  time,  and 
sometimes,  not  always,  there  are  qualitative  polar  changes.  Abnormal 
electrical  reactions  can  sometimes  be  discovered  long  after  voluntary 
power  over  the  muscles  has  been  completely  restored.  Sensibility  is 
mostly  retained ;  when  lost  it  is  seldom  lost  higher  up  than  the  knees. 
Patellar  reflex  is  abolished  as  a  rule,  but  is  sometimes  retained  even  when 
the  palsy  is  great.  On  the  other  hand,  patellar  reflex  is  sometimes  lost 
for  a  considerable  time  during  or  after  diphtheria,  although  the  legs 
never  show  any  weakness.  When  the  reflex  returns  it  has  been  noted, 
in  a  few  rare  cases,  to  be  excessive  for  a  time,  and  to  be  associated  with 
ankle  clonus.  The  palsied  limbs  are  sometimes  painful.  Recovery  of 
the  proper  use  of  the  limbs,  and  of  normal  electrical  reactions,  will 
certainly  occur,  and  is  only  a  matter  of  time.  But  the  time  necessary 
is  often  considerable,  and  may  amount  to  six  or  eight  months  or  more. 


DIPHTHERIA  74! 


The  hemiplegia  which  occurs  now  and  then  in  the  course  of  diph- 
theria is  a  different  form  of  disease,  being  due  either  to  cerebral  haemor- 
rhage or  to  embolism  of  the  cerebral  arteries ;  in  the  latter  case  the 
source  of  the  embolus  is  not  always  discovered.  \Vide  section  on 
Cerebral  Disease.] 

The  muscles  of  the  trunk  sometimes  suffer  in  the  ordinary  form  of 
diphtheritic  paralysis,  but  the  case  is  not  rendered  more  serious  thereby 
unless  the  diaphragm  and  intercostals  be  paralysed.  A  cause  of  death 
is  paralysis  of  the  respiratory  muscles.  The  sphincters  are  very  seldom 
affected. 

The  eyes  sometimes  suffer.  The  commonest  affection  is  dimness  of 
sight,  due  either  to  asthenopia  consequent  upon  paralysis  of  the  ciliary 
muscle  (cycloplegia),  or  to  amblyopia  consequent  upon  retinal  insensibil- 
ity and  contraction  of  the  field  of  vision ;  in  the  latter  case  glasses  are 
useless.  Any  form  of  ophthalmoplegia  externa,  indicated  by  diplopia  or 
squint,  is  less  common.  Incomplete  blepharoptosis  has  been  observed. 
The  pupil  is  unaffected,  or  at  most  but  somewhat  dilated  and  sluggish. 

Palsy  of  the  oesophagus,  tongue,  lips,  cheeks,  are  possible  but  very 
improbable  occurrences.  The  failure  of  the  heart  is  in  some  cases  per- 
haps of  a  neuro-paralytic  nature. 

In  children  and  in  some  epidemics  death  is  not  seldom  the  end  of 
diphtheritic  palsy.  When  death  does  not  ensue  complete  recovery  is 
certain  sooner  or  later.  The  duration  of  paralysis  in  cases  of  recovery 
depends  much  upon  the  extent  of  the  affection.  When  confined  to  the  soft 
palate  recovery  may  be  expected  in  two  or  three  weeks ;  when  the  limbs 
are  affected  the  duration  will  probably  be  three  or  four  months.  A 
duration  of  eight  months,  or  even  more,  has  been  noticed  in  rare  cases. 
Excluding  cases  of  heart  failure  death  is  due  either  to  laryngeal  or  re- 
spiratory palsy.  Laryngeal  palsy  causes  death  through  inability  to  cough 
and  to  expectorate  properly,  the  result  being  accumulation  of  mucus  in 
the  lungs.  Death  is  seldom  due  to  impaction  of  a  morsel  of  food  in  the 
larynx.  Pneumonia  from  the  entry  of  smaller  particles  of  food  into 
the  windpipe  is  a  much  more  common  event,  especially  in  cases  of 
tracheotomy,  or  of  anaesthesia  of  the  glottis. 

When  paralysis  follows  nasal  diphtheria,  the  fauces  may  be  unaffected 
while  the  limbs  suffer  severely. 

Although  good  observers  have  found  changes  in  the  medulla  oblon- 
gata and  spinalis  in  cases  of  diphtheritic  palsy,  yet  the  prevailing  opinion 
is  that  the  chief  and  often  the  only  cause  of  the  paralysis  is  multiple 
neuritis.  The  cause  of  the  neuritis  is  supposed  to  be  a  specific  soluble 
poison ;  the  palatal  palsy  which  follows  palatal  diphtheria  looks  like  a 
purely  local  effect  of  the  poison. 

XI.  Eruptions.  —  Besides  the  purpura  and  erysipelas  which  have 
been  already  referred  to,  erythema  and  urticaria  of  no  constant  or 
peculiar  characters  have  been  observed.  Suffusion  of  the  skin,  almost 
scarlatiniform,  is  common. 

XII.  Arthritis.  —  Kheumatoid  affection  of  the  joints  has  been 
observed  in  rare  cases  and  in  some  epidemics. 


742  SYSTEM   OF  MEDICINE 

Diagnosis  of  Diphtheritic  Sore  Throat.  —  Diphtheritic  sore  tliroat 
is  not  in  all  cases  attended  by  the  formation  of  false  membrane,  and 
is  therefore  sometimes  indistinguishable  by  the  naked  eye  from  simple 
or  catarrhal  sore  throat.  The  proof  of  this  assertion  is  afforded  by  two 
facts :  First,  that  the  bacillus  has  been  found  to  exist  upon  the  mucous 
membrane  of  throats  which  were,  to  the  naked  eye,  simply  slightly 
reddened  and  swollen.  Next,  observations  made  in  epidemics  of  diph- 
theria have  rendered  it  certain  that  the  disease  is  sometimes  transmitted 
by  cases  which  have  the  characters  of  simple  catarrhal  or  inflamed  sore 
throat.     (See  Latent  Diphtheria.) 

But  the  diagnosis  of  diphtheritic  sore  throat  relates  mainly  to  the 
false  membrane.  Inasmuch  as  not  all  sore  throats  accompanied  by  false 
membranes  are  diphtheritic,  we  endeavour  to  distinguish  the  different 
kinds  of  pellicular  angina  faucium.  Even  if  it  were  admitted  that  the 
bacillus  is  the  absolutely  peculiar  and  necessary  note  of  diphtheria,  yet 
it  is  clear  that  for  the  immediate  needs  of  practice  a  mere  inspection  of 
the  throat  must  be  relied  upon,  and  it  is  in  this  spirit  that  the  following 
remarks  upon  diagnosis  are  written :  — 

1.  Many  vesicants  and  escharotics,  when  applied  to  the  fauces,  pro- 
duce appearances  which  closely  resemble  diphtheria.  Cantharides,  lunar 
caustic,  nitric  acid,  liq.  ammonise,  carbolic  acid,  white  precipitate,  hot 
chestnuts  or  potatoes,  boiling  water  and  steam,  may  be  mentioned  as 
instances  of  such  irritants.  The  diagnosis  in  many  cases  cannot  be 
made  from  the  look  of  the  throat  alone.  The  conditions  Avhich  led  to 
the  pellicular  inflammation  must  be  known. 

2.  The  disease  (or  rather  the  diseases),  which  in  England  is  most 
commonly  called  follicular  tonsillitis,  demands  very  careful  considera- 
tion in  regard  to  its  relation  with  diphtheria.  Many  cases  of  this  follic- 
ular tonsillitis  are  diphtheria  in  an  early  stage,  the  appearance  of 
ulceration  round  the  mouths  of  the  tonsillar  crypts  being  due  to  false 
membrane,  which  often  is  first  formed  in  that  situation.  The  membrane 
may  spread  afterwards  so  as  to  cover  the  greater  part  of  the  fauces  in 
two  or  three  days.  In  other  cases  the  membrane  does  not  spread  upon 
the  fauces,  but  laryngeal  diphtheria  is  associated  with  the  tonsillar  affec- 
tion ;  in  others  again  the  membrane  does  not  spread  in  any  direction, 
and  the  true  nature  of  the  disease  becomes  apparent  only  when  the  pa- 
tient infects  another  person  with  manifest  diphtheria :  or  the  reverse 
may  be  the  case,  that  the  disease  conveyed  from  a  person  suffering  from 
manifest  diphtheria  will  take  on  the  form  of  follicular  tonsillitis  in  the 
infected  patient.  But  although  in  all  these  cases  there  can  be  no  doubt 
concerning  the  diphtheritic  nature  of  the  follicular  tonsillitis,  yet  it 
seems  to  be  equally  certain  that  in  other  cases  the  disease  is  not  diph- 
theritic, those,  namely,  which  show  no  contagious  tendency.  But  ad- 
mitting this  distinction,  it  can  seldom  be  drawn  in  a  given  patient,  and 
therefore  in  practice  it  is  wise  to  consider  the  disease  to  be  in  all  cases 
probably,  or  at  least  possibly,  diphtheritic. 

3.  Herpes,  of  the  same  nature  as  herpes  labialis,  may  affect  the  palate 


DIPHTHERIA  743 


SO  as  to  produce  the  appearance  of  one  or  more  small  false  membranes 
which  show  no  tendency  to  spread  after  they  have  once  been  formed. 
The  diagnosis  (not  always  certain)  is  much  helped  by  the  concurrence 
of  herpes  on  the  tongue,  cheeks,  or  lips. 

4.  A  fungus  (oidium  albicans  ?)  sometimes  affects  the  fauces,  and 
causes  them  to  be  covered  by  a  growth  which  looks  like  a  false  mem- 
brane, and  which  may  be  so  extensive  as  to  cover  the  soft  palate  and 
tonsils.  Compared  with  the  false  membrane  of  diphtheria,  the  growth 
of  oidium  is  of  a  purer  and  more  opaque  white  colour,  it  is  much  softer 
also,  and  when  once  it  has  been  removed  by  detergents  it  seldom  re- 
appears.    Microscopic  examination  is  easy  and  decisive. 

5.  A  fungous  growth  (leptothrix  buccalis  ?)  sometimes  occurs  within 
the  crypts  of  the  tonsils,  and,  coming  to  the  surface,  simulates  follicular 
tonsillitis.  Or  the  growth  may  spread  over  the  tonsil  so  as  to  form  a 
white  patch.  The  chief  distinction  from  oidium  and  pellicular  diseases  is 
to  be  found  in  the  fact  that  the  leptothrix  affection  is  essentially  chronic. 

6.  At  any  time  during  the  first  week  of  scarlet  fever  false  mem- 
brane may  appear  upon  the  fauces.  This  membrane  is  said  to  be  due 
to  nicrococci,  and  not  to  afford  the  Klebs  bacillus.  Yet  by  the  unaided 
eye  the  exudation,  which  is  sometimes  abundant,  is  not  to  be  distin- 
guished from  that  of  diphtheria.  The  diagnosis  depends  mainly  upon  the 
eruption.  The  scarlatinal  false  membrane  is  very  much  more  prone  to 
be  followed  by  ulceration  than  is  the  diphtheritic,  and  the  lymphatic 
glands  are  much  more  likely  to  suppurate.  It  is  quite  true  that  scarlet 
fever  does  not  often  affect  the  larynx,  yet  in  rare  cases  of  that  disease 
false  membrane  may  be  found  even  there.  Subsequent  paralysis  does 
not  occur.  True  diphtheria  may  complicate  scarlet  fever  during  the 
second  or  third  week,  and  may  occur  in  scarlatinal'  nephritis  at  any  stage. 

7.  The  mucous  tubercles  of  syphilis,  when  they  involve  the  fauces 
and  before  ulceration  sets  in,  may  resemble  diphtheria  closely. 

8.  In  rare  cases  of  typhoid  fever  and  early  in  the  disease,  false 
membrane  forms  upon  the  fauces ;  it  does  not  last  for  more  than  a  few 
days,  but  it  cannot  be  distinguished  from  diphtheria  until  the  course  of 
the  disease  is  manifest. 

It  seems  unnecessary  to  do  more  than  refer  to  the  faucial  affections  of 
sraall-pox,  chicken-pox,  and  pemphix.  The  ulceration  of  tubercular  an- 
gina faucium  is  sometimes  at  first  mistaken  for  diphtheria.  And  the  same 
is  true  of  that  very  uncommon  disease,  primary  gangrene  of  the  fauces. 

Recurrent  Pellicular  Angina.  —  Some  forms  of  pellicular  angina  are 
very  prone  to  recur,  and  the  recurrences  may  be  frequent,  for  example, 
once  every  two  or  three  months  for  a  year  or  two,  or  even  as. many  as 
four  attacks  in  twelve  weeks.  The  appearance  of  the  throat  is  that  of 
slight  diphtheria  (or  follicular  tonsillitis) ;  but  the  precise  nature  of  the 
disease  is  doubtful,  and  it  is  equally  doubtful  whether  that  nature  be  the 
same  in  all  cases.  This  recurrent  pellicular  angina  is  often  a  very  febrile 
disorder,  is  not  attended  V)y  albuminuria,  nor  followed  by  paralysis.  It 
can  seldom  hie  traced  to  insanitary  conditions;  and  when  it  recurs  fre- 


744  SYSTEM   OF  MEDICINE 

quently  it  seems  to  be  probable  that  the  contagium  vivum  lurks  about 
the  throat  in  an  inactive  state.  In  many  cases  the  disease  is  but 
slightly  if  at  all  contagious. 

An  attack  of  true  diphtheritic  sore  throat  does  not  protect  against 
recurrence  of  the  disease.  Yet  as  a  rule  (which,  however,  does  not  always 
hold  good)  recurrent  diphtheria  is  not  so  severe  and  dangerous  as  the 
first  attack. 

Prognosis.  —  The  prognostics  which  may  be  derived  from  individual 
symptoms  will  be  found  scattered  through  the  preceding  pages  and 
need  not  be  repeated  here. 

The  cause  of  death  differs  in  different  cases,  (i.)  Suffocation  by 
extension  of  disease  to  the  larynx  is  common,  (ii.)  Poisoning  of  the 
blood  (malignant  diphtheria)  is  a  less  common  cause  of  death.  This 
malignity  is  indicated  by  nasal  discharge,  glandular  swelling,  erysipela- 
tous redness  of  the  skin  over  the  swelling,  tendency  to  haemorrhage, 
failure  of  the  circulation  (as  shown  by  a  bad  pulse,  pallor,  and  coldness 
of  the  surface),  and  delirium.  Death  is  often  sudden,  (iii.)  Heart 
failure,     (iv.)  Palsy  of  respiratory  muscles. 

Recovery  of  the  former  state  of  health  is  sometimes  a  very  slow 
proceeding,  even  excepting  the  cases  of  paralysis. 

Treatment.^  —  From  the  remotest  ages  of  medicine  it  has  always 
been  assumed  that  the  foremost  indication  for  the  treatment  of 
diphtheria  consists  in  disinfection  of  the  primary  disease,  which  is 
usually  that  of  the  throat.  Both  laboratory  experiments  and  clinical 
experience  point  to  carbolic  acid  as  the  germicide  which  most  of  all 
combines  efficacy  and  safety.  It  may  be  used  in  a  solution  as  strong  as 
twenty  per  cent  in  the  case  of  children,  and  thirty  per  cent  in  the  case 
of  adults.  Glycerine,  castor  oil,  and  rectified  spirit  have  been  much 
employed  as  solvents  for  the  acid;  sulphoricinic  acid  has  of  late  been 
recommended  as  the  vehicle  (8),  under  the  belief  that  it  affords  the  least 
painful  application ;  I  have  used  this  sulphoricinic  phenol  and  believe 
it  to  be  efficient  for  the  purpose.  Remove  as  much  of  the  false 
membrane  as  possible  by  means  of  some  close  soft  material  ("  molleton" 
is  suitable)  (9)  tied  on  the  end  of  a  probe  or  an  osier  twig,  or  held 
by  forceps,  and  afterwards  apply  the  carbolic  solution  freely  to  the 
denuded  surface.  Should  the  false  membrane  continue  to  form  and 
to  show  signs  of  spreading,  the  treatment  may  be  repeated  once  or 
oftener,  according  to  the  discretion  of  the  physician.  These  applicar 
tions  to  the  throat  tend  to  exhaust  the  strength  of  the  patient,  and  the 
doctrine  of  local  disinfection  may  be  carried  out  in  practice  to  a  danger- 
ous length.  The  frequent  use  (for  two  or  three  minutes  every  hour)  of  a 
spray  of  a  saturated  solution  of  boric  acid  is  always  serviceable,  whether 
the  throat  be  also  swabbed  with  carbolic  acid  or  not.  If  deglutition 
be  painful  it  is  wel>  for  the  patient  to  benumb  his  fauces  by  means 
of  ice  before  attempting  to  swallow. 

The  most  important  part  of  general  treatment  consists  in  feeding  the 
J  For  the  serum  treatment  refer  to  the  last  chapter. 


DIPHTHERIA  745 


patient,  and  milk  is  the  most  suitable  article  of  food.  It  should  be  given 
every  two  hours  by  day,  and  every  three  hours  by  night.  Brandy  is 
useful  and  even  necessary  in  many  cases,  especially  if  an  insufficient 
quantity  of  milk  be  taken,  or  if  the  patient  be  exhausted,  or  if  the  heart 
show  signs  of  failing.  Should  the  patient  refuse  to  take  the  necessary 
quantity  of  food  he  must  be  fed  by  means  of  a  soft  catheter  passed 
through  the  nostril  into  the  oesophagus. 

It  is  not  possible  to  lay  down  any  universal  rule  concerning  the 
employment  of  drugs.  None  are  specific,  and  the  indications  for  their 
use  must  be  left  to  the  judgment  of  the  practitioner  who  is  directing  the 
treatment  of  a  case.  Chlorate  of  potash  is  cleansing  to  the  mouth,  but 
to  give  the  salt  in  large  doses  is  useless  or  even  dangerous.  The  old- 
fashioned  chlorine  mixture^  is  the  best  way  of  giving  the  chlorate. 

Signs  of  heart  failure  should  be  carefully  watched  for.  If  they 
appear  the  patient  must  be  kept  as  still  as  possible  in  the  recumbent 
position,  and  he  must  not  be  allowed  to  sit  up,  still  less  to  get  out  of  bed, 
for  any  purpose.     Alcohol  and  strychnia  are  the  best  medicines. 

If  there  be  any  signs  of  laryngeal  paralysis  the  patient  must  be  fed 
by  means  of  a  tube  through  the  nose,  and  by  nutritious  enemata.  The 
use  of  the  tube  is  favoured  in  most  cases  by  insensibility  of  the  fauces 
and  pharynx.  If  vomiting  follow  the  first  use  of  the  tube  the  practice 
should  not  therefore  be  given  up,  for  the  vomiting  is  seldom  repeated. 
The  patient  must  be  watched,  and  if  he  vomit  he  must  be  turned  over  on 
his  side,  with  his  head  low,  so  that  the  vomit  may  not  enter  the  larynx. 

Treatment  of  palsy  of  the  limbs  is  guided  by  the  knowledge  that,  if 
the  breathing  muscles  escape  and  the  heart  do  not  fail,  the  patient  will 
recover.  The  chief  means  of  promoting  recovery  consist  in  rest  and  in 
maintaining  or  improving  the  nutrition  of  the  whole  body.  Massage  and 
electricity  may  be  used,  but  must  be  used  gently.  In  respiratory  jjalsy 
faradisation  of  the  phrenic  nerve  has  been  known  to  do  good. 

For  the  vomiting  and  the  purpuric  state  no  treatment  avails ;  the 
nephritis  must  be  managed  upon  general  principleso 

B.  Diphtheritic  Croup  (Laryngitis) 

That  is  to  say,  diphtheria  which  causes  predominant  laryngeal  symp- 
toms, is  discovered  by  means  of  the  laryngoscope,  or  of  the  expectora- 
tion, or  of  certain  indirect  signs  of  the  disease. 

I.  Laryngoscope.  —  The  use  of  the  laryngoscope,  which  is  not  always 
easy  even  in  the  case  of  adults,  is  difficult  or  quite  impossible  in  the  case 

1  Put  ten  grains  of  powflered  chlorate  of  potash  into  a  pint  bottle,  and  add  half  a  drachm 
of  stron<(  hydrocliloric  acid.  Keep  the  bottle  corked  until  the  effervescence  has  ceased  ; 
then  add  an  ounce  of  cold  water  and  shake  the  bottle  well,  not  allowing  tlie  gas  to  escape ; 
then  add  another  ounce  of  water,  and  again  agitate  well,  and  so  on  until  the  bottle  is  full. 
The  resulting  solution  does  not  taste  nearly  so  badly  as  it  smells;  a  little  sugar  may  be 
added.  A  tablespf)onful  or  two,  according  to  the  age  of  the  patient,  may  be  given  fre- 
quently. An  adult  may  take  the  whole  pint  in  the  day.  Chlorine  vapour  was  recom- 
mended by  .J.  JoliMslono  as  early  as  1779. 


746  SYSTEM   OF  MEDICINE 


of  children,  especially  young  children.  Hence  it  seldom  avails  much  in 
the  diagnosis  of  croup ;  ^  however,  in  a  case  of  doubtful  nature  it  is  always 
well  to  try  what  the  laryngoscope  can  show.  A  small,  warmed  mirror 
can  be  passed  back  into  the  fauces  without  any  attempt  to  depress  the 
tongue  or  to  draw  it  out  of  the  mouth,  and  in  this  way  the  epiglottis,  at 
least,  can  be  seen,  if  there  be  not  much  gargling  of  frothy  mucus  in  the 
throat.  Should  false  membrane  appear  this  is  enough,  but  it  need  not 
be  said  that  the  nonappearance  of  membrane  proves  nothing. 

II.  Expectoration.  —  Children  seldom  expectorate  false  membrane 
before  tracheotomy  has  been  performed;  ejection  of  false  membrane 
through  the  tracheotomy  wound  is  a  very  common  event.  Yet  even 
after  tracheotomy  for  diphtheritic  croup  it  may  happen  that  no  false 
membrane  will  at  any  time  be  seen.  Adults,  on  the  other  hand,  suffer- 
ing from  diphtheria  strictly  confined  to  the  windpipe,  will  sometimes 
expectorate  false  membrane  in  large  quantities,  and  this  even  when  the 
dyspnoea  is  slight  and  the  chief  laryngeal  symptom  is  dysphonia. 

III.  Signs  of  Laryngeal  Disease.  —  In  most  cases  the  diagnosis  depends 
upon  certain  signs  which  indicate  derangement  of  the  laryngeal  func- 
tions. These  functions  are  two  —  vocal  and  respiratory:  vocal,  that  is 
the  proper  and  peculiar  function  of  the  larynx,  the  larynx  being  the  organ 
of  voice  ;  respiratory,  that  is  transmission  of  the  breath,  the  larynx  being 
part  of  the  windpipe.  The  signs  of  disease  correspond  with  these 
functions.  Disorder  of  the  vocal  function  is  indicated  by  dysphonia; 
disorder  of  the  respiratory  function,  by  laryngeal  dyspnoea  and  laryngeal 
stridor.  To  these  must  be  added  a  third  sign,  wholly  adventitious, 
allied  to  voice  on  the  one  hand  and  to  breathing  on  the  other,  namely, 
a  peculiar  stridulous  or  laryngeal  cough. 

1.  Dii^phonia.  — As  the  voice  is  the  peculiar  function  of  the  larynx, 
so  dysphonia  is  the  pathognomonic  sign  of  laryngeal  disease.  Dysphonia 
relates  to  the  quality  or  to  the  loudness  of  voice,  (a)  When  the  quality 
of  the  voice  is  changed  it  is  called  paraphonia,  of  which  hoarseness  is 
the  commonest  form,  being  a  lesion  of  the  simple  glottic  sound  and  not 
of  the  articulated  voice.  (6)  When  the  loudness  of  the  voice  is  dimin- 
ished it  is  called  aphonia,  a  term  Avhich  implies  not  only  absolute  priva- 
tion of  voice,  but  also  any  degree  in  diminution  thereof.  When  aphonia 
is  complete  the  patient  can  speak  only  in  a  whisper^  whispering  being 
articulation  pure  and  simple  without  any  glottic  sound. 

2.  There  is  nothing  pathognomonic  about  the  disordered  respiratory 
functions  met  with  in  laryngeal  disease.  Laryngeal  stridor  and  dyspnoea 
have  to  be  distinguished  from  other  forms  of  stridor  and  dyspnoea;  and 
this  can  be  done  by  determining  the  presence  or  absence  of  certain  by- 
symptoms  (signa  assidentia).  (a)  By  stridor  is  meant  a  sound  which  is 
produced  in  the  windpipe  (larynx,  trachea,  bronchi)  by  breathing,  and 
which  can  be  heard  without  auscultation.  Stertor,  on  the  other  hand,  is 
a  soxmd  which  breathing  produces  in  the  parts  above  the  windpipe. 

1  For  exact  definition  of  the  word  Croup,  see  Medico-Chb'.  Trans,  for  1879,  vol.  Ixxii, 
p.  27. 


DIPHTHERIA 


747 


Narrowing  of  the  windpipe  is  the  cause  of  stridor,  and  its  loudness 
depends  upon  tlie  swiftness  of  the  air-currents ;  hence  when  the  narrow- 
ing of  the  air  passages  becomes  great,  and  the  air  currents  become 
correspondingly  weak,  stridor  diminishes  or  even  disappears.  The 
peculiar  quality  of  stridulous  breathing  is  a  fact  which  must  be  taught 
by  experience,  and  which  cannot  be  described  by  words,  (b)  The  char- 
acters and  associated  symptoms  of  laryngeal  dyspnoea  are  these :  —  (a) 
The  dyspnoea  is  chiefly  inspiratory  or  expiratory ;  usually  the  inspiratory 
movement  is  much  prolonged,  but  it  may  happen  that  the  expiration  will 
be  at  least  twice  as  long  as  inspiration,  (fd)  The  dyspnoea  affects  the 
movements  of  both  sides  of  the  chest,  inspiratory  dyspnoea  being  marked 
by  powerful  contraction  of  all  the  inspiratory  muscles,  and  by  recession 
of  the  yielding  parts  of  the  chest,  expiratory  dyspnoea  being  marked 
by  powerful  and  prolonged  contraction  of  all  the  expiratory  muscles, 
(y)  The  breath-sounds  heard  by  auscultation  are  weakened.  (8)  The 
nostrils  dilate  during  inspiration  or  expiration,  or  are  permanently 
dilated,  (e)  The  up  and  down  movements  of  the  larynx  (depressed 
during  inspiration)  which  attend  respiration  are  much  increased  in 
laryngeal  dyspnoea;  similar  movements  of  the  lower  jaw  are  some- 
times to  be  seen.  (^)  The  radial  pulse  is  withdrawn  from  the  linger 
during  inspiration  in  severe  laryngeal  dyspnoea. 

3.  The  stridulous  cough  (or  croupy  cough),  a  most  important  sign  of 
laryngeal  disease,  does  not  admit  of  being  described  in  words. 

IV.  Course  of  Disease.  —  In  a  case  of  diphtheritic  croup  dysphonia 
and  stridor  mostly  precede  dyspnoea,  inasmuch  as  dyspnoea  requires  a 
greater  amount  of  disease  than  suffices  for  the  production  of  dysphonia 
and  stridor.  The  voice  is  more  or  less  weakened  (aphonia)  and  husky 
(paraphonia),  yet  in  strict  truthfulness  it  must  be  said  that  sometimes  the 
voice  is  very  little  affected,  or  even  not  at  all.  The  breathing,  instead  of 
being  silent,  becomes  dry  and  husky,  characters  more  marked  in  inspira- 
tion than  in  expiration.  The  cough  is  usually  dry  and  husky ;  sometimes 
it  is  loose;  and  sometimes  there  is  a  loud  barking  cough  {tussis  ferina)  ; 
the  noisier  the  cough  the  less  the  obstruction. 

Dyspnoea  follows,  often  the  day  afterwards ;  but,  as  a  rule,  it  does  not 
attain  a  high  degree  for  another  day,  or  even  for  two  or  more  days  after 
its  onset.  There  are  no  remissions,  worthy  so  to  be  called,  in  the 
dyspnoea ;  when  once  it  sets  in  it  abides,  except  that  it  sometimes  abates 
shortly  before  death.  Moderate  dyspnoea  may  at  any  time  become 
suddenly  very  great  so  as  to  demand  instant  tracheotomy.^  In  adults 
the  dyspnoea  comes  on  later,  progresses  less  rapidly,  and  is  less  severe 
than  is  the  case  with  children  —  the  reason  of  the  difference  being 
due  chiefly  to  the  relatively  small  size  of  the  glottis  in  children,  but 
partly  to  the  more  powerful  inspiration  of  the  adult,  and  to  his  smaller 
liability  to  collapse  of  lung. 

1  SlionUl  the  reader  require  a  pioturesqno  description  (in  the  style  of  Aretaeus)  of  the 
dyspnrna  of  r^roup,  he  may  refer  to  'I'roussean,  who  lias  performed  this  work  once  for  all 
(Trou.'jseau,  (Jlin.  Mid.,  New  Sydenham  Soc.  vol.  ii.  p.  477). 


748  SYSTEM   OF  MEDICINE 

V.  Comitant  Symptoms.  —  1.  The  lividity  of  the  patient  is  not 
exactly  proportionate  to  the  dyspnoea.  Sometimes  there  is  but  little 
lividity,  or  even  none  at  all,  though  the  dyspnoea  be  permanent  and  at 
intervals  great.  Lividity  is  often  due  in  part  to  associated  pulmonary 
disease,  bronchitis  (catarrhal  or  diphtheritic),  congestion  of  lungs,  or 
collapse. 

2.  The  fever  is  not  high.  Indeed,  the  temperature  is  often  normal, 
or  even  subnormal,  especially  when  the  lividity  is  great.  When  the 
lividity  is  not  great  the  temperature  may  rise  to  102^^,  or  if  the  fauces 
be  affected,  even  higher.  Scarcely  need  it  be  said  that  tracheotomy 
interferes  with  the  course  of  temperature. 

3.  The  fauces  often  look  healthy,  but  even  upon  apparently  healthy 
fauces  specific  bacilli  may  breed.  In  some  cases  small  or  extensive 
false  membranes  Avill  be  seen. 

4.  Puffiness  on  one  or  both  sides  of  the  neck  may  exist,  or  even  an 
enlarged  gland  or  two,  the  fauces  being  natural. 

5.  Albuminuria  is  common,  yet  sometimes  there  is  none  even  in 
fatal  cases.  There  is  often  an  excess  of  flocculent  deposit  containing 
leucocytes. 

6.  Symptoms  of  the  virulent  kind,  due  to  poisoning  of  the  blood,  do 
not  occur.  Paralysis  (except,  perhaps,  glottic  paralysis)  does  not  follow 
diphtheritic  laryngitis,  yet  the  patellar  tendon  reflex  will  sometimes  be 
lost  for  a  long  time  after  an  attack  of  membranous  croup  in  persons 
who  were  known  to  have  such  a  reflex  before  they  suffered  from  diph- 
theria. 

Prognosis. — 1.  Tlecovery  occurs  in  a  very  small  proportion  of  the 
cases  of  laryngitis  which  have  been  proved  to  be  diphtheritic  by  the  ex- 
pectoration of  false  membrane,  or  by  the  comitant  affection  of  the 
fauces.^  Tracheotomy  saves  a  few  lives,  but  recovery  may  occur  with- 
out tracheotomy.  The  younger  the  patient  the  smaller  the  chances  of 
life,  for  reasons  which  have  been  already  referred  to  when  speaking  of 
dyspnoea ;  but  even  children  of  less  than  a  year  old  may  escape  with  life, 
after  having  expectorated  false  membrane. 

The  feeble  and  husky  voice  and  croupy  cough  will  remain  for  a  week 
or  more  after  the  dyspnoea  has  ceased,  both  in  cases  which  have  under- 
gone tracheotomy  and  those  which  have  not.  The  laryngoscope,  when  it 
can  be  used,  does  not  always  afford  an  explanation  of  these  symptoms. 

Recovery  after  tracheotomy  is  sometimes  imperfect,  that  is  to  say, 
the  tube  cannot  be  removed ;  the  reasons  of  this  will  be  given  hereafter. 

Relapse  occurs  in  rare  cases ;  the  patient  has  survived  the  worst 
period  of  the  disease,  and  seems  to  be  convalescent,  although  not  quite 
well,  when  the  diphtheria  breaks  out  again  in  full  vigour,  and  will  proba- 
bly kill  the  weakened  patient. 

Diphtheritic  croup  very  seldom  recurs  after  an  interval  of  perfect 
health.     But  it  is  a  disease  which  does  not  often  give  the  patient  a 

1  The  serum  treatment  enables  us  to  give  a  very  much  more  favourable  prognosis  in 
cases  of  laryngeal  diphtheria:  see  the  last  chapter. 


DIPHTHERIA  749 


chance  of  undergoing  it  a  second  time.  The  croup  which  recurs  is  of 
the  catarrhal  and  spasmodic  kind. 

2.  Death  is  due  to  one  of  two  causes,  either  to  laryngeal  or  to  pul- 
monary dyspnoea. 

(a)  Laryngeal  dyspnoea  is  a  cause  of  death  which  is  now  usually  pre- 
vented by  tracheotomy.  The  duration  of  cases  which  are  fatal  without 
tracheotomy  is  two,  three,  or  four  days  from  the  onset  of  the  croupy 
symptoms.  Unfavourable  conditions  which  aggravate  the  fatal  tendency 
of  croup  are  infancy  and  rickets,  for  reasons  which  are  sufficiently 
obvious. 

(/8)  Pulmonary  dyspnoea  is  due  to  many  causes  :  —  (i.)  Extension  of 
the  inflammation  downwards  into  the  lungs,  the  smaller  air-tubes  becom- 
ing choked  by  false  membrane,  or  more  commonly  by  creamy  muco-pus ; 
upon  this  condition  lobular  pneumonia  (catarrhal  or  broncho-pneumonia) 
is  very  apt  to  supervene,  (ii.)  Congestion  of  the  lungs,  which  occurs 
when  the  lungs  cannot  inspire  more  than  from  one-fourth  to  one-half  of 
their  normal  supply  of  air.  (iii.)  Collapse  of  lungs  more  or  less  extensive, 
(iv.)  Acute  emphysema  (or  insufflation)  of  the  front  part  of  the  lungs 
beneath  the  sternum  and  the  neighbouring  cartilages,  (v.)  Inability  to 
cough  and  consequent  retention  of  secretions,  (vi.)  Pneumothorax, 
which  is  not  uncommon  in  fatal  cases  which  have  undergone  tracheotomy. 

Pulmonary  dyspnoea  mostly  sets  in  from  four  to  seven  days  from  the 
onset  of  the  croup.  Hence  it  is  especially  seen  in  cases  of  tracheotomy, 
because  other  cases  of  laryngeal  diphtheria  by  the  end  of  the  first  week 
are  either  dead  or  recovering.  The  dyspnoea  sometimes  becomes  very 
great  all  at  once. 

The  signs  of  pulmonary  affection  are  these :  —  (i.)  Increase  of  fever, 
especially  in  bronchitis  and  pneumonia,  (ii.)  Physical  signs  of  bron- 
chitis, extensive  collapse,  insufflation  of  lungs,  or  pneumothorax,  (iii.) 
Expectoration  from  canula  becomes  more  or  less  abundant  or  sticky,  or 
even  purulent  if  the  patient  live  long  enough,  (iv.)  The  dyspnoea 
follows  one  of  two  courses:  (a)  Either  it  recurs,  and  becomes  as  great 
as  before,  so  that  nothing  whatever  is  gained  by  having  substituted,  by 
means  of  tracheotomy,  pulmonary  for  laryngeal  dyspnoea.  Conscious- 
ness being  retained,  the  patient  suffers  as  much  distress  after  the  trache- 
otomy as  he  suffered  before  it.  (^)  Or  vital  debility  prevails,  there 
being  no  great  dyspnoea,  but  the  respiration  becoming  very  frequent, 
and  the  pulse  very  small  and  weak.  Lividity  steadily  increases.  The 
animal  constitution  soon  suffers ;  drowsiness  ensues,  the  patient  being 
almost  continually  asleep  unless  disturbed  by  cough;  sleepiness  passes 
into  coma  and  death,  which  is  easy  and  without  dyspnoea. 

Tracheal  Diphtheria.  —  Now  and  then  a  case  will  be  met  with  in  which 
the  disease  is  almost  limited  to  the  trachea. 

The  tracheitis  is  not  primary,  but  is  preceded  by  a  diphtheritic 
affection  of  the  fauces  or  larynx,  which  may  have  been  slight  or  severe, 
(i.)  The  y)rimary  sore  throat  may  be  attended  by  the  least  possible  ex- 
udation, and  the  laryngitis  be  indicated  by  nothing  more  than  a  little 


750  -  SYSTEM  OF  MEDICINE 

hoarseness,  and  perhaps  a  few  shreds  of  false  membrane  seen  by  the 
laryngoscope.  In  about  seven  days  from  the  first  signs  of  illness  the 
patient  begins  to  expectorate  casts  from  the  trachea,  (ii.)  Or,  after  a 
severe  and  regular  attack  of  diphtheritic  angina  and  croup  (which  will 
in  some  cases  have  rendered  tracheotomy  necessary),  the  patient  seems 
to  be  fairly  convalescent,  when  the  disease  relapses  in  the  tracheal  form, 
expectoration  of  false  membrane  occurs,  but  no  recurrence  of  angina 
faucium  or  of  laryngitis. 

This  tracheal  diphtheria  often  deserves  the  name  of  chronic,  the 
patient  expectorating  casts  of  the  trachea  from  time  to  time  for  two 
months  or  even  longer  from  the  beginning  of  the  disease.  Albuminuria, 
amblyopia,  and  paralytic  symptoms  may  occnr.  The  prognosis  is 
doubtful ;  some  patients  die  in  one  way  or  another,  and  some  survive. 

Diagnosis.  —  1.  Catarrhal  laryngitis  (catarrhal  croup)  and  diphtheritic 
laryngitis  cannot  be  distinguished  during  life  unless  false  membrane 
be  coughed  up,  or  be  seen  upon  the  larynx  or  fauces.  Catarrhal  croup 
is  never  fatal,  however  severe  the  dyspnoea  be  for  a  time,  unless  the 
inflammation  spread  to  the  bronchi  so  that  the  patient  really  dies  from 
suffocating  bronchitis.  A  case  of  croup  which  becomes  steadily  worse 
is  probably  diphtheritic.  But,  on  the  other  hand,  what  seems  to  be 
catarrhal  croup  may  be  diphtheria  in  its  slightest  form. 

2.  The  respiratory  stridor  in  some  cases  of  catarrhal  croup  is  exces- 
sive, and  reaches  a  height  of  noisiness  which  is  uncommon  in  diphtheritic 
croup.  This  stridulous  laryngitis  is  especially  apt  to  occur  in  measles 
just  before  the  rash  comes  out;  the  dyspnoea  and  distress  of  the  patient 
are  great ;  the  rash  appears,  and  the  croupy  symptoms  speedily  subside. 
The  croup  which  occurs  in  measles  from  four  to  fourteen  days  after  the 
appearance  of  the  rash  is  a  more  serious  disease ;  it  often  renders 
tracheotomy  necessary,  and  is  usually  laryngeal  diphtheria. 

3.  Spasmodic  croup  (spasmodic  laryngitis,  Millar's  acute  asthma  for 
the  most  part)  is  distinguished  from  other  kinds  of  croup  on  account  of 
a  peculiarity  in  the  course  of  the  dyspnoea.  The  onset  (as  in  all  sorts 
of  croup)  is  marked  by  dysphonia  and  stridor.  Dyspnoea  soon  follows 
and  attains  a  high  degree,  especially  in  the  middle  of  the  night.  After 
urgent  dyspnoea  has  lasted  from  half  an  hour  to  two  hours  it  begins  to 
abate,  and  soon  becomes  slight,  the  dysphonia  and  stridor  continuing. 
Such  attacks  of  dyspnoea  are  prone  to  recur  for  two  or  three  nights  in 
succession,  each  fit  being  less  severe  than  the  foregoing.  Now  and  then 
(but  very  seldom)  diphtheritic  croup  will  take  on  the  spasmodic  form, 
wherefore  it  is  prudent  not  to  be  too  confident  in  pronouncing  at  first 
upon  the  benignant  nature  of  spasmodic  croup.  Laryngismus  stridulus 
cannot  possibly  be  mistaken  for  diphtheritic  croup. 

4.  When  a  child  has  inhaled  a  foreign  body  which  sticks  in  the 
larynx,  and  when  the  history  of  the  occurrence  of  the  accident  is  wanting 
or  untrustworthy,  it  is  easy  to  mistake  such  a  case  for  croup.  It  will 
hardly  be  possible  to  gain  any  help  from  the  laryngoscope.  At  the  in- 
stant of  the  foreign  body  entering  the  glottis  urgent  dyspnoea  occurs,  so 


DIPHTHERIA  751 

that  an  attack  of  laryngismus  is  simulated,  and  the  patient  may  die  on 
the  spot.  But  if  he  survive  the  dyspnoea  abates,  and  then  the  case  sim- 
ulates croup.  The  diagnosis  sometimes  cannot  be  made  until  after  tra- 
cheotomy by  exploring  the  larynx  by  means  of  a  probe  passed  upwards 
through  the  wound. 

5.  Exacerbations  of  dyspncea  occurring  in  children  suffering  from 
pectoral  diseases,  such  as  hydrothorax  and  acute  pulmonary  consumption, 
sometimes  strongly  simulate  croup ;  and  the  more  so  when  the  dyspnoea 
is  attended  by  a  husky  cough. 

6.  In  the  case  of  adults  the  diseases  most  likely  to  simulate  laryn- 
geal diphtheria  are  sundry  forms  of  laryngitis,  oedema  glottidis,  laryn- 
geal paralysis  coming  on  suddenly,  and  hysterical  laryngismus.  But  in 
adults  the  laryngoscope  is  available. 

Treatment.  —  Inasmuch  as  we  cannot  apply  germicides  to  the  air- 
passages,  and  as  we  possess  no  antidote  to  diphtheritic  poison  in  the 
blood,  it  follows  that  for  us  no  direct  specific  treatment  of  laryngeal 
diphtheria  is  possible.^  Moreover,  very  little,  short  of  tracheotomy,  can 
be  done  to  mitigate  the  most  distressing  symptom.  To  surround  the 
patient  with  pure,  warm,  and  somewhat  moist  air  Avould  seem  to  be  indi- 
cated by  common  sense.  The  only  local  application  which  can  be  recom- 
mended is  that  of  ice  or  of  ice-cold  water  to  the  front  of  the  neck. 
Emetics  are  best  avoided ;  they  empty  the  stomach  of  food,  and  any  good 
they  may  do  to  the  dyspnoea  is  very  temporary ;  usually  they  do  no 
good  at  all. 

When  the  dyspnoea  becomes  considerable  the  remedy  of  tracheotomy 
must  not  be  deferred  too  long.  It  removes  the  laryngeal  dyspnosa,  but 
lividity  often  persists,  and  pulmonary  dyspnoea  often  supervenes  and  kills 
the  patient,  as  has  been  already  described.  Tracheotomy  is  sometimes 
followed  by  evils  of  its  own,  for  example  (i.)  Emphysema  of  the  medi- 
astinum, due,  according  to  Dr.  Champneys,  to  the  fascia  being  stripped  off 
from  the  trachea  in  the  operation,  (ii.)  Pneumothorax  and  Mediastinal 
Suppuration  are  apt  to  follow  emphysema  of  the  mediastinum,  (iii.) 
Thrombosis,  starting  from  veins  injured  during  the  operation,  and  pos- 
sibly extending  so  far  as  the  right  auricle,  (iv.)  Embolism  of  a  large 
branch  of  the  pulmonary  artery,  possibly  followed  by  gangrene  of  the 
corresponding  portion  of  lung.  (v.)  Ulceration  of  the  trachea,  due 
to  irritation  set  up  by  the  end  of  the  canula.  (vi.)  Sloughing  of  phage- 
daenic  ulceration  due  to  septic  infection  of  the  wound. 

Tracheotomy,  although  it  usually  raises  the  temperature  of  the  body, 
does  not  always  do  so.  It  is  a  bad  sign  when  the  nostrils  act  strongly, 
or  when  the  breathing  through  the  canula  becomes  sawing  or  hissing. 

Young  children  after  tracheotomy  should  be  fed  by  means  of  an  india- 
rubber  catheter  passed  through  a  nostril  into  the  oesophagus,  and  the 
same  method  should  be  employed  in  all  cases  which  show  any  tendency 
for  the  drink  swallowed  to  pass  into  the  larynx. 

The  tube  should  be  removed  as  soon  as  possible,  nor  is  it  too  early  to 
1  Refer  to  the  last  chapter  upon  ihe  Serum  Treatment. 


752  SYSTEM  OF  MEDICINE 


make  the  attempt  within  twenty-four  hours  after  the  operation.  But 
sometimes  the  tube  cannot  be  removed  for  a  long  time  after,  or,  indeed, 
cannot  be  removed  at  all.  The  cause  of  the  difficalty  is  not  always  the 
same.  An  abundant  growth  of  gra,nulations  sometimes  obstructs  the 
windpipe  about  the  wound ;  this  is  said  to  be  especially  the  case  when 
the  cricoid  cartilage  has  been  divided.  Cicatricial  contraction  of  the 
windpipe  above  or  below  the  wound  is  another  possible  cause  of  obstruc- 
tion. The  trachea  is  sometimes  dislocated  backwards,  so  that  the  chan- 
nel of  the  wiadpipe  below  the  wound  is  not  continuous  with  that  above. 
But  in  many  cases  it  is  hard  to  say  wliat  the  cause  of  tlie  difficulty  is, 
and  little  or  no  help  can  be  gained  from  the  use  of  the  laryngoscope. 
Paralysis  of  the  glottic  dilators  is  an  explanation  possible  in  some 
patients ;  in  some  the  emotion  of  fear  seems  to  play  a  large  part  in 
aggravating  any  distress  which  follows  removal  of  the  tube.  In  many  of 
these  doubtful  cases  time  alone  will  suffice  to  cure. 

The  use  of  tubage  or  intubation  of  the  glottis  is  a  topic  which  hardly 
needs  to  be  discussed  with  reference  to  diphtheritic  laryngitis.  In  this 
disease  tubage  is  not  a  reasonable  method  of  treatment  unless,  in  a  given 
case,  we  know  that  the  exudation  is  confined  to  the  larynx  and  will  not 
spread  beyond  it.^  But  these  are  certainties  to  which  we  cannot  attain, 
and  in  practice  we  have  nothing  more  to  guide  us  than  probabilities 
which  may  be  high  or  which  may  be  low. '  If  we  can  believe  that  the 
croup  is  not  membranous,  or  that,  if  membranous,  the  disease  does  not 
extend  below  the  larynx,  we  may  be  disposed  to  try  intubation,  but 
always  with  the  prospect  of  having  to  perform  tracheotomy  afterwards. 
My  own  opinion  is  that  tracheotomy  should  be  preferred  in  all  cases. 
Difficulties  and  dangers  attend  tracheotomy,  and  tubage  is  not  free 
from  them.  What  are  called  statistics  are  of  little  value  in  determining 
the  relative  merit  of  the  two  operations,  and  are  of  no  value  at  all,  if 
among  successful  intubations  are  to  be  reckoned  cases  in  which  the  tube 
passed  out  per  anum. 

C.   Nasal  Diphtheria 

Diphtheritic  membranes  in  the  nose  are  often  associated  with  diph- 
theria of  the  fauces,  a  combination  which  usually  indicates  a  severe  form 
of  the  disease,  but  not  ahvays.  Very  slight  pellicular  sore  throat,  so 
slight  that  its  diphtheritic  nature  is  doubtful,  may  be  attended  and  fol- 
lowed by  puriform  discharge  from  the  nose,  the  patient  in  all  other 
respects  seeming  to  be  in  good  health ;  and  yet  this  discharge  will  be 
capable  of  conveying  diphtheria  to  other  people.  Still  the  rule  is,  as 
aforesaid,  that  diphtheria  affecting  both  throat  and  nose  is  malignant 
or  pestilent  diphtheria. 

Diphtheria  sometimes  affects  the  nose  alone,  so  far  as  can  be  made 
out.    The  sign  of  this  form,  as  of  all  forms,  of  nasal  diphtheria  is  stuffing 

1  See  the  last  chapter  on  the  Serum  Treatment. 


DIPHTHERIA  753 

of  the  nose  and  a  puriform  discharge,  sometimes  offensive,  sometimes 
bloody,  and  often  very  irritant  to  the  nostrils  and  upper  lip.  Tlie 
haemorrhage  is  sometimes  sufficient  to  weaken  the  patient,  or  even  to  be 
the  cause  of  deatli.  The  redness  and  swelling  may  spread  from  the 
nostrils  so  as  to  affect  the  whole  nose  and  the  eyelids.  The  swelling  is 
sometimes  attended  by  erysipelatous  redness  of  the  skin.  Yet  it  may 
happen  that  there  shall  be  no  discharge,  and  stuffiness  be  the  only  sign 
of  nasal  disease.  Very  seldom  do  membranes  come  away  so  as  to  be 
discovered  in  the  discharge ;  they  can  sometimes  be  seen  by  inspection 
of  the  nasal  fossae,  more  commonly  they  are  limited  to  the  hinder  parts 
of  those  cavities. 

The  glands  at  the  angle  of  the  jaw  tend  to  be  swollen,  tender,  and 
painful.  Should  one  nostril  alone  be  affected  the  glands  will  be  enlarged 
upon  the  same  side. 

The  general  symptoms  of  diphtheria  confined  to  the  nose  are  usually 
marked  enoiigh,  but  they  are  often  supposed  to  be  due  to  a  common 
cold  in  the  head,  and  are  not  much  attended  to.  Albuminuria  is  usually 
present  during  the  time  of  the  nasal  discharge,  and  even  for  some  time 
afterwards.  Paralysis  will  follow  in  some  cases,  and  may  present  this 
peculiarity,  that  the  fauces  are  not  affected  even  although  the  limbs 
suffer  severely 

Nasal  diphtheria  is  to  be  treated  upon  the  same  principles  as  f  aucial 
diphtheria. 

D.   Other  Local  Forms  of  Diphtheria 

Otitis  media  is  sometimes  diphtheritic,  and  false  membranes  are 
found  in  the  tympanum  after  death.  The  amount  of  associated  f aucial 
disease  may  be  considerable  or  may  be  slight,  even  so  slight  that  its 
nature  is  doubtful.  The  signs  of  otitis  are  the  same  as  those  of  other 
forms  of  the  disease.  The  diagnosis  depends  upon  the  discovery  of 
diphtheria  elsewhere.  Erysipelas  of  the  ear  and  neighbouring  parts 
sometimes  follows  upon  rupture  of  the  tympanic  membrane.  Chronic 
otorrhoea  may  ensue. 

A  portion  of  the  skin  which  is  excoriated  or  blistered  is  prone  to  be 
attacked  by  diphtheria  in  a  patient  already  suffering  from  that  disease; 
the  membrane,  if  thick,  looks  very  much  like  a  layer  of  lard.  The  skin 
around  is  often  erysipelatous. 

A  granulating  wound  is  very  seldom  attacked,  the  wound  of  tracheot- 
omy often  becomes  foul  and  phagedgenic,  but  anything  like  false  mem- 
brane is  rarely  or  never  seen. 

Conjunctival  diphtheria  (which  is  said  to  be  sometimes  due  to  the 
di.sease  spreading  up  the  lachrymal  passages),  and  diphtheria  of  the 
vulva,  vagina,  anus,  or  prepuce,  are  diseases  very  uncommon  in  England. 

The  oesophagus  is  seldom  affected.  This  form  of  disease  affords  no 
characteristic  symptoms,  and  is  usually  not  suspected  during  life  unless 
a  membranous  cast  be  rejected. 

VOL.  I  3  c 


754  SYSTEM  OF  MEDICINE 

Diphtheria  of  the  stomach  has  been  referred  to  in  the  chapter  on 
vomiting. 

E.   Latent  Diphtheria 

The  diphtheritic  poison  may  affect  the  throat  without  being  revealed 
by  the  formation  of  false  membrane.  In  this  case  the  mucous  membrane 
is  either  red,  swollen,  tender  and  painful,  or  it  looks  quite  natural. 
The  former  condition  cannot  be  distinguished  from  simple  inflamed  or 
catarrhal  sore  throat,  unless  there  be  good  reason  for  believing  that  the 
patient  has  been  exposed  to  the  operation  of  the  diphtheritic  poison, 
unless  the  specific  bacillus  be  found  in  the  secretions,  unless  the 
patient  convey  diphtheria  to  some  neighbour,  or  unless  the  peculiar 
paralytic  symptoms  follow  what  seemed  to  be  a  common  sore  throat. 
After  a  manifest  attack  of  diphtheritic  angina  faucium  the  throat  may 
seem  to  have  returned  to  its  normal  condition,  and  yet  the  microscope 
may  discover  the  specific  bacillus  in  the  secretions,  even  after  a  con- 
siderable time  (seven  months  it  is  said)  has  elapsed  since  the  cessation 
of  the  disease. 

Diphtheria  of  the  larynx  is  often  latent ;  that  is  to  say,  a  patient  has 
croup,  and  from  first  to  last  it  is  impossible  to  say  whether  the  disease 
be  diphtheritic  or  not. 

Latent  nasal  diphtheria  is  either  primary  or  secondary :  (i.)  A  patient 
has  a  discharge  from  one  or  both  nostrils,  which  is  deemed  at  first  to  be 
a  simple  coryza,  and  which,  if  the  disease  last  several  weeks,  is  supposed 
to  be  due  to  syphilis,  disease  of  the  turbinate  bones,  or  of  the  maxillary 
antrum ;  and  surgical  proceedings  may  be  recommended,  But  the  debility 
of  the  patient  is  noted  to  be  greater  than  the  local  disease  can  account 
for,  or  the  urine  is  found  to  be  albuminous,  or  paralytic  symptoms  occur, 
and  thus  the  true  nature  of  the  disease  becomes  apparent,  (ii.)  The 
latent  nasal  diphtheria  which  is  secondary  to  a  manifest  attack  of  the 
disease  has  been  already  described. 

S.  Gee. 

Serum  Treatment 

As  explained  elsewhere  [see  art.  on  "  Serum  Therapeutics  "],  in  certain 
diseases  the  blood  serum  of  artificially  protected  animals,  if  injected  into 
others  still  susceptible,  has  a  protective  power ;  and  Behring  conceived 
the  idea  that  a  similar  treatment  might  be  adopted  in  diphtheria  (1). 
He  found  that  it  could  be  used  not  only  as  a  protecting  agent,  but  also 
as  a  cure  (2),  and  after  many  trials  he  succeeded  in  producing  a  serum 
strong  enough  to  be  of  use  for  man.  From  that  time  to  this  modifica- 
tions have  continually  been  introduced  by  Behring  himself  and  by 
others,  which  have  enabled  us  to  produce  stronger  and  stronger  prepara- 
tions of  the  serum:  to  describe  these  in  detail  is  beyond  the  scope  of 
the  present  article.  To  Aronson  we  owe  the  employment  of  horses, 
from  which  animals  the  serum  now  in  use  is  obtained. 

The  new  remedy  was  first  employed,  and  the  first  accounts  of  its 


DIPHTHERIA  755 

effects  were  published  by  Berlin  physicians  (3,  4).  Their  results  were 
confirmed  in  Paris  by  E,oux,  and  by  other  physicians  in  Germany. 
Since  then  it  has  been  used  all  over  the  world. 

It  is  unnecessary  now,  and  will  probably  be  still  less  needful  when 
these  words  are  published,  to  quote  at  length  the  great  number  of  clinical 
and  statistical  papers  on  which  our  judgment  has  been  formed.  They 
have  been  collected  and  excellently  analyzed  up  to  July  1895  by  Welch. 
No  one  man  has  published  finer  work  upon  the  subject  than  Baginsky, 
whose  book,  besides  resting  on  a  larger  number  of  cases  than  has  fallen 
to  the  lot  of  any  other  physician,  contains  the  most  cogent  proof  of  the 
value  of  the  serum  ever  yet  brought  forward.  Between  15th  March 
1894  and  15th  March  1895  he  treated  by  the  antitoxin  525  children 
up  to  fourteen  years  of  age,  of  whom  83,  or  15 '6  per  cent,  died.  The 
supply  of  serum  failed  about  August  and  September,  and  during  that 
time  126  children  were  treated  without  the  antitoxin,  of  whom  61,  or 
48*4  per  cent,  died.  When  the  serum  was  resumed  the  mortality  at 
once  fell  again.     The  higher  rate  is  about  the  level  of  previous  years. 

At  the  Eastern  Hospital  in  London  (8),  from  1st  January  1893  to 
22nd  October  1894,  797  patients  under  fifteen  years  of  age  were  treated 
by  the  old  methods,  of  whom  310,  or  38 '8  per  cent,  died.  From  23rd 
October  to  27th  November  1894,  72  such  patients  were  treated  by  the 
antitoxin,  of  whom  only  14,  or  19-4  per  cent,  died. 

At  St.  Bartholomew's  Hospital  (9)  we  treated,  during  1893  and  the 
first  part  of  1894,  95  cases  under  ten  years  of  age  with  50  deaths,  a  rate 
of  52-7  per  cent.  Between  1st  July  1894  and  8th  July  1895,  50  cases 
of  the  same  age  were  treated  with  the  antitoxin,  of  whom  only  8  died, 
a  rate  of  16  per  cent.  This  fall  in  the  death-rate  must  be  a  little  dis- 
counted ;  first,  because  proportionately  more  patients  were  admitted  in 
the  first  three  days  after  symptoms  were  noticed ;  and,  secondly,  because 
proportionately  fewer  patients  were  admitted  under  two  years  of  age 
during  the  second  period  than  during  the  first.  But  the  difference  thus 
made  is,  when  calculated,  slight,  and  if  by  grouping  like  cases  with  like 
the  numbers  are  more  closely  compared,  the  value  of  the  serum  is  more 
clearly  shown.  Thus,  of  cases  in  which  the  diphtheria  affected  together 
with  other  parts  the  nose  — 

During  the  first  period  28  died  out  of  39 
"  second  "       3     "  ''     12 

Of  cases  in  which  both  fauces  and  larynx,  but  not  the  nose,  were 
affected  — 

During  the  first  period  16  died  out  of  39 
"  second  "       4     "  "     20 

Of  tracheotomy  cases  — 

During  the  first  period  39  died  out  of  67 
"  second  "        6     ''  "     32 

Most  physicians  agree  that  under  this  treatment  the  local  symptoms 
clear  up  with  much  greater  rapidity  than  of  old.     That  the  disease  is 


756  SYSTEM  OF  MEDICINE 

also  robbed  of  its  power  on  the  constitution  is  proved  partly  by  the  great 
fall  in  the  death-rate  and  partly  by  clinical  observation.  It  does  not, 
however,  appear  to  influence  the  temperature  (9),  and  whether  paralysis 
occurs  less  often  now  is  still  doubtful.  Hayward  (9)  found  that  of  the 
above  50  cases  only  2  showed  any  trace  of  paralysis ;  however,  the  num- 
ber is  but  small,  and,  moreover,  the  average  rate  of  incidence  is  an 
unknown  quantity.  No  hospitals  retain  their  patients  long  enough  to 
settle  the  question,  and  I  have  had  many  out-patients  suffering  with 
these  symptoms  who  had  been  discharged  from  hospitals  as  cured. 
Albuminuria  is  certainly  not  more  —  in  our  case  it  was  rather  less  — 
frequent  under  this  treatment,  and  the  same  is  true  of  nephritis. 

Dr.  Gee  thinks  it  probable  that  intubation  will  now  be  of  more  use 
than  hitherto.  The  great  objection  to  intubation  has  been  that  it  affords 
no  egress  for  the  membranes  continuously  formed  in  the  trachea.  If 
by  serum  we  can  stop  the  formation  of  membrane  the  objection,  ceases 
to  be  valid.  . 

In  some  cases  the  injection  of  the  serum  is  followed  by  a  rash, 
erythematous  or  urticarious,  upon  the  skin  [see  also  art.  on  "  Serum 
Therapeutics"].  In  a  few  cases  there  is  itching,  but  it  has  no  other 
ill  effect,  and  it  passes  off  sometimes  within  a  few  hours,  sometimes 
within  a  few  days.  Less  often  —  we  have  never  seen  it  —  there  is  pain 
and  swelling  in  some  of  the  joints,  which  is  also  transient.  Both  these 
effects  are  due  rather  to  the  serum  than  to  the  antitoxin — whatever 
that  may  be — which  it  contains;  and  the  smaller  the  dose  of  serum 
the  less  likely  are  these  symptoms  to  occur. 

The  injections  are  best  made  deeply  into  the  buttock.  The  syringe 
must  be  such  that  it  can  be  perfectly  sterilised  by  boiling,  and  should 
hold  at  least  10  c.c.  It  is  best  to  connect  it  with  the  needle  by  an  india- 
rubber  tube.  The  whole  should  be  boiled  before  each  injection,  and  the 
skin  washed  first  with  soap  and  water,  and  then  with  a  -^-^  solution  of 
carbolic  acid.  The  puncture  should  afterwards  be  covered  with  a  small 
piece  of  isinglass  plaster,  or  similar  protective  [see  art.  on  "Serum  Thera- 
peutics "].  The  dose  varies  with  the  different  preparations  of  serum. 
Of  Klein's  serum,  which  we  are  now  using  at  St.  Bartholomew's  Hospital, 
we  give  5-8  c.c.  once  or  twice  daily  for  several  days,  or  even  oftener, 
according  to  the  severity  of  the  case.  In  serious  cases  the  treatment 
must  be  pushed  to  get  the  full  effect  immediately,  or  as  quickly  as  pos- 
sible. Especially  where  there  is  broncho-pneumonia  the  injections  should 
be  practised  energetically ;  for  Dr.  Kanthack  and  Mr.  J.  W.  W.  Stephens 
have  shown  that  in  such  cases  the  lungs  generally,  if  not  always,  contain 
the  diphtheria  bacilli  in  enormous  numbers ;  in  other  words,  the  amount 
of  poison  to  be  rendered  harmless  is  very  considerable  (vide  supra).  The 
strongest  serum  is  the  best.  "W".  P.  Hekkingham. 

REFERENCES 

1.  LoNGSTAFF,  G.  B.,  M.A.  Oxon.  Studies  in  Statistics.  London,  Edward  Stan- 
ford, 1891.  — 2.  Thorne  Thornb,  R.,  M.B.,  &c.    "On  the  Origin  of  Infection,"  Trans- 


DIPHTHERIA  'jyj 


actions  of  the  Epidemiological  Society  of  London,  vol.  iv.,  Sessions  1875-80.  —  3.  Thorne 
Thorne,  R.,  C.B.,  M.B.,  F.R.S.  —  Diphthena :  its  Natural  History  and  Prevention, 
being  the  Milroy  Lectures  delivered  before  the  Royal  College  of  Physicians  of  London, 
1891.  Macmillan  and  Co. — 4.  "Presidential  Address  to  the  Epidemiological  Society," 
Session  1894-95.  See  Transactions  of  the  Society.  —  5.  Power,  Mr.  W.  H.  Report  to  the 
Local  Government  Board  on  an  Epidemic  of  Diphtheria  in  North  London,  December 
1878. — 6.  Diphtheria:  its  Natural  Hist07'y  and  Prevention.  Milroy  Lectures,  1891. 
Macmillan  and  Co.  —  7.  Report  of  the  Medical  Officer  of  the  Local  Goveriiment  Board 
/or  1889.  —  8.  Repoj'ts  on  Seiver  Air  Investigations.  By  J.  Parry  Laws,  F.I.C.  Presented 
to  the  London  County  Council,  1893.  Steel  and  Jones,  4  Spring  Gardens,  S.W.  — 9.  These 
publications  are  issued  by  Messrs.  J.  and  A.  Churchill,  New  Burlington  Street,  London. 

E.  T.  T. 

10.  HiRSCH,  August.  Handhook  of  Geographical  and  Historical  Pathology.  Trans- 
lated by  Charles  Creighton.  New  Syd.  Soc.  1886,  vol.  iii.  chap.  5.  — 11.  Haeser,  Hein- 
RiCH.  Lehrhuch  der  Geschichte  der  Medicin :  dritte  Aufl.  Jena,  1882,  vol.  iii.  pp.  428 
et  passim..  — 12.  Index  Catalogue  of  the  Library  of  the  Surgeon-General's  Office,  United 
States  Army,  vol.  iii.  Washington,  1882.  And  its  continuation,  the  Index  Medicus. — 
13.  Bretonneau,  Pierre.  —  Des  inflammations  speciales  du  tissu  muqueux,  et  en  par- 
ticuUer  de  la  Diphthe'rite,  ou  Inflammation  Pelliculaire,  connue  sous  le  nom  de  croup, 
d'angine  maligne,  d'angin.e  gangreneuse,  etc.  Paris,  1826.  — 14.  Bretonneau,  Pierre. 
Memoirs  on  Diphtheria,  translated  by  Dr.  Sample  for  the  New  Sydenham  Society,  1859, 
p.  177. —  15.  Trousseau.  Clin.  Med.  (edit.  1865),  i.  380.  — 16.  Rabot  and  Philippe. 
"De  la  myocardite  diphteritique  aigue,"  Arch,  de  med.  exper.  vol.  iii.  p.  647.  — 17.  Jour- 
nal de  med.  et  de  chir.  pratiques,  vol.  Ixii.  p.  724.  Paris,  1891.  — 18.  Traite  de  med.  par 
Charcot  et  autres,  vol.  iii.  p.  221.    Paris,  1892.  ^ 

b.    (jr. 

Bacteriology  of  Diphtheria :  — 1 .  Papers  by  Dr.  E.  Klein  and  Dr.  Sidney  Martin 
in  Annual  Reports  of  the  Local  Gov.  Board  1891-92  and  1892-93.  —  2.  Dr.  Klein's  article 
in  A  Treatise  of  Hygiene,  by  Stevenson  and  Murphy.  —  3.  Th.  Escherich.  Diphtheria, 
Croup,  Serumtherapie.  —  4.  Numerous  papers  by  Roux,  generally  in  conjunction  with 
others,  in  Pasteur's  Annales.  —  5.  Loffler.  Mittheilungen  a.  d.  kaiserl.  Gesundheit- 
samte,  ii.  p.  439.  Babes  (in  Wiener  klin.  Wochenschr.  1889,  No.  14 ;  and  Tangl,  C'e?i- 
tralb.f.  Bakt.  und  Parasit.  vol.  x.  No.  1).^ — 6.  Councilman,  W.  T.  American  Journ. 
of  the  Med.  Sc.  1893,  vol.  cvi.  No.  5.  Williams,  F.  ibidem.  — 7.  A  very  good  summary 
on  the  Pseudo-diphtheria  bacillus,  with  full  literary  references,  will  be  found  in  the 
"Report  on  Bacteriological  Investigations  and  Diagnosis  of  Diphtheria,"  Scientific 
Bulletin,  No.  1,  Health  Department,  City  of  New  York,  1895,  pp.  31-49. —8.  For  refer- 
ences respecting  the  escape  of  the  diphtheria  bacillus  into  the  blood  and  tissues,  see 
J.  H.  Wright.  Boston  Med.  and  Surg.  Journ.  1894.  —  9.  Bribger  and  Frankel. 
Berlin  klin.  Wochenschr.  1S90.  Frankel,  ?;6icZe??i,  1893.  — 10.  Sidney  Martin.  Rep. 
of  the  Local  Government  Board,  1891-1892,  Supplement,  1892-1893,  Supplement.  — 
11.  Washbourn,  GooDALL,  and  Card.  Clinical  Society,  14th  Dec.  1894.  — 12.  Gabrit- 
SCHEvrsKY.  Ann.  de  I'lnst.  Pasteur,  1894.  Evting.  New  York  Med.  Journ.  10th  and 
17th  Aug.  1895.  Waldstein,  Berl.  klin.  Wochenschr.  1895,  No.  17.  Goldscheider 
and  Jacob.  Zeitschr.  f.  klin.  Med.  1894,  xxv.  p.  273.  Morse,  Bo.<tton  City  Hosp.  Med. 
:ind  Surg.  Reports  18!t5.  — 13.  Behring.    Die  Geschichte  der  Diphtheric.    Leipzig,  1893. 

Further  references  will  be  found  under  "  Immunity"  and  "  Serum  Therapeutics." 

A.  A.  K. 

Serum  Treatment:  —  !.  Behring.  Deutsche  med.  Wochenschr.  1890,  p.  1113. — 
2.  Behr/ng  and  Wernicke.  Zeitschr.  f.  Hygiene,  1892,  xii.  p.  11. — 3.  Heubner. 
Internnt.  Med,.  Congress.  Rome,  1894.  — 4.  Ehrlich,  Kossel,  and  Wassermann. 
Detitsche  med.  Woclienschr.  April  1894.  —  6.  Roux.  Internal.  Congress  of  Hygiene. 
Buda-Pesth,  1894.  —  6.  Welch.  Trans,  of  Assoc,  of  American  Phys.  1895,  vol.  x. — 
7.  Baginsky.  Die  Serum.  Thernpie  der  Diphtheria.  Berlin,  1895. — 8.  Washbourn, 
GooDALL,  and  Card.  Clin.  Trans.  1895,  xxviii.  p.  01.-9.  .S^^.  Burih.  Hosp.  Rep.  1895, 
voLxxxi.  W.   P.   H. 


758  SYSTEM   OF  MEDICINE 


TETANUS 

Syn.  —  Greek,  TeVavo?  (a  straining,  from  TetVw)  ;  Latin,  Uigor  Nervorum 
(Celsus) ;  Germ.,  StarrJcrampf. 

Tetanus  may  occur  in  any  person  of  either  sex,  at  any  age ;  it  may 
ensue  from  any  wound  at  any  part  of  the  body,  and  in  any  condition 
of  the  wound ;  or  without  any  apparent  wound.  It  less  often  follows 
wounds  of  the  trunk  than  of  the  extremities,  and  wounds  of  the  lower 
extremities  give  rise  to  it  more  frequently  than  those  of  other  parts ;  but 
it  does  not  appear  that  wounds  of  the  feet  or  hands  are  more  liable  to 
cause  it  than  those  of  other  parts  of  the  limbs.  On  the  whole,  however, 
it  occurs  more  frequently  in  parts  exposed  to  contact  with  earth  and  dirt. 
How  the  popular  but  mistaken  idea  arose  that  it  has  any  especial  rela- 
tion to  injuries  in  the  region  between  the  thumb  and  the  forehnger  is  not 
easy  to  tell.  It  is  most  likely  to  occur  in  cases  of  severe  or  lacerated 
wounds,  or  when  some  foreign  body  is  lodged  in  a  simple  incised  wound, 
or  in  compound  fractures  or  burns.  It  may  ensue  upon  a  mere  scratch ; 
the  slightest  Avounds,  such  as  those  caused  by  subcutaneous  injections; 
dilation  of  the  neck  of  the  uterus  by  a  sponge-tent ;  after  confinements 
(the  post-parturient  cases  are  said  to  be  especially  fatal) ;  after  cupping ; 
the  insertion  of  a  seton;  the  extraction  of  a  tooth;  the  injection  of  a 
hydrocele  ;  ^  or  the  plugging  of  a  nostril  for  epistaxis.  In  a  woman  in 
Addenbrooke's  Hospital  the  only  discoverable  local  lesion  was  a  chronic 
ulcer  of  the  leg.  It  has  also  been  known  to  take  place  after  complete 
cicatrisation  of  the  wound  (4).  In  horses  it  is  said  to  be  caused  by 
wounds  in  the  gums  from  eating  straAV ;  and  cases  supposed  to  be  idio- 
j)athic  may  have  originated  in  this  way.  It  is  liable  to  follow  exposure 
to  cold  and  a  damp,  chilly  atmosphere,  as  in  the  cases  of  wounded  sol- 
diers lying  upon  the  field  of  battle.  In  an  early  case  of  ovariotomy  in 
the  country,  long  before  the  days  of  antiseptic  surgery,  all  had  gone  on 
well,  the  wound  had  nearly  healed,  and  I  had  taken  my  leave  of  the 
patient,  when  tetanus  supervened  and  proved  fatal.  I  witnessed  another 
fatal  case  after  ovariotomy,  Avith  antiseptic  precautions,  performed  by 
the  late  Dr.  Meadows.  I  judge  that  the  disease  has  been  less  frequent 
since  the  introduction  of  the  antiseptic  method  in  the  treatment  of 
wounds ;  and  we  may  hope  that  this  immunity  Avill  be  still  more  observ- 
able as  the  new  methods  are  more  generally  and  completely  carried  out, 
and  a  more  thorough  cleansing  and  quicker  healing  of  wounds  effected. 

For  obvious  reasons  the  disease  is  more  frequent  in  men  than  in 
women,  and  it  is  said  to  be  less  fatal  in  women.  I  have  seen  three  cases 
in  women,  and  it  proved  fatal  in  all.  One  female  infant,  whose  case  is 
subsequently  mentioned,  recoA^ered.     It  is  most  frequent  between  the 

1  Gross  relates  that  in  a  lad  who  had  a  hruised  chin  with  a  small  ulcer  on  the  tonsiie 
probably  caused  at  the  same  time,  and  who  died  of  tetanus,  a  large  hydatid  was  found  in 
the  liver. 


TETANUS  759 


ages  of  ten  and  twenty,  and  is  rare  after  sixty  (20).  It  is  much  more 
common  in  warm  countries  than  intemperate  regions,  which  is  somewhat 
remarkable,  seeing  that  its  occurrence  in  the  latter  is  often  attributable 
to  exposure  to  cold  and  damp.  It  sometimes  occurs  as  an  epidemic.  Gross 
says  (I  do  not  know  upon  what  authority)  that  in  1858  it  appeared  in 
rapid  succession  in  several  of  the  London  hospitals.  Macnamara  (5) 
states  that  in  Bengal  tetanus  has  been  observed  to  occur  especially  after 
changes  of  temperature,  and  that  it  is  rarely  absent  from  the  hospitals 
of  Calcutta.  He  adds  that  within  a  period  of  five  years  83  cases  were 
treated  in  the  surgical  wards  of  the  Mayo  Hospital;  of  these  44  were 
traumatic,  and  24  (a  small  proportion)  died :  of  the  remaining  39  idio- 
pathic cases  10  died  (3,  21).  It  is  more  frequent  and  more  fatal  in 
military  than  in  civil  practice.  The  records,  however,  of  the  "  Great 
Rebellion"  (see  appendix)  are  more  favourable  than  those  usually 
given  of  the  results  in  civil  practice. 

G.  M.  H. 

Pathology.  —  Although  it  is  only  within  recent  years  that  any  proof 
of  the  bacterial  origin  of  tetanus  has  been  forthcoming,  this  disease  has 
for  some  time  been  classified  by  surgeons  amongst  the  specific  infective 
fevers  of  septic  origin.  Perhaps  one  of  the  most  remarkable  f oreshadow- 
ings  of  the  exact  nature  of  tetanus  is  given  by  Sir  James  Simpson  who, 
writing  in  1854,  says  :  "  Tetanus  is  known  to  follow  wounds  very  various 
in  their  degree  of  severity.  .  .  .  The  disease,  when  developed,  essentially 
consists  of  an  exalted  or  superexcited  state  of  the  reflex  spinal  system, 
or  of  some  segment  or  portion  of  that  system."  He  then  goes  on  to  say, 
"We  have  in  obstetric  pathology  evidence  almost  amounting  to  certainty 
that  the  analogous  superexcitable  state  of  the  cerebro-spinal  system  of 
nerves  which  gives  rise  to  eclampsia  or  puerperal  convulsions  is  gener- 
ally produced  by  the  existence  of  a  morbid  poison  in  the  blood.  And 
it  seems  not  impossible  that  the  generation  of  a  special  blood  ]3oison,  at 
the  site  of  the  wound  or  elsewhere,  may  sometimes  in  the  same  way 
give  rise  to  obstetrical  and  surgical  tetanus."  He  further  pointed  out 
that  the  symptoms  of  this  disease  are  comparable  to  those  produced  by 
strychnine  and  brucine.  It  was,  however,  found  impossible  by  clinical 
observation  to  determine  the  nature  of  this  poison,  and  it  was  not  until 
several  years  after  the  publication  of  Koch's  experiments  on  septicaemia 
that  this  poison  was  proved  to  be  the  result  of  the  activity  of  a  micro- 
organism which  had  found  a  nidus  in  injured  tissues. 

Most  of  the  earlier  experiments  were  directed  to  the  discovery  of 
micro-organisms  in  the  blood,  in  the  lymphatics  around  a  wound,  or  along 
the  course  of  the  pei'ipheral  and  central  nerves.  Simpson  says  that 
attempts  had  been  made  even  liefoi-e  his  time  to  reproduce  the  disease 
experimentally  by  injections  of  the  blood  of  patients  who  had  succumbed 
to  tetanus.  But  all  such  attempts  were  fruitless,  and  the  matter  was 
eventually  settled  by  a  very  different  line  of  experiment. 

Carle  and  Rattone,  iu  1884,  discovered  a  virus  in  tetanus  that  could 


76o  SYSTEM   OF  MEDICINE 

be  inoculated  from  man  to  animals  (of  twelve  rabbits  inoculated,  all 
except  one  Avere  attacked)  ;  they  regarded  this  virus  as  a  contagium 
vivum,  probably  a  bacterium.  In  the  following  year  ISTicolaier  published 
his  dissertation,  in  which  he  recorded  his  success  in  obtaining  from  pus 
a  virus  which  he  was  able  to  propagate  outside  the  living  organism ; 
he  also  found  that  certain  aniinals,  such  as  rabbits,  guinea-pigs  and  mice, 
when  inoculated  with  particles  of  soil  obtained  either  from  the  streets  or 
from  cultivated  land,  became  affected  by  symptoms  which  he  described  as 
tetanic  in  character  and  as  identical  with  those  observed  in  man.  This 
soil,  introduced  into  a  little  pocket  under  the  skin,  was  almost  invariably 
followed  by  an  abscess.  The  pus  in  this  abscess  was  found  to  contain 
several  species  of  micro-organisms,  one  of  which  (although  he  carried  on 
cultivations  for  seven  generations  he  could  never  obtain  absolutely  pure) 
he  identiiied  as  being  specially  active  in  setting  up  tetanic  convulsions. 
He  described  this  organism  as  a  small,  slender  bacillus,  somewhat  longer 
but  thinner  than  Koch's  bacillus  of  mouse  septicemia,  but  he  gave  no  fur- 
ther specific  features  of  identification.  In  1886  Rosenbach  corroborated 
and  established  Nicolaier's  observations,  by  inoculating  two  guinea-pigs 
with  pus  from  a  tetanic  patient,  which  produced  tetanic  muscular  con- 
traction like  that  invariably  produced  by  the  inoculation  of  Nicolaier's 
earth.  Eosenbach  also  produced  evidence  that  one  of  two  bacilli  was 
probably  the  cause  of  the  tetanic  condition  :  (a)  a  rapidly-growing,  thick 
bacillus,  which  developed  large  spores,  and  had  the  power  of  peptonising 
serum ;  (b)  a  slender  bacillus,  which  first  appeared  in  the  liquefied  serum, 
and  then  formed  spores.  He  agreed  Avith  ISTicolaier  that  the  tetanus 
bacillus  was  probably  the  small  and  slender  organism. 

It  Avas  not  till  1889  that  the  tetanus  bacillus  Avas  obtained  in  pure 
cultures  by  Kitasato,  and  also  by  Tizzoni  and  Cattani,  who  Avere  able  to 
separate  the  specific  tetanus  organism,  as  at  present  recognised,  from  the 
pus  of  the  abscesses  occurring  in  cases  of  tetanus,  and  from  the  tissues 
immediately  surrounding  these  abscesses.  Knud  Faber,  in  investiga- 
tions carried  on  about  the  same  time  as  those  of  Kitasato,  although  not 
successful  in  obtaining  a  pure  culture  of  the  tetanus  bacillus,  states  that 
his  experiments  support  Kitasato's  view  that  the  organism  is  an  obligate 
anaerobe.  He  Avas  the  first  to  obtain  by  filtration  of  very  virulent  tetanus 
cultures  a  perfectly  germ-free  filtrate  Avhich,  Avhen  inoculated  into  animals, 
reproduced  the  Avhole  of  the  disease  phenomena  of  experimental  tetanus. 

The  organism  described  by  these  authors,  and  noAv  recognized  as  the 
specific  cause  of  tetanus,  usually  occurs  as  delicate  threads,  and  it 
varies  in  length  from  4:  fx.  to  5  /x  long,  to  but  slender  threads ;  these 
are  slightly  thicker  than  the  bacillus  of  mouse  septicaemia  (one  of 
the  smallest  organisms  known),  and  the  ends  are  someAvhat  rounded. 
In  the  shorter  rods,  Avhich  are  non-motile  during  this  stage,  spores 
usually  make  their  appearance  at  blood  temperature  in  about  thirty 
hours  after  multiplication  has  commenced ;  but  at  the  temperature 
of  the  room  they  are  not  observed  until  about  a  week  has  elapsed 
from  the  commencement  of  the  groAvth,  although  the  organism  con- 


TETANUS  761 


tinues  to  grow  readily  enough  at  this  temperature.  Until  the  spores 
begin  to  form  the  threads  are  usually  motile,  and  the  segmentation 
into  short  rods  may  be  incomplete ;  but  as  soon  as  sporulation  com- 
mences the  segments  become  more  perfectly  marked  out,  they  become 
motionless,  and  a  clear  point  is  observed  at  one  end  of  the  rod;  this 
becomes  larger  and  larger  until  it  causes  marked  distension  of  the  end 
of  the  bacillus  in  which  it  is  developed,  and  thus  is  formed  what  is 
known  as  the  "pin-head"  or  "drum-stick"  bacillus.  This  organism 
grows  best  at  a  temperature  of  from  36°  C.  to  that  of  the  blood.  Below 
14°  C.  it  becomes  inactive :  at  42°  C.  to  43°  C.  it  also  becomes  less  active, 
and  undergoes  what  are  looked  upon  as  degenerative  changes,  involu- 
tion forms  being  pretty  constantly  developed ;  and  exposure  to  a  tem- 
perature of  from  60°  C.  to  65°  C.  rapidly  kills  off  the  bacillus,  but  does 
not  destroy  any  spores  that  may  have  been  formed.  These  spores  are 
exceedingly  resistant,  even  to  moist  heat,  as  they  can  withstand  the 
action  of  water  at  a  temperature  of  80°  C.  even  for  an  hour;  whilst 
steam  at  a  temperature  of  100°  C.  does  not  appear  to  be  fatal  to  them  in 
a  less  time  than  five  minutes.  It  is  also  stated  that  it  requires  fifteen 
hours  of  treatment  with  a  1  in  20  watery  solution  of  carbolic  acid,  or 
three  hours  with  a  1  per  1000  corrosive  sublimate  solution,  to  kill  them. 
Protected  from  air  and  light  the  spore  may  retain  its  vitality  for  as  long 
a  period  as  twelve  months,  at  the  end  of  which  time  it  still  appears  to  be 
capable,  under  certain  conditions,  of  developing  into  the  vegetative  form. 
The  tetanus  bacillus  is  anaerobic,  and  grows  best  in  an  atmosphere  of 
hydrogen ;  it  appears,  however,  to  be  almost  as  inactive  in  the  presence 
of  carbonic  acid  gas  as  in  the  presence  of  more  than  traces  of  oxygen. 

This  bacillus  is  stained  by  Gram's  method.  The  spores  are  best 
stained  by  leaving  them  for  some  time  in  a  10  per  cent  alcoholic  solution 
of  basic  fuchsin,  10  parts,  added  to  100  parts  of  a  5  per  cent  watery 
solution  of  carbolic  acid.  The  specimen  may  be  left  in  this  stain  for 
about  twelve  hours  ;  or  the  same  result  may  be  obtained  in  two  or  three 
minutes  if  the  solution  be  heated  until  steam  rises  from  it.  The  bacilli 
give  up  the  stain  in  25  per  cent  solutions  of  mineral  acids,  but  the 
spores  retain  it  firmly.  A  contrast  stain  is  obtained  by  placing  the 
specimen  for  a  couple  of  minutes  in  a  watery  solution  of  methylene  blue. 

The  tetanus  bacillus  has  been  found  in  garden  earth,  in  dust  from  the 
streets,  between  the  boards  of  the  floors  of  rooms,  and  in  the  pus  from 
certain  suppurating  wounds.  It  has  also  been  met  with  in  the  excrement 
of  animals,  especially  of  the  horse.  Marchesi  found  that  samples  of  soil 
freshly  gathered  often  give  rise  to  mixed  infections  in  which  tetanus 
poison  may  not  appear  to  play  a  part ;  but  if  to  the  same  soils  he  added 
a  5  per  cent  solution  of  carbolic  acid  (which  appears  to  kill  most  other 
organisms),  he  could  usually  demonstrate  their  tetanising  power ;  other 
infections  seldom  or  never  occurring.  By  using  this  method  he  has 
been  able  to  y)roduce  tetanus  symptoms,  not  always  at  the  first  attempt 
but  oflfn  on  the  second;  and  he  points  out  that  the  absence  of  an  infec- 
tion after  the  first  inoculation  does  not  necessarily  show  that  a  soil 


762  SYSTEM  OF  MEDICINE 

contains  no  tetanising  organisms.  He  has  found  tetanus  bacilli  to  a 
depth  of  two  metres ;  but,  below  that,  soils  examined  by  him  had  not 
the  power  of  inducing  tetanus  when  inoculated  subcutaneously. 

It  always  occurs,  then,  in  these  positions  along  with  other  organisms, 
and,  from  the  fact  that  it  grows  anaerobieally,  it  had,  as  we  have  seen, 
been  known  to  exist  for  fi^ve  years  before  any  one  succeeded  in  obtaining 
it  in  pure  culture.  Kitasato,  however,  at  last  overcame  the  difficulty 
by  taking  advantage  of  the  fact  that  the  spores  of  this  organism  are 
specially  resistant  to  the  influence  of  heat.  Taking  as  his  seed  material 
some  of  the  pus  from  the  wound  of  a  patient  sutf ering  from  tetanus,  he 
made  cultures  on  the  surface  of  agar-agar.  At  the  end  of  a  couple  of 
days  he  found  a  number  of  organisms  developed  on  the  nutrient  medium 
kept  at  the  temperatm-e  of  the  body ;  and  amongst  these  were  charac- 
teristic tetanus  bacilli.  He  then  exposed  some  of  the  mixture  for  one 
hour  to  a  temperature  of  80°  C. ;  from  the  material  so  treated  he  made 
fresh  anaerobic  cultures,  and  in  a  certain  proportion  of  these  he  was 
able  to  obtain  pure  groups  of  the  tetanus  bacillus.  It  should  be  pointed 
out,  however,  that  certain  anaerobic  bacilli,  which  may  even  be  mistaken 
for  the  tetanus  bacillus,  except  that  they  do  not  give  rise  to  a  similar 
poison,  may  form  spores  Avhich  are  equally  resistant  to  the  action  of 
heat.  This  admixture  most  frequently  accompanies  the  tetanus  organ- 
ism when  it  occurs  in  soil ;  but,  as  a  rule,  we  are  not  met  by  the  same 
difficulty  when  the  cultures  are  made  directly  from  purulent  material 
derived  from  tetanus  cases. 

The  bacillus,  as  we  have  seen,  grows  best  at  the  temperature  of  the 
body,  and  anaerobieally.  It  certainly  retains  its  virulence  only  so  long 
as  the  free  access  of  oxygen  is  interfered  with ;  but  it  is  stated  that 
constant  cultivation  in  an  atmosphere  of  pure  hydrogen  also,  to  a  certain 
extent,  interferes  with  its  virulence. 

It  grows  readily  on  any  of  the  ordinary  media  to  which  an  addition 
of  2  to  3  per  cent  of  grape  sugar  is  made,  even  when  oxygen  is  present 
at  the  surface  of  the  mass.  In  gelatine  plates  at  the  tenijoerature  of  the 
room  there  are  seen  at  the  end  of  about  four  days  small,  slowly  growing 
colonies  with  delicate  marginal  processes.  Under  the  microscope  each 
colony  appears  to  have  a  dense  centre  Avhilst  the  margin  is  clearer,  and 
radiating  from  the  main  mass  are  numerous  exceedingly  fine  threads. 
In  stab-cultures  in  gelatine,  kept  at  a  temperature  of  21°  or  22°  C,  a 
growth  makes  its  appearance  in  the  deeper  part  of  the  gelatine  in  the 
form  of  a  fir-tree,  situated  some  little  distance  from  the  upper  surface 
of  the  medium,  the  gray,  delicate,  fluffy-looking  branches  getting  longer 
and  longer  as  the  surface  is  left.  At  the  end  of  the  second  week 
the  gelatine  begins  to  liquefy,  and  this  liquefaction  continues  until  the 
whole  becomes  a  cloudy,  sticky  fluid.  After  a  time  the  growth  sinks  to 
the  bottom,  leaving  the  upper  part  of  the  gelatine  comparatively  clear. 
There  is  a  similar  growth  in  grape  sugar  agar ;  but  as  this  medium  can 
be  kept  at  the  temperature  of  the  body,  the  growth  goes  on  much  more 
rapidly,  and  is  of  course  not  accompanied  by  liquefaction.     It  is  a  dis- 


TETANUS  763 


puted  point  whether  gas  bubbles  are  formed  under  these  conditions  or 
not.  This  appears  to  be  entirely  a  question  of  the  rate  of  formation  of 
gas ;  if  it  is  formed  more  rapidly  than  it  can  be  diffused  through  the 
agar  —  as  in  the  case  of  very  energetic  growth  —  bubbles  may  be  seen ; 
but  this,  in  my  experience,  is  comparatively  rare,  and  the  presence  of 
gas  bubbles  affords  strong  evidence  of  the  impurity  of  the  culture.  In 
grape  sugar  peptone  bouillon  the  organisms  grow  luxuriantly,  especially 
at  the  temperature  of  the  body,  and  the  fluid  rapidly  becomes  cloudy ; 
but  after  a  lapse  of  six  or  seven  days  the  upper  layers  of  the  fluid 
become  clear,  and  a  grayish  white  mass  falls  to  the  bottom  of  the  tube. 
All  these  cultures  have  a  peculiarly  disagreeable  aromatic  odour. 

Tlie  Tetanus  Bacillus  is  a  Facultative  Parasite. — It  grows  outside 
the  body,  and  is  especially  associated  with  the  stable  and  with  manured 
fields.  Sheep  and  cattle  are*  often  affected.  The  disease  is  most  com- 
mon amongst  agricultural  labourers,  gardeners,  soldiers  on  campaign,  in 
those  who  go  about  with  bare  feet,  or  who,  like  young  children,  are 
liable  to  get  their  knees  or  hands  accidentally  wounded  by  contact  with 
the  ground.  It  is  somewhat  important  to  remember  these  facts,  as  it 
has  been  found  that  the  tetanus  organism  only  retains  its  virulence 
under  cultivation  so  long  as  it  is  grown  under  anaerobic  conditions ; 
especially  is  this  the  case  where  there  has  been  no  time  for  spores  to 
develop  themselves.  Even  the  pus  from  wounds  of  a  patient  suffering 
from  tetanus  may  no  longer  be  capable  of  setting  up  tetanus  infection, 
as  the  bacilli  are  often  there  placed  under  conditions  unfavourable  to 
the  retention  of  their  specific  virulence. 

Inoculation.  —  This  infective  process  may  be  set  up  in  the  smaller 
animals  by  the  insertion  under  the  skin  of  minute  particles  of  almost 
any  cultivated  garden  earth  ;  by  inoculation  of  pure  anaerobic  cultures 
of  the  tetanus  bacillus ;  by  the  inoculation  of  a  pure  cidture  plus  the 
tetanus  poison,  or  plus  lactic  acid  or  bacillus  prodigiosus ;  or  by  inocula- 
tion into  a  bruised  wound.  It  is  worthy  of  note,  however,  that  the  older 
the  culture  and  the  more  poison  there  is  present,  the  greater  the  cer- 
tainty that  the  disease  will  follow  inoculation.  It  should  be  remembered 
that  the  tetanus  bacillus  forms  its  poison  exceedingly  slowly,  and  that 
the  organisms  themselves,  if  unaccompanied  by  any  material  which  will, 
as  it  were,  draw  off  the  attention  or  paralyse  the  activity  of  the  tissue 
cells,  are  rapidly  destroyed  by  these  cells  —  so  rapidly,  indeed,  that  they 
have  no  time  to  form  sufficient  poison  to  set  up  the  nerve  changes  asso- 
ciated with  the  disease.  Slowly  as  the  poison  is  formed,  however,  it  is 
tremendously  active,  as  will  readily  be  supposed  when  I  say  that  the 
five-millionth  part  of  a  cubic  centimetre  of  a  filtered  two  to  four  weeks 
old  slightly  alkaline  broth  culture  of  the  tetanus  bacillus  —  that  is,  of  a 
solution  of  the  poison  formed  Vjy  these  organisms  —  is  sufficient  when 
inoculated  subcutaneously  into  a  mouse  to  kill  that  animal  in  twenty- 
four  hours.  The  lethal  dose  for  a  rabbit  is  about  a  thousand  times  this 
quantity;  for  dogs  five  to  ten  thousand  times;  and  for  fowls  and 
jHgeons  ten  to  twenty-five  thousand  times  of  an  even  stronger  fluid. 


764  SYSTEM  OF  MEDICINE 

Tetanus  may  be  produced  in  frogs,  but  only,  it  appears,  when  their  tem- 
perature is  maintained  at  a  higher  point  than  normal :  the  period  of 
incubation  usually  extends  over  a  period  of  two  or  three  weeks.  Un- 
like the  poison  produced  by  many  other  organisms,  that  of  the  tetanus 
bacillus  seems  to  produce  much  the  same  results  whether  it  be  injected 
subcutaneously  into  the  thorax  or  abdomen,  or  into  the  veins.  This 
bacillus  appears  never  to  attack  an  animal  from  the  alimentary  canal. 

In  experimentally  produced  tetanus  the  spasms  are  first  observed  in 
the  muscles  near  the  site  of  inoculation ;  but  ultimately  the  process  may 
become  general.  After  intra-peritoneal  and  after  intra-venous  injection, 
however,  there  is  usually  a  general  infection  from  the  commencement. 
In  many  cases  the  changes  at  the  seat  of  inoculation  may  be  so  slight  as 
to  be  overlooked  unless  carefully  searched  for.  This  point  is  of  special 
importance  as  many  cases  of  tetanus  are  said  to  be  idiopathic ;  in  these, 
however,  it  is  probable  that  the  initial  local  damage  has  escaped  obser- 
vation. Even  in  experimental  tetanus  there  is  as  a  rule  only  slight 
infiltration  at  the  seat  of  inoculation.  This  absence  of  local  manifesta- 
tion significantly  indicates  also  that  the  tissues  at  this  point  are  incapa- 
ble of  reacting,  and  that  the  poison  has  been  rapidly  absorbed  from  the 
point  of  introduction.  It  is  only  when  mixed  cultures  are  injected,  or 
cultures  mixed  with  other  foreign  bodies,  such  as  pus,  pieces  of  tissue 
from  a  wound,  soil,  etc.,  that  a  local  suppuration  takes  place. 

The  tetanus  bacillus,  or  its  spores,  when  introduced  alojie  does  not  set 
up  suppuration.  Vaillard  points  out  in  connection  with  this  class  of  case, 
that  in  one  of  his  animal  experiments,  in  which  he  had  introduced  spores 
under  the  skin,  the  wound  healed  immediately.  For  some  time  no 
symptoms  of  tetanus  arose ;  but  when  later  the  wounded  limb  was  irri- 
tated the  spores  became  active  and  an  attack  of  tetanus  was  the  result. 
In  those  cases  where  tetanus  is  propagated  in  Avounds  treated  antisepti- 
cally,  it  must  be  assumed  that  spores  which  have  not  been  killed  by  the 
antiseptic  agents  have  remained  latent  in  the  healing  tissues  for  some 
time.  Later  they  have  developed  into  bacilli,  have  commenced  the 
manufacture  of  their  toxins,  and  so  have  induced  an  attack  of  tetanus. 

Vaillard  and  Rouget,  along  with  Vincent,  state  that  spores  of  the 
tetanus  bacillus  from  which  all  traces  of  poison  have  been  removed  by 
careful  washing,  when  inoculated  alone  into  an  animal,  are  incapable  of 
setting  up  tetanus.  Klipstein,  on  the  other  hand,  maintains  that  this 
washing  of  the  spores  injures  them  so  seriously  that  they  certainly  lose 
a  great  part  of  their  infective  property,  but  that  this  infective  power  is 
never  entirely  lost.  Vaillard  and  Rouget,  however,  are  satisfied  that 
their  own  observations  are  correct.  It  is  certainly  a  fact  that  in  many 
cases  pure  cultures  of  tetanus  bacillus  fail  to  set  up  a  tetanic  infection ; 
but  this  may  be  due  to  the  activity  of  the  tissues,  as  equally  well- 
marked  failures  may  be  observed  in  the  infective  agents  of  other 
diseases. 

Speaking  generally,  tetanus  follows  so  distinctive  and  regular  a 
course  that  it  may  be  divided  into  three  stages  (Knud  Faber)  —  (a)  the 


TETANUS  765 


incubation  period,  (h)  the  stage  in  which  local  spasms  are  developed,  and 
(c)  the  stage  in  which  we  have  general  tetanic  convulsions.  In  certain  of 
the  smaller  and  very  susceptible  animals  the  incubation  period  extends 
over  a  comparatively  short  time,  especially  in  the  case  of  the  experi- 
mentally produced  disease.  For  instance,  in  mice  inoculated  with  pure 
fluid  cultures  of  the  tetanus  bacillus,  the  incubation  period  may  be  as 
short  as  five  or  six  hours,  though  it  may  be  as  long  as  from  twenty-four 
to  forty-eight  hours.  When  earth  is  used  the  incubation  period  is  some- 
what longer,  and  is  usually  put  down  at  from  two  to  three  days.  In  the 
guinea-pig  the  incubation  period  is  slightly  longer,  being  usually  from 
one  to  two  days.  There  is  some  difference  of  opinion  as  to  the  period 
of  incubation  in  the  rabbit.  Knud  Faber  describes  the  incubation  period 
in  this  animal  as  being  from  twenty-four  to  forty -eight  hours ;  other 
observers  place  it  at  from  eight  to  fourteen  days.  There  can  be  no  doubt 
that  the  period  of  incubation  varies  considerably  in  rabbits  according  to 
the  dose  administered  and  the  size  and  age  of  the  animal  experimented 
upon.  Trismus,  which  is  a  marked  feature  in  the  rabbit  when  the  incu- 
bation period  is  short,  is  seldom  observed  in  the  mouse  and  the  guinea- 
pig.  After  injection  of  very  virulent  cultures  the  general  tetanic 
convulsions,  as  seen  in  the  mouse,  are  never  observed  in  the  rabbit. 
A  most  important  point  observed  by  Knud  Faber  is  that  there  is  not 
a  gradual  transition  from  the  local  spasm  into  the  general  tetanic  con- 
vulsions, but  a  sharp  line  of  demarcation  between  the  two ;  the  general 
muscular  spasm  beginning  as  an  entirely  new  phenomenon  perfectly 
distinct  from  the  local  symptoms.  The  disease  in  the  rabbit  is  spe- 
cially interesting,  because  in  it  the  disease  manifests  itself  much  as  it 
does  in  the  human  subject,  both  as  regards  the  non-fatal  form  of  the 
disease,  in  which  merely  local  spasms  are  developed,  and  the  malignant 
type,  which  begins  with  local  spasms,  and  passes  on  to  trismus  and 
stiffening  of  the  neck;  when  an  intra-venous  injection  of  the  virus  is 
made  a  general  tetanic  condition  may  be  produced  corresponding  in 
almost  every  detail  with  that  seen  in  the  human  subject.  In  the  human 
subject  the  period  of  incubation  is  of  course  somewhat  longer,  from  one 
to  twenty -two  days ;  in  the  frog,  as  we  have  seen,  this  period  of  incuba- 
tion is  from  one  to  two  weeks. 

On  examination  it  is  found  that  the  tetanus  bacillus  is  localised 
entirely  in  the  region  of  the  seat  of  inoculation :  it  is  never  found  in 
the  blood  or  fluids  of  viscera,  or  in  distant  tissues ;  and  no  changes  are 
demonstrable  in  the  various  organs.  Hence  the  failure  of  earlier  experi- 
menters to  produce  the  disease  by  the  injection  of  blood  from  tetanic 
patients.  Tetanus,  then,  is  essentially  a  toxic  infective  process,  the 
poison  being  absorbed  from  the  seat  of  inoculation,  where  it  may  have 
been  originally  introduced  in  sufficiently  large  quantities  to  bring  about 
the  characteristic  tetanic  symptoms  in  a  very  short  time  ;  or  the  tetanus 
organisms  may  there  be  so  favourably  situated  that  they  can  develop  a 
sufficient  quantity  of  their  products  to  set  up  toxic  symptoms  :  the  bacilli 
are  distinctly  localised,  but  the  poison  may  be  widely  diffused.     Kitasato 


766  SYSTEM  OF  MEDICINE 

and  Knud  Faber,  working  independently,  pointed  out  that  tlie  whole  of 
the  phenomena  of  a  fatal  attack  of  tetanus  could  be  induced  by  the  injec- 
tion of  the  poison  quite  apart  from  the  bacilli  by  which  it  was  formed. 
Kitasato  inoculated  mice  at  the  root  of  the  tail  with  cultures  of  the 
bacillus ;  and  after  a  half,  one,  and  one  and  a  half  hours  respectively, 
he  cut  freely  around  the  inoculation  wound  and  carefully  cauterised  it, 
thus  removing  all  the  bacilli  that  he  had  introduced.  He  found,  how- 
ever, that  only  the  animals  in  which  the  parts  were  removed  at  the  first 
of  these  intervals  escaped  an  attack  of  tetanus ;  from  which  he  argued 
that  the  poison  formed  by  the  bacilli  is  the  essential  factor  of  the  disease 
in  experimental  tetanus,  and  not  the  bacilli  themselves.  Vaillard  and 
Vincent,  who  repeated  these  experiments,  obtained  much  the  same  results. 

Most  cases  of  accidental  traumatic  tetanus  differ  materially  from 
cases  experimentally  produced,  in  that  other  organisms  and  foreign 
bodies  are  frequently  introduced  with  the  specific  bacillus  ;  suppuration 
is  set  up,  and  under  these  conditions  this  bacillus  appears  to  have  pecul- 
iar powers  of  developing  its  poison.  It  is  sometimes  held  that  the  tetano- 
toxin  is  produced  for  a  time  only,  and  that  the  development  of  the 
bacillus  is  soon  arrested,  even  in  cases  that  ultimately  succumb  to  the 
disease ;  but  Roux  and  Vaillard  maintain  that  this  is  not  the  case,  and 
that  before  a  case  of  tetanus  can  be  treated  with  any  degree  of  success 
the  infective  focus  must  be  freely  removed  so  that  the  supply  of  toxin 
may  be  cut  short.  So  long  as  bacilli  continue  to  multiply  in  the  wound 
they  are  probably  producing  poison  ;  and  therefore  every  attempt  should 
be  made  to  cut  short  their  increase.  The  point  of  entrance  of  tetanus 
virus  is  usually  a  wound  which  may  be  at  the  outer  surface  ;  say,  of  the 
uterus  shortly  after  childbirth,  or  in  the  severed  cord  of  new-born  chil- 
dren. Patients,  as  we  have  seen,  are  usually  affected  when  working 
amongst  horses,  or  when  wounded  while  following  agricultural  pursuits. 
It  is  maintained,  indeed,  that  the  horse  is  the  natural  host  of  the  tetanus 
bacillus,  which  is  found  in  and  spread  with  the  dung  of  this  animal. 

The  tetanus  poison  resembles  the  enzymes  in  many  respects ;  it  is 
destroyed  at  a  temperature  of  ^^°  G.  in  about  five  minutes :  if  kept 
at  the  temperature  of  the  body  for  any  length  of  time  it  gradually 
becomes  weakened.  When  kept  on  ice,  and  protected  from  the  action 
of  light,  it  retains  its  poisonous  properties,  unchanged,  for  months.  By 
the  addition  of  0-5  per  cent  carbolic  acid,  or  of  an  equal  volume  of  glyce- 
rine, it  may  likewise  be  preserved  for  some  time.  It  is  not  affected  by 
drying  at  ordinary  temperatures ;  but  owing  to  its  great  instability  in  the 
presence  of  most  of  the  ordinary  chemical  reagents,  it  is  an  exceedingly 
difficult  matter  to  obtain  this  poison  as  a  pure  substance.  Brieger  first 
isolated  three  substances — tetanin,  tetano-toxin,  and  spasmo-toxin  —  by 
means  of  which  tetanic  symptoms,  and  in  some  instances  death,  could  be 
induced  in  animals  ;  but  these  substances  had  to  be  given  in  doses  of  such 
enormous  volume  that  it  is  evident  that  none  of  them  can  be  the  essential 
poison  of  tetanus  which  acts  in  the  extremely  minute  doses  described  on 
p.  763.      Kitasato  and  Weyl  obtained  two  ptomaines,  one  very  slightly 


TETANUS  -je^ 


toxic,  which  they  named  chlorhydrate  of  tetanin,  the  other  a  tetano- 
toxin  compound  which  produced  paralytic  symptoms.  Brieger  and 
Frankel  then  described  a  proteid  poison  which  they  obtained  from  cultures 
of  the  tetanus  bacillus,  and  named  tox-albumin ;  they  obtained  it  by 
saturating  with  alcohol  the  fluid  in  which  the  organism  had  grown, 
whereupon  a  precipitate  having  an  extremely  powerful  action  is  thrown 
down.  It  was  maintained,  however,  that  this  albuminous  precipitate 
simply  serves  as  a  kind  of  network  in  which  the  essential  toxic  substance 
is  entangled ;  and  Knud  Faber,  Tizzoni  and  Cattani,  and  Vaillard  and 
Vincent,  affirmed  that  this  poison  is  probably  of  the  nature  of  a  diastase. 
Brieger  and  Kitasato  and  Weyl  then  succeeded  in  obtaining  an  extremely 
virulent  poison  which  does  not  give  the  reaction  for  albumins.  It  con- 
sists of  yellow,  transparent  flakes  readily  soluble  in  water ;  it  is  not 
destroyed  by  drying,  nor  in  the  dried  state  by  absolute  alcohol,  chloroform, 
or  anhydrous  ether ;  it  is  very  readily  decomposed  by  acids  or  alkalies, 
by  sulphuretted  hydrogen,  and  by  high  temperature :  in  these  features 
it  resembles  tetanus  poison  in  its  original  solution.  Its  toxic  power  is 
represented  as  being  500  times  as  great  as  that  of  atropin ;  and  120  to 
400  times  as  great  as  that  of  strychnine.  Although  so  much  knowledge 
of  the  physiological  action  of  this  substance  has  been  obtained,  very  little 
light  has  been  thrown  on  its  chemical  composition.  Brieger  and  Cohn 
maintain  that  since  tetanus  bacilli  have  the  power  of  producing  the 
poison  in  non-albuminous  media  the  poison  must  be  looked  upon  as  prob- 
ably non-proteid.  It  must  be  remembered  in  this  connection,  however, 
that  the  protoplasm  of  many  bacteria  has  the  power  of  building  up  pro- 
teid substances  out  of  non-proteid  foods.  The  virulence  of  the  poison 
and  the  nature  of  its  action  upon  animals  both  indicate  that  it  belongs  to 
the  enzymes  or  diastases. 

Tetanus  in  man  is  accompanied  by  the  same  series  of  processes  that 
have  been  induced  in  animals  in  experimental  tetanus.  As  we  have 
already  seen,  it  occurs  sometimes  in  patients  suffering  from  suppurating 
wounds,  such  suppuration  being  the  result  of  a  mixed  infection.  In  man 
as  in  animals  it  is  found  that  the  bacilli  never  pass  from  the  immediate 
neighbourhood  of  the  seat  of  the  original  lesion  which,  then,  must  be 
looked  upon  as  merely  the  local  manufactory  of  the  poison.  The  toxic 
products  of  the  tetanus  bacillus  can,  however,  be  demonstrated  in  the  blood 
of  the  general  circulation;  and  in  certain  comparatively  recent  experi- 
ments tetanic  symptoms  have  been  induced  in  mice  by  injecting  the  serum 
of  the  blood  from  a  tetanic  patient:  again  toxic  products  have  been 
obtained  from  the  liver,  spleen  and  spinal  cord  of  patients  who  had 
succumbed  to  tetanus.  These  toxic  products,  obtained  by  throwing 
down  an  alcoholic  precipitate  and  dissolving  it  in  water,  when  injected 
into  small  animals  have  set  up  all  the  symptoms  of  tetanus.  The 
tetanic  poison  appears  to  be  excreted  in  the  urine  and  also  in  the  milk. 

Bacteriological  Diagnosis.  —  A  drop  of  the  pus  or  other  suspected 
material  is  inoculated  into  a  subcutaneous  pocket  just  above  the  root  of 
the  tail  of  a  mouse;  if  the  matei'ial  contain  tetanus  bacilli  the  animal 


768  SYSTEM    OF  MEDICINE 

usually  succumbs  in  the  course  of  a  few  days.  Or  a  small  amount  of  pus 
taken  from  the  seat  of  inoculation  may  be  used  for  inoculating  nutrient 
media  to  be  treated  by  Kitasato's  method.  Or  again  the  suspected 
material  may  be  inoculated  into  bouillon  which  is  incubated  in  a.n  atmos- 
phere of  hydrogen  for  three  to  five  days ;  this  broth,  with  the  organisms 
growing  in  it,  is  then  placed  in  a  water  bath  kept  at  a  temperature  of 
80°  C. :  here  it  is  left  for  one  hour,  after  which  a  fresh  anaerobic  bouillon 
culture  is  made,  and  this  process  is  repeated  until  pure  cultures  of  the 
tetanus  bacilhis  are  obtained. 

Effect  of  Tetanic  Poison  on  the  Nervous  System.  —  From  the  fact  that 
muscular  spasms  are  such  a  constant  and  striking  feature  in  poisoning 
due  to  the  action  of  the  tetanus  bacillus,  and  from  the  fact,  too,  that  the 
dosage  of  the  poison  can  be  pretty  accurately  measured,  and  the  living 
bacilli  eliminated  from  the  equation,  much  experimental  work  has  been 
done  on  the  etiology  and  pathology  of  tetanus;  though  many  points 
still  remain  to  be  cleared  up.  As  regards  the  pathogenesis  of  the  disease, 
the  earlier  researches  of  Pasteur  on  rabies  led  those  who  were  engaged 
on  the  investigations  to  suppose  that  tetanus  is  due  to  the  presence 
and  action  of  some  virus  which  they  assumed  to  be  formed  in  the 
nervous  system,  especially  in  the  spinal  cord  ;  and  that  the  violent  ner- 
vous symptoms  were  induced  by  the  action  of  this  virus.  Knud  Faber 
made  a  number  of  experiments  on  inoculation  of  the  nervous  centres 
with  the  tetanus  virus :  but,  like  the  experiments  of  those  whose  work 
in  this  direction  had  preceded  his  own,  they  entirely  failed ;  as  did  also 
his  attempts  to  obtain  any  bacilli  from  the  tissues  of  the  central  nervous 
system  even  in  marked  cases  of  tetanus.  On  this  account  he  concluded 
that  the  virus  could  not  be  formed  in  the  central  nervous  system,  as  it 
was  evident  that  the  poison  could  not  be  formed  without  the  inter- 
vention of  the  tetanus  bacilli.  Following  up  Brieger's  intoxication 
theory,  Knud  Faber  was  able  to  show  that  a  pure  culture  of  the 
tetanus  bacillus  produces  during  its  growth  a  poison  or  group  of 
poisons  which,  when  separated  entirely  from  the  bacilli,  is  capable 
of  setting  up  characteristic  tetanic  symptoms.  This  fact  was  not 
entirely  new,  but  it  is  to  Knud  Faber  that  we  owe  the  first  observa- 
tion that  the  poison  only  acts  after  a  certain  period  of  incubation, 
this  period  depending  upon  the  amount  of  the  poison  introduced.  He 
also  pointed  out  that  it  has  many  of  the  characteristics  of  the  diastase  or 
enzyme  group,  and  that  Ave  should  argue  from  this  period  of  incubation 
that  it  must  have  time  to  set  up  certain  fermentive  or  diastatic  changes 
in  the  fluids  or  tissues  of  the  body.  He  also  showed  that  five  minutes 
heating  at  a  temperature  of  65°  C.  is  sufficient  to  destroy  the  activity  of 
this  poisonous  substance ;  and,  moreover,  as  was  afterwards  pointed  out 
by  Vaillard  and  Vincent,  that  the  poison  can  be  separated  from  a  filtered 
fluid  by  the  method  used  for  separating  diastase,  that  is,  along  with  a 
precipitate  from  a  solution  of  calcium  hydrate  by  weak  phosphoric  acid. 
This  is  a  very  important  matter  in  connection  with  the  production  of 
the  toxin  of  tetanus. 


7ETANUS  769 

An  important  fact  to  be  borne  in  mind  is  that  when  this  poison  is 
introduced  into  the  subcutaneous  tissues  it  sets  up  local  spasmodic  con- 
tractions; when  injected  intravenously  general  contractions  occur  at  the 
very  outset  after  the  incubation  period ;  the  incubation  period  is,  however, 
well  marked  in  both  cases.  ISTow  come  the  observations  of  Tizzoni  and 
Vaillard,  who  cut  through  the  nerves  of  a  limb  before  inoculating  the  ani- 
mal with  tetanus  virus.  This  limb  remained  flaccid  when  all  the  rest  of 
the  muscles  had  been  thrown  into  a  state  of  spasm.  Buschke,  adopting  a 
different  method,  curarised  a  tetanised  frog,  and  found  that  tetanus  was 
immediately  cut  short.  It  may,  therefore,  be  concluded  that  the  poison 
does  not  act  directly  either  on  the  muscles  themselves  or  on  the  peripheral 
nerves.  He  also  found  that  the  tetanic  state  still  remains  even  after 
removal  of  the  brain  of  the  frog.  Then  again  tetanus  is  not  set  up  on 
the  direct  application  of  tetanus  virus  to  the  cortex  of  the  cerebrum.  On 
the  other  hand,  progressive  destruction  of  the  spinal  cord  caused  the 
tetanic  symptoms  to  disappear  from  the  part  corresponding  to  the  region 
of  the  spinal  cord  removed  from  the  tetanised  animal.  Consequently  the 
action  of  the  poison  seems  to  be  localised  in  the  spinal  cord  just  as  in 
the  cases  of  strychnine  and  brucin  poisoning  pointed  out  by  Simpson. 

Gumprecht,  from  a  series  of  experiments  on  frogs  —  in  one  series  of 
v/hich  he  used  strychnine,  and  in  another  filtered  bouillon  cultures  of  teta- 
nus bacilli  —  came  to  the  conclusion  that  the  general  spasms  produced  by 
both  substances  must  be  referred  to  a  toxic  affection  of  the  central  nervous 
system  causing  increased  reflex  excitability  of  the  spinal  cord.  The  local 
tetanic  spasms,  although  more  difficult  to  explain,  he  considers  also  to  be 
due  to  excitation  of  the  nerve  centres,  this  excitation  taking  place  at  a  very 
early  period  after  the  introduction  of  a  large  dose  of  the  poison,  which, 
as  pointed  out  by  Behring  and  Vaillard  and  Vincent,  may  travel  in  an 
almost  incredibly  short  space  of  time  from  the  seat  of  inoculation  through- 
out the  body.  Gumprecht  maintains,  too,  that  the  local  spasms  around 
the  point  of  inoculation  do  not  arise  reflexly  by  irritation  of  the  peripheral 
ends  of  the  sensory  nerves  ;  for  when  the  whole  of  the  sensory  nerve  roots 
of  a  limb  were  cut,  and  the  limb  completely  anaesthetised,  tetanic  spasms 
still  made  their  appearance.  He  also  found  that  the  motor  terminal  plates 
and  the  muscle  itself  were  unaltered  by  the  tetanus  poison ;  as  muscles 
tetanised  for  a  long  period  still  gave  perfectly  normal  contraction  curves, 
and  there  was  complete  absence  of  the  reaction  of  degeneration  from  such 
muscles.  Gumprecht  considers  that  the  local  symptoms  are  most  readily 
ex]jlained  on  the  assumption  that  the  poison  travels  along  the  nerves, 
and  thus  enters  the  spinal  cord  at  certain  definite  points,  corresponding, 
of  course,  to  the  point  of  inoculation,  where  it  is  more  or  less  localised 
foi-  some  time  after  its  arrival  at  the  cord.  In  this  way  he  explains  the 
extension  of  the  tetanic  symptoms  to  those  muscles  which  have  their  nerve- 
centres  in  the  immediate  neighbourhood  of  those  of  the  nerves  which  pass 
from  the  site  of  inoculation;  it  is  found  also,  and  probably  for  the  same 
reason,  that  tlie  inoculated  half  of  the  body  of  the  experimented  animal 
is  usually  affected  earlier  and  more  profoundly  than  the  opposite  side. 


770  SYSTEM  OF  MEDICINE 

Goldscheider  agrees  with  Gumprecht  that  after  the  subcutaneous 
injection,  of  the  tetanus  bacillus,  or  tetanus  poison,  the  outbreak  of  gen- 
eral tetanus  is  preceded  by  the  contraction  of  those  muscles  which  lie 
next  to  the  region  of  inoculation ;  and  he  believes  that  this  is  due  to  the 
action  of  the  tetanus  poison  on  the  central  nerve  cells,  in  consequence 
of  which  they  assume  an  increased  and  ever  increasing  excitability,  the 
change  taking  place  gradually,  but  going  on  continuously  so  long  as  there 
is  an  absorption  of  the  poison  from  the  wound.  He  maintains,  too,  that 
the  poison  is  conveyed  to  the  nerve  centres  by  the  nerve  trunks,  and 
that  it  there  acts  on  the  ganglion  cells,  increasing  their  excitability  and 
gradually  covering  a  larger  and  larger  area ;  but  he  believes  that  in  addi- 
tion there  is  diffusion  of  the  poison  by  means  of  the  blood  and  Ijanph,  to 
which  the  general  spasms  are  to  be  attributed.  An  exceedingly  inter- 
esting point  is  noted  in  connection  with  the  resistance  of  fowls  to  the 
action  of  strychnine  in  which  irritability  of  the  central  nervous  system 
is  such  a  marked  feature;  for  it  is  found  that  the  fowl  has  also  a  similar 
resistance  to  the  action  of  the  tetanus  poison,  large  doses  of  which  may 
be  introduced  subcutaneously  with  very  slight  effect  indeed.  A  some- 
what similar  explanation  may  be  obtained  from  Brunner's  observation, 
that  spasms  in  the  facial  muscles  are  set  up  both  by  subcutaneous  inocula- 
tion in  the  face,  and  by  subdural  inoculation  in  the  opposite  half  of  the 
brain.  Kiibler  in  a  note  on  this  observation  points  out  that  tetanus  in  man 
does  not  follow  the  course  above  described.  In  man  local  symptoms  in 
the  vicinity  of  the  site  of  infection  are  seldom  manifested ;  trismus  is  as  a 
rule  the  first  sign,  the  pharyngeal  muscles  are  then  affected,  and  gradually 
in  turn  the  muscles  of  the  trunk  and  the  lower  limbs.  This  criticism, 
however,  does  not  appear  to  be  very  forcible.  In  cases  of  tetanus  in  the 
human  being,  except  in  those  which  run  their  course  with  exceeding 
rapidity,  the  formation  and  diffusion  of  the  poisonous  products  of  the  teta^ 
nus  bacillus  go  on  much  more  slowly  than  in  animals  under  experiment ; 
and  it  appears  quite  probable  that,  as  diffusion  takes  place  so  slowly,  a  cer- 
tain time  is  required  for  the  poison  to  accumulate  to  a  degree  sufficient 
to  give  rise  to  manifest  symptoms  of  nervous  irritation.  If  this  be  so, 
those  muscles  which  are  least  under  control,  and  which  under  emotion 
are  most  readily  stimulated,  would  be  first  attacked,  and  this  appears  to 
be  the  order  in  which  they  are  attacked  in  tetanus  —  those  muscles,  that 
is,  are  first  attacked  which  are  least  under  control  of  the  will,  and  in 
which  the  inhibitory  mechanism  is  least  strongly  developed. 

Following  up  Pasteur's  and  Salmon  and  Smith's  experiments  on  the 
production  of  immunity,  and  on  the  antitoxic  power  of  the  serum  of  immu- 
nised animals  in  the  treatment  of  a  particular  specific  septicaemia,  certain 
experiments  were  made  on  the  establishment  of  immunity  from  tetanus. 
For  a  long  time  these  experiments  bore  little  fruit.  At  length  Behring 
and  Kitasato  succeeded  in  producing  a  transient  immunity  in  rabbits  by 
inoculating  them  Avith  the  filtrate  from  a  culture  of  the  tetanus  bacillus, 
and  then  injecting  at  the  same  point  a  small  quantity — 3  c.c.  of  a  1  per 
cent  solution  —  of  terchloride  of  iodine  for  five  days  at  intervals  of  twenty- 


TETANUS  771 


four  hours.  On  injecting  0-2  c.c.  of  tlie  blood  of  a  rabbit  so  immunised 
into  a  mouse  (an  animal  in  which  they  had  previously  failed  to  obtain 
any  immunity),  the  animal  was  found  to  have  become  protected  to  a 
certain  extent  against  the  disease  when  the  virus  was  inoculated  sub- 
cutaneously.  This  same  treatment  also  proved  efficacious  when  carried 
out  after  mice  had  already  been  infected  with  the  tetanus  bacillus,  and 
even  after  symptoms  had  appeared  after  such  infection.  It  was  found, 
moreover,  that  as  much  as  three  hundred  times  the  lethal  dose  of  a 
virulent  culture,  if  first  mixed  with  a  certain  quantity  of  serum  from 
an  immunised  animal,  might  be  injected  without  producing  any  morbid 
symptoms.  The  following  year  Tizzoni  and  Cattani  confirmed  Behring 
and  Kitasato's  observations  on  the  specific  antitoxic  power  of  blood 
serum  taken  from  immunised  animals.  Roux  and  Vaillard  obtained 
similar  results  by  taking  four  to  five  weeks  old  bouillon  cultures  of  the 
tetanus  bacillus,  passing  them  through  a  Chamberland  filter  to  keep 
back  the  bodies  of  the  bacilli,  and  then  injecting  them,  mixed  with 
weak  iodine  solution,  using  less  and  less  iodine  at  each  successive 
injection  until,  as  the  animals  became  more  and  more  poison  proof, 
considerable  quantities  of  the  unmixed  fluids  could  be  tolerated.  Once 
attained,  they  found  that  this  immunity  may  be  easily  kept  up  by 
fortnightly  injections  ;  but  that  if  the  animal  be  left  untreated  for  a 
fortnight  or  three  weeks  the  antitoxic  power  of  the  serum  begins  to 
diminish,  though  it  may  not  be  entirely  lost  for  a  very  long  time  — 
say  a  couple  of  years.  When  tetanus  poison  is  injected  it  is  absorbed 
rapidly,  and  antitoxic  substance  almost  as  rapidly  makes  its  appearance 
in  the  blood ;  Eoux  points  out  that  thirty -five  minutes  after  the  injec- 
tion of  toxin  into  the  abdominal  cavity  of  a  rabbit  antitoxin  may  be 
found  in  the  blood  drawn  from  the  lateral  vein  of  the  ear. 

Tetanus  was  really  the  first  disease  of  this  class  in  which  careful 
investigation  led  to  results  which,  though  comparatively  unimportant  in 
themselves,  paved  the  way  for  the  more  important  serum  treatment  of 
diphtheria.  In  tetanus  there  was  a  certainty  of  obtaining  definite 
symptoms  in  animals  in  which  the  experimental  infection  succeeded ; 
here  also  the  toxic  products  of  the  bacillus  could  be  readily  separated, 
and  the  dose  required  to  produce  certain  symptoms  accurately  deter- 
mined. Ehrlich,  and  Tizzoni  and  Cattani  again,  experimenting  with  the 
rat  and  rabbit  and  treating  them  with  the  blood  serum  of  animals 
which  had  been  rendered  refractory  to  tetanus,  maintained  that  they 
were  always  able  to  obtain  a  cure  if  the  injections  were  commenced  as 
soon  as  the  slightest  symptoms  manifested  themselves.  When  the  local 
symptoms  were  established,  or  beginning  to  disappear,  the  results 
obtained  by  the  serum  treatment  in  their  hands  -were  slower  and  less 
certain ;  while  in  those  cases  in  which  tetanus  was  already  becoming 
generalised  success  never  followed  this  treatment.  In  the  light  of  the 
somewhat  unsuccessful  use  of  antitoxic  serum  in  tetanus  in  the  human 
subject,  it  is  interesting  to  find  that  the  quantity  of  serum  required  for 
a  successful  result  after  local  symptoms  have  commenced  is  at  least  one 


772  SYSTEM   OF  MEDICINE 

or  two  thousand  times  greater  than  that  required  to  confer  an  antece- 
dent immunity.  This  remarkable  fact  should  be  borne  in  mind  in 
determining  the  efficacy  of  the  antitoxic  serum  method  of  treatment. 
Further,  it  is  calculated  that  a  dose  of  serum  at  least  150  times  as  great 
as  the  above  must  be  employed  if  any  success  is  to  be  obtaijied  when 
the  local  symptoms  have  reached  their  height. 

The  curative  action  of  the  serum  is  said  to  depend  entirely  on 
the  proportion  of  antitoxin  which  it  contains,  so  that  given  the  pro- 
portion of  antitoxin  in  the  serum  the  dose  can  be  accurately  calculated. 
Antitoxin  is  said  by  Koux  and  Vaillard  to  be  an  enzyme,  which  it 
resembles  in  many  respects,  but  it  differs  in  its  comparative  stability ;  it 
will  stand  even  a  temperature  of  70°  C.  without  undergoing  any 
appreciable  alteration.  Tetanus  antitoxin  may  be  kept  indefinitely  by 
evaporating  blood  serum  at  low  temperature  in  vacuo.  At  the  moment 
of  using  it  is  dissolved  in  six  times  its  weight  of  sterilised  distilled  water. 

Tizzoni  and  Cattani  found  that  the  antitoxic  substance,  when  pre- 
cipitated from  the  serum  by  alcohol,  does  not  lose  its  strength;  they 
urge,  therefore,  that  the  alcoholic  precipitate,  which  is  non-dialysable, 
may  be  substituted  for  the  serum  itself.  Assuming  that  the  experiments 
made  on  the  rabbit  can  be  applied  to  man,  they  calculate  that  it  would  be 
necessary  to  give  0-7  c.c.  of  the  serum,  or  0-06  gramme  of  its  alcoholic 
precipitate,  at  the  outbreak  of  the  first  symptoms  of  tetanus ;  whilst  at  a 
more  advanced  period  it  might  be  necessary  to  inject  210  c.c.  of  serum, 
or  12  grammes  of  its  precipitate.  This  is  an  exceedingly  large  quantity 
to  inject  subcutaneously,  yet  in  medical  practice  even  this  quantity  has 
failed  to  give  satisfactory  results.  In  fact,  these  observers  were  unable  to 
obtain  a  much  greater  percentage  of  recoveries  by  this  method  than  had 
previously  been  obtained  in  cases  treated  without  serum.  They  were 
the  first  to  differ  from  Behring  who  maintained  that  the  antitoxin,  or 
the  antitoxic  sermn,  directly  destroys  or  antagonises  the  toxin  formed 
by  the  tetanus  bacillus ;  they  rather  ascribe  to  it  a  power  of  enabling  the 
tissue  cells  to  continue  their  work  in  the  presence  of  larger  doses  of 
poison.  Eoux  and  Vaillard  also  maintain  that  Behring's  theory  is  un- 
tenable, namely,  that  each  injection  of  toxin  diminishes  the  immunising 
power  of  serum ;  and  that,  if  too  large  or  too  frequent  doses  be  injected, 
the  antitoxic  property  of  the  blood  may  disappear  for  a  space  and  the 
blood  actually  become  toxic.  Were  the  antitoxic  serum  merely  a 
neutraliser  of  the  toxin,  the  horse  under  these  conditions  should  mani- 
fest the  symptoms  of  tetanus.  This,  however,  is  not  the  case,  and  since 
the  antitoxin  has  disappeared,  the  immunity  of'  the  animal  must  depend 
upon  something  else,  a  something  which  appears  to  be  the  habituation 
of  the  tissue  cells  to  the  presence  of  the  toxin;  the  cells  can  go  on 
doing  their  work  under  the  gradually  acquired  new  conditions,  and  no 
tetanus  is  set  up.  This  result  is  best  obtained  by  the  injection  (into  a 
horse)  of  200  or  300  c.c.  of  the  toxin,  after  which  dose  the  animal 
is  ready  to  supply  a  sufficiently  potent  serum. 

Antitoxic  serum  confers  an  immunity  which  is  perfect  for  a  time,  but 


TETANUS  773 

is  more  transient  than  the  immunity  brought  about  by  the  injection  of 
toxins  or  of  the  specific  organism  (when  it  may  last  for  as  long  a  period 
as  a  couple  of  years).  In  most  cases  it  is  lost  at  the  end  of  six  or  eight 
weeks.  Immunity  certainly  continues  as  long  as  any  antitoxin  remains 
in  the  blood.  As  would  be  expected,  therefore,  the  antitoxic  property  of 
blood  disappears  long  before  the  immunity  of  the  animal  from  the  dis- 
ease is  lost.  This  immunity  can  only  be  obtained  with  the  toxins  when 
they  are  injected  repeatedly  and  in  large  quantities.  It  must  be  remem- 
bered in  this  connection  that  the  antitoxic  substance  is  constantly  being 
excreted  by  the  kidneys,  by  the  mammary,  and  probably  by  other  glands ; 
but  a  certain  quantity  undoubtedly  remains  for  some  time  after  the  in- 
jections have  been  discontinued.  Ehrlich  believes  that  the  hereditary 
transmission  of  immunity  is  due  to  the  large  quantities  of  antitoxin  ex- 
creted in  the  milk :  if  this  opinion  be  true  the  stability  of  the  antitoxic 
substance  is  much  greater  than  has  generally  been  supposed.  The  prac- 
tical importance  of  this  assertion  should  not  escape  observation. 

Although  the  antitoxin  is  so  rapidly  excreted  by  the  glands,  it  has 
been  observed  that  repeated  blood  lettings,  if  they  be  carried  on  during 
a  short  period,  do  not  seem  to  lower  the  antitoxic  power  of  the  serum. 

In  man,  as  in  animals,  it  is  found  that  the  shorter  the  incubation 
period  —  that  is,  the  period  intervening  between  the  infection  and  the 
outbreak  of  the  disease  —  the  more  severe  the  disease  and  the  worse  the 
prognosis.  It  is  stated  that  of  those  cases  where  the  incubation  period 
is  under  ten  days,  not  more  than  3  to  4-5  per  cent  recover ;  when  the 
incubation  period  is  from  eleven  to  fifteen  days,  25  per  cent  recover ; 
in  those  cases  in  which  the  incubation  period  is  still  longer,  about  half 
the  patients  attacked  throw  off  the  disease.  Different  authors  give 
somewhat  different  statistics,  but  these  are  the  general  results. 

Dr.  Kanthack,  in  a  series  of  tables  of  the  cases  that  have  been 
treated  with  antitoxin  serum,  gives  the  duration  of  the  incubation 
period,  date  of  the  disease  when  treatment  was  begun,  qiiantity  of  serum 
injected,  the  result  and  the  duration  of  the  illness.  It  is  gathered  from 
these  tables  that  the  cases  of  cure  all  belong  to  the  chronic  or  benign  (?) 
form  of  tetanus ;  whilst  those  cases  that  ended  fatally  were  invariably 
developed  in  less  than  fourteen  days;  in  the  majority  of  cases  the  dura- 
tion of  the  disease  did  not  exceed  four  or  five  days.  In  these  cases,  too, 
the  period  of  incubation  was  comparatively  brief.  These  tables,  have 
been  brought  well  up  to  date,  and  bring  out  the  fact  that,  so  far,  the 
success  obtained  by  the  antitoxic  serum  treatment  of  tetanus  is  compara- 
tively slight,  except  in  exceedingly  chronic  cases,  where  it  appears  to 
have  been  attended  with  a  little  more  success  than  has  been  attained 
by  the  ordinary  methods. 

Ehrlich's  theory  of  immiinity  is  based  upon  the  fact  that  in  an  animal 
immune  from  a  specific  infective  or  toxic  disease  the  tissues  are  poison 
proof;  that  is,  the  poison  (the  tetanus  poison,  in  this  instance)  can  no 
longer  exercise  upon  the  immune  animal  or  its  tissues  any  deleterious 
effects.     As  is  well  known,  some  animals  are  less  susceptible  to  the 


774  SYSTEM  OF  MEDICINE 

action  of  certain  specific  infective  diseases  than  are  others ;  and  in  the 
case  of  tetanus  it  has  been  found  that  comparatively  insusceptible  ani- 
mals—  such  as  the  dog  and  the  fowl — may  be  rendered  less  and  less 
susceptible,  by  the  injection  of  gradually  increasing  doses  of  the  specific 
poison.  It  is  then  found  that  their  serum  (although  previously  it  had 
no  antitoxic  action  when  injected  into  another  animal),  and  in  cattle 
the  milk,  and  in  the  fowl  the  yolk  of  the  ^g%,  have,  as  the  result  of  this 
treatment,  acquired  considerable  immunising  power;  and  this  serum 
(or  these  other  substances)  on  being  artificially  introduced  by  injection 
into  susceptible  animals  acts  so  rapidly  upon  their  tissues  that  they  in 
turn  are  rendered  comparatively  insusceptible.  This  power,  as  we  have 
already  seen,  is  extremely  well  marked  if  the  serum  be  introduced  at 
the  same  time  or  shortly  after  the  tetanus  poison;  but  its  power  of 
doing  good  diminishes  more  and  more  rapidly  as  the  tetanus  poison 
obtains  a  longer  start. 

Susceptible  animals,  such  as  the  mouse,  rabbit,  horse  and  sheep,  may 
also  be  immunised;  but  in  their  case  the  process  requires  to  be  much 
more  carefully  carried  on,  and  is  necessarily  much  more  tedious  and  pro- 
longed. Behring  after  long-continued  experiment  found  that  he  was 
able  to  obtain  the  necessary  immunity  by  injecting  bouillon  cultures  of 
the  tetanus  bacillus,  to  which  had  been  added  a  solution  of  iodine  tri- 
chloride, first  in  the  proportion  of  0-25  per  cent,  then  of  0-2  per  cent, 
then  of  0-15  per  cent,  until,  finally,  unaltered  culture  was  used,  first  in 
small  doses  at  intervals  of  three  to  five  days,  then  in  constantly  increas- 
ing doses  at  intervals  of  eight  days.  In  place  of  this  method  Vaillard 
has  produced  a  similar  immunity  by  injecting  for  a  few  days  a  filtrate 
previously  heated  to  60°  C,  then  a  series  heated  to  55°  C,  and  finally  to 
50°  C.  Gram's  solution  and  lactic  acid  have  both  been  also  used  for  the 
purpose  of  attenuating  the  strength  of  the  tetanus  poison  and  the  activ- 
ity of  the  bacilli. 

Behring  has  shown  that  mice  which  had  been  poisoned  with  fatal 
doses  could  be  cured  even  after  the  appearance  of  the  first  tetanus 
symptoms,  in  some  cases  five  hours  after.  The  animals  survived,  but 
only  after  a  prolonged  illness;  and  if  he  allowed  a  period  of  twelve 
hours  to  intervene  between  the  first  appearance  of  the  tetanus  symptoms 
and  the  commencement  of  treatment,  the  cases  almost  invariably  had 
a  fatal  termination.  He  worked  this  out  so  accurately  that  he  found  if 
the  animal  were  treated  before  inoculation  with  the  tetanus  bacillus  it 
required  for  its  protection  only  one-hundredth  part  of  the  dose  that 
was  necessary  if  the  treatment  was  not  commenced  until  a  quarter  of 
an  hour  after  infection. 

The  immunising  serum  appears  to  have  a  special  action  on  the  same 
tissues  as  those  attacked  by  the  poison  —  probably  on  the  ganglion  cells 
of  the  central  nervous  system ;  and  the  substance  first  in  the  field,  be  it 
toxin  or  antitoxin,  appears  to  work  at  a  very  great  advantage  over  that 
subsequently  introduced.  It  should  be  pointed  out  that  even  in  those 
cases  in  which,  through  the  use  of  large  doses  of  antitoxic  serum,  the 


TETANUS  775 


action  of  the  toxin  is  brought  to  a  standstill,  these  cells  may,  before  the 
treatment  com  :nenced,  have  suffered  very  considerably ;  if  so  the  recovery 
must  necessarily  be  slow :  in  other  cases  the  damage  to  the  tissues  may 
be  so  far  advanced  that  recovery  is  impossible ;  for  it  must  be  borne  in 
mind  that  the  antitoxin  can  play  no  part  in  regenerating  structures 
already  destroyed  or  impaired.  Its  power  appears  to  be,  if  used  sufti- 
ciently  early,  to  fortify  the  cells  against  the  action  of  the  poison,  allowing 
them  to  carry  on  their  work  unchanged  in  the  presence  of  what,  under  ordi- 
nary conditions,  would  lead  to  their  complete  disorganisatiou.  It  should 
be  noted  in  this  connection,  too,  that  the  symptoms  of  spasm  and  irrita- 
bility, for  some  short  time  after  the  exhibition  of  the  dose  of  serum,  are 
considerably  increased ;  as  though  a  contest  for  the  mastery  were  actually 
taking  place  in  the  central  nerve-cells.  The  more  marked  this  feature 
the  more  prolonged  is  the  process  of  recovery.  It  indicates,  apparently, 
considerable  disorganisation  of  the  cells  before  the  antitoxic  serum  has 
had  time  to  act.  German  observers  agree  with  Tizzoni  and  Cattani  that, 
up  to  the  present,  no  case  treated  by  the  antitoxic  serum  method  has 
recovered  which  might  not  have  recovered  under  ordinary  treatment ; 
none  of  them  were  so  acute  as  to  indicate  a  fatal  prognosis.  On  the  other 
hand  this  method  does  not  give  rise  to  any  unfavourable  conditions,  so 
that  in  cases  in  which  dirty  wounds  might  contain  the  factors  of  tetanus, 
prophylactic  doses  of  the  tetanus  antitoxin  might  be  injected. 

While  on  this  point,  it  may  be  well  to  indicate  the  difference  between 
the  results  obtained  by  the  antitoxic  serum  treatment  in  tetanus,  and 
by  the  similar  method  of  treatment  in  diphtheria.  In  both  cases  there 
is  a  manufactory  of  the  poison  on  or  near  the  surface  of  the  body. 
In  both  cases  there  is  an  absorption  of  this  poison  into  the  body,  and 
in  both  cases  the  nervous  and  muscular  systems  are  specially  attacked 
by  the  poison.  But  in  the  case  of  diphtheria  our  attention  is  called 
to  the  manufactory  of  the  poison  at  a  very  early  stage  of  the  disease ; 
for  it  usually  occurs  in  some  part  of  the  throat,  where  it  gives  rise  to 
considerable  discomfort :  moreover,  from  the  nature  of  the  tissues  in 
this  region  a  false  membrane  is  usually  formed  at  a  very  early  stage  of 
the  disease.  Attention  is  therefore  drawn  to  the  local  poison  manu- 
factory almost  as  soon  as  it  begins  to  discharge  its  poisons  into  the 
system,  and  the  serum  may  be  utilised  to  antagonise  the  poison  before 
it  has  had  time  to  injure  the  nerves  and  muscles.  It  is  interesting  to 
note,  too,  that  in  a  large  number  of  cases  of  diphtheria  paralysis,  the 
diphtheria  has  been  said  to  be  slight;  that  is,  the  local  manifestations 
of  the  disease  have  not  attracted  attention,  and  the  process  has  been 
allowed  to  go  on  so  long  that  the  poison,  though  perhaps  small  in 
amount,  has  been  allowed  to  act  for  a  considerable  length  of  time,  and 
thus  to  bring  about  paralysis.  In  tetanus,  on  the  other  hand,  the  local 
wound  by  which  the  poison  is  absorbed  is  for  a  long  time  looked  upon 
mei-ely  as  a  wound,  a  suppurating  one  perhaps,  but  not  a  manufactory  of 
the  tetanus  poison ;  consequently  nothing  is  known  of  the  tetanus  until 
the  poison  has  had  time  to  exert  its  evil  influence  on  the  nervous  system : 


776  SYSTEM  OF  MEDICINE 

now  by  the  time  we  find  out  that  the  patient  is  suffering  from  tetanus 
this  disease  is  so  far  advanced  that  any  chance  of  treating  it  successfully 
by  means  of  antitoxic  serum  is  reduced  to  a  minimum. 

German  Sims  Woodhead. 

Symptoms.  —  The  chief  symptom  and  feature  of  tetanus  is  the  occur- 
rence, and  recurrence  at  varying  intervals,  of  spasms  of  greater  or  less 
severity  in  the  voluntary  muscles.  These  spasms  are  superadded  to  a 
state  of  persistent  tension  of  the  muscles  which,  however,  like  the 
spasms,  is  commonly  relaxed  during  sleep.  They  sometimes  commence 
in  the  neighbourhood  of  the  wound  and  spread  to  other  parts  of  the 
body.  It  was  so  in  a  case  of  gunshot  wound  of  the  thigh,  in  a  case  of 
wound  in  the  perineum  by  a  pitchfork,  and  in  the  case  of  a  wound  in  the 
face  by  the  lash  of  a  whip,  all  of  which  I  saw.  In  another  case  the  spasms 
in  the  injured  part  (the  thigh)  continued  after  those  in  the  rest  of  the  body 
had  ceased  under  the  influence  of  chloroform.  In  all  these  the  affection 
was  severe,  and  proved  fatal.  In  inoculated  animals  the  earliest  tetanic 
symptoms  commence  in  the  muscles  adjacent  to  the  wound,  and,  later, 
become  general  (6).  But  more  commonly  in  man  the  tension  and  spasms 
are  first  observed  in  the  neck,  giving  the  sensation  of  ordinary  stiff  neck 
from  cold.  This  is  quickly  followed  by  tension  and  spasms  of  the  muscles 
of  the  jaw,  causing  more  or  less  inability  to  open  the  mouth  or  protrude 
the  tongue,  the  tip  of  which  is  pressed  between  the  teeth  in  the  attempt 
to  show  it ;  and  the  tongue  is  often  wounded  by  the  sudden  closure  and 
snapping  together  of  the  teeth.  The  effort  to  put  out  the  tongue  causes 
spasm  of  the  facial  muscles,  giving  that  peculiar  strained  expression  or 
grin  designated  the  risus  sardonicus.  Often  on  asking  a  patient  to  show 
the  tongue  have  I  been  startled  by  the  unexpected  manifestation  of  this 
fatal  omen  in  cases  of  wounds  which  otherwise  seemed  to  be  doing 
well.  Coincident  with  these  early  symptoms,  or  soon  after,  the  front  of 
the  abdomen  is  felt  to  be  firm  or  hard  from  contraction  of  the  abdominal 
muscles.  There  may  also  be  a  sense  of  oppression  or  pain  about  the 
precordia,  penetrating  to  the  spine,  which  is  attributed  to  tension  of 
the  diaphragm;  though,  it  may  be  observed,  the  tension  and  spasm 
of  the  muscles  in  this  stage  are  not  commonly  attended  with  pain.  Soon 
the  spasms  extend  to  the  other  muscles  of  the  trunk  and  to  the  muscles 
of  the  limbs,  and,  in  some  instances,  are  so  severe  as  to  cause  rupture  of 
their  fibres ;  this  event  has  occurred  in  the  rectus  abdominis  and  psoas 
magnus.  Indeed,  a  case  is  quoted  by  Curling  from  Desportes  in  which 
both  thigh-bones  were  broken  by  the  force  of  the  contracting  muscles, 
and  another  in  which  the  second  cervical  vertebra  was  dislocated.  The 
spasms  usually  affect  the  voluntary  muscles  in  all  parts  about  equally, 
those  of  the  fingers,  however,  least ;  and  the  pain  attendant  on  them  varies. 
I  do  not  think  the  pain  is  generally  so  severe  as  commonly  stated,  and  it 
rarely  equals  that  attendant  on  common  "  cramp."  In  some  cases  it  is 
sufficient  to  cause  the  patient  to  cry  out,  but  often  even  boys  do  not 
give  this  or  any  indication  of  great  suffering;  the  condition  is  rather 


TETANUS  777 


that  of  forced  and  distressful  straining,  "which  is  often  very  exhausting. 
Wlien  the  spasm  ceases  the  patient  is  worn  out,  subsides  into  quietude, 
and  perhaps  into  sleep.  The  pain  is  chiefly  felt  along  the  back ;  and  the 
dominating  power,  with  perhaps  more  excited  contraction,  of  the  dorsal 
and  lumbar  muscles,  as  compared  with  the  muscles  in  front  of  the  body, 
causes  some  arching  of  the  trunk  backwards,  to  which  the  term  of  opistho- 
tonos has  been  given.  I  have  not  seen  this  condition  in  the  marked  form 
occasionally  described,  nor  have  I  seen  the  bending  in  the  opposite  di- 
rection called  emprosthotonos,  nor  that  to  one  side  called  pleurosthotonos. 
The  spasms  arise  spontaneously,  sometimes  waking  the  patient  from 
sleep.  They  may  be  excited  by  any  slight  cause  which  disturbs  the 
patient,  and  are  often  induced  by  the  effort  to  swallow  the  viscid  saliva 
which  accumulates  in  the  mouth,  is  pressed  out  between  the  lips  and  is  a 
source  of  much  distress.  The  muscles  of  the  glottis  are  not  uncommonly 
affected,  causing  noisy,  difficult  inspiration,  or  stopping  of  the  breathing ; 
and  death  may  thus  result.  Kot  unfrequently,  when  the  sufferer  has 
become  worn  out,  a  severe  spasm,  compressing  the  thorax,  suspending 
respiration,  and  embarrassing  the  heart's  action,  squeezes  life  out,  as  it 
were,  and  leaves  no  power  to  recover  it.  In  acute  cases  death  usually 
occurs  about  the  third  day.  In  less  severe  cases  life  may  be  prolonged  for 
a  fortnight  or  three  weeks,  or  even  more.  These  prolonged  cases  afford  the 
best  prospect  of  recovery.  On  the  whole,  the  disease  is  most  severe  and 
most  quickly  fatal  when  it  commences  soon  after  the  injury,  and  when 
the  injury  is  most  severe.  The  brain  commonly  shows  no  sign  of  being 
affected,  the  intellect  remaining  clear  to  the  last,  though  delirium  has 
ensued  in  a  few  cases.  The  pulse  is  quickened  during  the  seizures,  but 
in  the  intervals  between  them  the  pulse  and  the  respiration  may  be 
natural  in  rate.  The  iris  commonly  responds  to  light,  and  variations 
which  have  been  observed  in  the  pupil  —  contraction  or  dilatation  —  were 
probably  due  to  the  drugs  administered.  The  temperature  varies,  and 
commonly  rises  during  the  paroxysms.  In  a  case,  lately  in  Addenbrooke's, 
in  which  tetanus  followed  a  wound  in  the  perineum  by  a  pitchfork,  the 
temperature  was  99 "5°  on  the  third  day  of  the  attack  (the  day  of  admis- 
sion), on  the  fourth  day  it  was  100°,  and  on  the  fifth  day,  during  a 
severe  and  prolonged  spasm  which  terminated  the  case,  it  rose  to  106-4°. 
In  a  lad,  who  recovered,  the  temperature  was  on  several  occasions 
104°-105°,  and  at  these  times  the  spasms  were  severe  and  frequent,  and 
the  breathing  hurried.  A  similar  remarkable  or  even  greater  rise  of  the 
thermometer  (up  to  110°)  has  been  observed  in  other  cases,  and  the 
high  temperature  probably  contributed  to  bring  life  to  an  end.  The 
thermometer  has  also  been  observed  to  rise  after  death.  In  some  in- 
stances, however,  where  death  has  been  preceded  by  a  longer  period  of 
exhaustion,  a  fall  of  temperature  has  preceded  the  fatal  event.^     In  the 

1  The  rise  of  temperature  may  be  due  to  the  increased  muscular  metabolism  caused  by 
the  continuous  and  the  spasmodic  contractions,  or  to  an  excitation  of  the  nerve  heat- 
centres.  This  question  is  much  discussed,  and  many  examples  p;iven  by  Rose,  "  Ueber 
Starrkrampf,"  in  the  JIandbuch  der  Chirarrjie,  von  Pitha  und  Billroth,  1  Band,  11  Abtheil, 


778  SYSTEM  OF  MEDICINE 

case  from  a  perineal  wound  just  mentioned  the  catheter  was  required 
on  the  third  day,  though  only  seven  ounces  of  urine  were  withdraAvn. 
Subsequently  the  urine  was  passed  voluntarily,  though  with  pain.  The 
amount  of  urine  varies,  in  some  cases  it  is  more,  in  some  less  than  nor- 
mal. It  has  been  found  to  contain  the  tetanus  toxin  in  considerable 
quantity,  and  injection  of  the  urine  into  animals  has  induced  fatal  tetanus. 
This  passage  of  toxin  with  the  urine  has  given  rise  to  the  idea  that  an 
increase  of  diuresis  might  assist  in  the  elimination  of  the  poisonous 
material  from  the  system ;  I  am  not  aware,  however,  that  the  idea  has 
been  carried  into  practice.  The  presence  of  the  toxin  does  not  cause 
any  increase  in  the  quantity  of  urine  secreted.  The  amount  of  toxin  in 
the  urine  has  been  observed  to  diminish  after  the  injection  of  antitoxin. 

As  tetanus  is  not  usually  attended  with  fever,  so  the  blood  drawn 
does  not  present  inflammatory  characters.  The  appetite  and  digestion  are 
good.  The  tongue  is  usually  whitish  and  the  perspiration  excessive.  In 
most  instances  there  is  marked  and  rapid  wasting  of  the  system  and 
diminution  of  strength.  This  toasting  and  exhaustion,  indeed —  this  rapid 
wearing  out  of  the  bodily  powers  —  constitutes  an  important  and  grave 
feature  in  the  malady,  and  one  which  directly  or  indirectly  leads  to  the 
fatal  result.  It  is  proportionate  to  the  acuteness  of  the  attack,  and  seems 
to  depend  upon  some  deleterious  influence  of  the  toxic  agent  acting  im- 
mediately upon  the  system.  I  say  this  because,  though  much  increased 
by  the  recurring  spasms,  it  goes  on  manifestly  when  these  are  mitigated 
or  suspended.  The  spasms,  in  truth,  are  but  a  peripheral  symptom  of 
the  disease,  though  they  exert  a  depressing  and  exhausting  influence 
upon  the  body. 

The  involuntary  muscles  do  not  appear  to  participate  with  those  of 
the  voluntary  system  in  the  disturbances  caused  by  tetanus.  The  bowels 
are  commonly  inactive,  the  muscles  of  the  alimentary  canal  give  no 
indication  of  spasms,  and  purgatives  act  as  usual.  The  bladder  and 
heart  are  in  like  manner  free.  Some  observers,  as  Dr.  Parry,  attach 
much  importance  to  the  state  of  the  heart,  and  think  it  to  be  the  organ 
which  first  loses  vital  power ;  there  seems  no  sufficient  reason  for  this 
view.  The  pulse  does  but  vary  Avith  the  state  of  the  patient,  rising 
during  the  paroxysms,  falling  again  when  they  subside,  and  becoming 
weaker  as  the  general  strength  fails ;  death  ensues  from  general  failure 
of  strength  or  violent  general  spasm  rather  than  from  any  special  failure 
or  spasm  of  the  heart. 

In  a  young  man,  a  horse-dealer  who  lived  on  the  other  side  of  Ely, 
and  was  confined  to  his  bed  by  a  rather  severe  grazed  wound  of  the  leg, 
the  first  indication  of  tetanus  was  a  shudder,  or  general  spasm,  caused 
by  the  removal  of  an  adherent  dressing.  The  affection  thus  ushered  in 
ran  on  quickly  to  a  fatal  termination. 

Many  cases  of  so-called  spontaneoiis  and  idiopathic  tetanus  have  been 
recorded  in  which  no  wound  or  other  local  lesion  could  be  discovered. 
I  remember  such  a  one  in  a  young  man  in  St.  Bartholomew's  Hospital 
under  Sir  Wm.  Lawrence.     Aperients  were  given,  and  he  recovered 


TETANUS  779 


The  attack  has  in  many  instances  been  attributed  to  cold  or  damp. 
A  healthy-looking  man,  set.  54,  was  admitted  into  Addenbrooke's 
Hospital,  11th  May  1856,  with  the  usual  symptoms  of  tetanus  well 
marked.  They  had  commenced  four  days  previously,  with  stiffness 
in  the  neck  and  jaws,  after  exposure  to  steam  and  cold  winds  in  his 
occupation  of  boiling  bones.  There  was  no  apparent  local  lesion.  The 
spasms  were  severe  and  general,  and  attended  with  difficulty  of  breathing, 
attributed  in  part  to  the  firm  closure  of  the  lips.  Still  he  was  able  to 
swallow  in  the  intervals,  though  with  some  difficulty.  Quinine,  beef  tea, 
and  wine  were  given  in  considerable  quantities  and  frequently.  Though 
thinner  and  weaker  he  held  on  without  change  for  a  week.  After  this 
he  grew  worse.  He  could  not  sleep,  yet  morphia  seemed  to  do  him 
harm,  causing  increase  of  spasm.  Chloral  did  better  and  gave  some 
repose.  On  the  26th  he  began  evidently  to  improve,  and  he  finally 
recovered,  though  it  was  long  before  he  was  free  from  the  stiffness  in 
the  back,  neck,  and  jaws. 

The  affection  is  said  also  to  have  occurred  in  cases  of  contusion,  and 
in  simple  fractures  and  dislocations.  The  following  case,  of  Avhich  Mr. 
Charles  Lucas,  of  Burwell,  has  kindly  sent  me  the  particulars,  appears  to 
belong  to  this  class.  A  stalwart  man,  set.  30,  received  a  kick'  from  a 
horse  in  the  left  thigh  on  9th  March  1883.  On  the  13th,  Avhen  first  seen 
by  Mr.  Lucas,  there  was  a  hard,  brawny  swelling,  very  tender  and  pain- 
ful, in  the  middle  of  the  outer  side  of  the  thigh.  No  scratch  or  trace  of 
wound  was  discoverable  there  or  elsewhere.  Fomentations  and  poultices 
were  applied.  In  the  night  of  the  24th  his  back  and  jaw  became  stiff,  he 
was  unable  to  open  his  mouth,  and  swallowing  was  difficult.  Next  day 
these  symptoms  had  increased,  and  there  were  violent,  painful  spasms, 
with  rigidity  of  the  muscles  of  the  face,  neck,  back,  and  abdomen ;  also 
pain  about  the  region  of  the  stomach,  firm  clenching  of  the  jaws  and  com- 
plete inability  to  swallow,  the  attempt  to  do  so  bringing  on  severe  spasms. 
A  free  incision  into  the  swelling  of  the  thigh  gave  vent  to  a  large  quantity 
of  foetid  greenish  fluid,  which  was  followed  by  almost  immediate  relief 
to  the  symptoms.  On  the  following  day,  26th,  and  on  the  27th  he  could 
swallow  gruel,  and  the  stiffness  and  spasms  had  nearly  subsided.  On  the 
28th  there  was  a  complete  recurrence  of  all  the  tetanic  trouble,  and  a 
cessation  of  the  discharge  from  the  wound.  The  symptoms  again  ceased 
when  the  wound  was  freely  reopened,  and  did  not  recur.  The  man 
completely  recovered,  though  the  convalescence  was  slow. 

In  this  and  similar  cases  it  is  possible  that  the  tetanic  symptoms 
may  be  due  to  reflex  irritation  of  motor  centres  in  the  spinal  cord  by 
the  local  disturbance,  rather  than  to  any  intermediate  influence  of 
bacilli  or  toxins  acting  through  the  blood. 

It  is  important  to  remark,  with  reference  to  the  possibility  of  the 
occurrence  of  idiopathic  tetanus,  that  the  reported  cases  of  this  nature 
have  in  most  instances  been  milder,  and  have  more  frequently  recovered 
than  the  traumatic  cases.  Still,  if  the  now  prevailing  view  be  correct 
that  the  disease  is  due  to  the  introduction  into  the  wound  of  certain 


780  SYSTEM  OF  MEDICINE 

special  bacteria,  there  must  be  some  lesion  to  admit  of  their  entrance. 
This  may  be  an  ulcer  in  the  mouth,  the  pharynx,  the  alimentary  canal 
(8),  or  in  some  other  undetected  part.  Possibly  the  proportion  of  re- 
coveries in  the  supposed  idiopathic  cases  is  attributable  to  the  fact  that 
the  undetected  local  lesion  is  small  in  them,  and  the  amount  or  virulence 
of  the  infection  less. 

Diagnosis. — Tetanus  may  be  distinguished  from  hydrophohia  by 
the  persistence  of  the  muscular  contraction  in  the  intervals  between 
the  spasms,  evinced  by  the  closure  of  the  jaws,  by  the  hardness  of  the 
abdomen,  also  by  the  cause  of  the  wound.  In  hydrophobia  there  is 
commonly  more  wildness  of  expression,  more  movement,  more  jerking  of 
the  limbs,  greater  apprehension  of  taking  any  fluid.  Even  the  mere  ap- 
proach of  a  drinking  cup  may  throw  the  sufferer  into  violent  spasms. 

There  is  a  variety  of  tetanus,  a  sort  of  modification  of  trismus,  described 
by  German  writers  as  kopftetantcs,  or  head-tetanus,  the  special  features  of 
which  are  that  it  is  caused  by  some  injury  to  the  face,  and  is  attended 
with  paralysis  of  the  side  of  the  face  injured.  I  have  seen  the  following 
examples  of  it :  —  (I.)  A  man,  set.  35,  in  the  Norwich  Hospital  in  1837, 
with  a  wound  in  the  forehead  caused  by  a  fall  from  a  cart,  lacerating 
the  occipito-frontalis  but  not  exposing  the  bone.  The  symptoms  began 
a  week  afterwards  with  stiffness  of  the  neck  and  jaws,  and  paralysis  of 
the  right  side  of  the  face,  the  mouth  being  drawn  to  the  left.  These 
were  followed  by  frequent  severe  spasms  of  the  jaw  and  body  muscles, 
more  especially  of  the  fore  part  of  the  body,  the  man  bending  forwards 
and  clasping  his  knees  with  his  hands,  this  being  attended  with  much 
suffering  and  difficulty  of  breathing.  There  was  no  loss  of  consciousness. 
He  died  the  day  after  his  admission.  The  brain  presented  no  morbid 
appearance.  The  spinal  marrow  and  the  lining  membrane  of  the  larynx 
were  ratlier  vascular.  (II.)  A  man,  aet.  34,  was  kicked  and  wounded 
about  the  head  and  face,  19th  December  1858.  On  the  morning  of  the 
27th  he  could  not  open  his  mouth  wide.  On  the  following  night  he  was 
troubled  and  kept  awake  by  sudden  closure  of  the  jaws  biting  his  tongue. 
This  occurred  each  night  and  was  a  source  of  much  pain.  On  the  4th 
of  January  he  came  into  Addenbrooke's  Hospital.  There  Avas  a  festering 
wound  on  the  bridge  of  the  nose  and  scars  on  the  forehead;  also  imper- 
fect power  of  movement  of  both  sides  of  the  face,  especially  of  the  right 
side  amounting  to  facial  paralysis  ;  inability  to  open  the  mouth  and  pro- 
trude the  tongue;  tension  of  abdominal  muscles ;  voice  indistinct ;  when  he 
tried  to  speak  he  put  his  finger  into  his  mouth  to  prevent  the  lips,  which 
were  drawn  to  the  left,  being  pressed  between  the  teeth  on  the  right  side ; 
difficulty  in  swallowing,  partly  owing  to  the  difficulty  in  deglutition  and 
partly  to  the  fluid  being  returned  between  the  lips.  The  introduction  of 
a  tube  into  the  pharynx  caused  severe  general  spasm ;  enemata  of  beef- 
tea  and  port  wine  were  therefore  given  twice  daily.  The  choking  and 
throat  spasms  caused  by  accumulation  of  phlegm  in  the  fauces  were  much 
relieved  by  smoking  tobacco.  He  gradually  recovered,  and  the  facial 
paralysis  nearly  or  quite  ceased.    (III.)  A  man,  set.  42,  was  admitted  into 


TETANUS  781 

Addenbrooke's  21st  March  1891,  with  a  wound  under  the  left  eye  by  a 
kick  from  a  horse.  There  was  paralysis  of  that  side  of  the  face,  with 
clenching  of  the  jaws,  abdominal  tension,  and  laryngeal  spasms.  These 
last  were  so  severe  and  almost  asphyxiating  during  the  night  that  tra- 
cheotomy was  performed,  with  great  relief.  On  the  23d  he  became  quiet, 
but  for  some  days  coughing  and  choking  was  caused  by  milk  and  other 
fluids  passing  into  the  trachea  and  bronchi,  and  escapiug  through  the 
wound  in  the  throat.  This  gradually  ceased  and  he  got  well.  During 
the  spasms  which  occurred  under  chloroform,  and  subsequently  through 
the  night,  the  back  and  limbs,  as  well  as  the  right  side  of  the  face, 
were  affected.  (IV.)  A  strong,  healthy  man,  ajt.  28,  on  4th  February 
1895,  fell  on  to  a  heap  of  dirt,  and  cut  the  cheek  just  below  the  left  eye- 
lid. The  wound  was  cleaned,  dressed,  and  united  by  sutures  at  the 
hospital.  On  the  6th  it  was  again  dressed  and  was  doing  fairly  well. 
On  the  10th  he  felt  a  little  stiffness  of  the  jaws.  On  the  11th  the  wound 
was  again  dressed,  but  the  stiffness  of  the  face  did  not  attract  much 
attention.  On  the  12th  this  symptom  had  increased.  On  the  13th  he 
was  admitted  into  the  hospital.  Milk  was  given,  but  he  became  less 
and  less  able  to  swallow  it.  On  the  morning  of  the  16th,  when  I  first 
saw  him,  the  affection  had  increased  considerably.  He  was  unable  to 
open, the  mouth  or  protrude  the  tongue.  The  attempt  to  do  so  caused 
severe  spasms  of  the  face,  neck,  and  back,  inducing  a  certain  amount  of 
opisthotonos,  also  decided  spasm  of  the  front  of  the  neck  with  blueness 
of  the  face.  There  was  no  hardness  of  the  abdomen  and  no  spasm  of  the 
limbs.  Decided  paralysis  of  the  left  side  of  the  face,  the  mouth  was 
drawn  to  the  right,  the  eyelids  could  not  be  closed,  and  the  left  pupil 
was  dilated.  He  had  been  able  to  swallow  very  little  during  the  night. 
The  case  was  evidently  urgent.  Antitoxin  was  telegraphed  for,-  but 
before  it  arrived  or  other  measures  were  taken  he  had  a  severe  spasm, 
during  which  he  became  blue  and  died  evidently  from  laryngeal  stop- 
page of  the  breath.  On  post-mortem  examination  on  the  18th  no  trace 
of  disease  was  discovered. 

It  will  be  observed  that  in  all  these  cases,  in  addition  to  the  wound 
of  the  face  with  paralysis,  clenching  of  the  jaws,  and  tension  of  the 
abdominal  muscles,  there  was  spasm  or  paralysis  of  the  glottis  which 
constituted  the  most  urgent  symptom.  This  was  fatal  in  ISTo.  IV.,  prob- 
ably also  in  No.  I.,  and  required  tracheotomy  in  No.  III. ;  in  No.  II.  the 
pipe  of  tobacco  seemed  to  give  relief.  The  paralysis  of  the  glottis  permit- 
ting fluids  to  pass  from  the  mouth  into  the  respiratory  passages  was  a  very 
troublesome  feature  in  No.  III. ;  and  in  No.  IV.  the  pupil  was  dilated. 
In  I.,  II.,  and  III.  the  muscular  affection  did  not  extend  beyond  the  ab- 
domen, where  it  caused  firmness  of  the  abdominal  wall ;  but  in  No.  IV. 
the  back  muscles  were  affected,  and  the  abdomen  was  soft.  In  all  the 
limbs  were  free.  The  facial  paralysis  is  difficult  to  explain.  It  has 
been  attributed  to  swelling  or  some  inflammatory  or  other  influence 
radiating  from  the  wound  and  involving  the  facial  nerve,  to  i7iflamma- 
tion  of  the  nerve  in  its  course  through  the  temporal  bone  or  on  the  crania] 


782  SYSTEM  OF  MEDICINE 

side  of  that  bone,  but  no  satisfactory  conclusion  has  been  arrived  at.  In 
No.  IV.  the  paralysis  extended  to  the  iris.  There  was  no  loss  of  con- 
sciousness or  of  sensation  in  the  parts  affected  in  any  of  the  cases. 

E.ose,  in  the  article  before  mentioned,  gives  two  similar  cases,  in  one 
of  them  the  affection  extended  to  the  limbs  and  the  patient  died  ;  in  the 
other  recovery  took  place.  In  the  early  part  of  last  year  a  case  of  kopf- 
tetanus  was  related  lay  Caretti.  There  was  a  lacerated,  contused  wound 
of  the  forehead,  paralysis  of  the  face  on  both  sides,  and  trismus.  The 
arrest  of  the  malady  was  attributed  to  the  use  of  antitoxin.  Another 
case  in  which  the  cure  was  also  attributed  to  antitoxin  is  there  quoted. 
[See  also  22.] 

The  spasms  of  strychma  poisoning  somewhat  resemble  those  of 
tetanus ;  but  they  are  more  sudden  and  more  rapid  in  sequence,  affect- 
ing the  whole  frame,  including  the  digits.  The  muscular  relaxation  in 
the  intervals  of  the  spasms  is  more  complete.  The  affection  is  more 
quickly  fatal,  or  on  the  other  hand  subsides;  a  speedy  termination 
which  contrasts  with  the  somewhat  slower  course  of  tetanus,  esj)ecially 
of  those  cases  of  tetanus  in  which  there  is  no  discoverable  external 
lesion.     Strychnia  may  be  found  in  the  urine. 

Tetany,  so-called  from  its  simulating  tetanus,  is  a  spasmodic  affection 
resulting  from  an  irritated  condition  of  the  nervous  centres,  either  origi- 
nating there,  or  transmitted  from  some  disorder  of  other  parts,  such  as 
the  stomach  or  bowels,  the  uterus,  the  urinary  or  genital  organs.  It 
appears  to  be  less  common  in  this  country  than  in  other  regions.  The 
spasms  progress  less  steadily  and  recur  less  regularly  than  those  of 
tetanus,  and  they  are  attended  with  less  wear  of  the  system.  Often 
they  are  localised,  and  not  unfrequently  they  are  confined  to  the  hands 
and  feet ;  this  is  particularly  the  case  in  children,  in  whom  the  malady, 
often  associated  with  rickets,  easily  yields  to  treatment,  or  subsides 
spontaneously.  In  some  instances  the  spasms  are  more  general,  more 
severe,  or  more  frequent,  and  they  may  lead  even  to  a  fatal  termination. 
This  has  occurred  in  several  cases  after  complete  removal  of  the  thyroid 
gland,  and  under  these  circumstances  the  diagnosis  from  tetanus  might 
be  difficult.  One  cause  of  tetany,  at  any  rate,  appears  to  be  a  deficiency 
in  the  secretion  of  the  thyroid  gland ;  and  cases  of  its  cure,  either  after 
removal  of  the  gland  or  otherwise,  by  administration  of  the  thyroid 
extract,  were  published  last  year  by  Dr.  Byrom  Bramwell  (23).  If  this 
sequence  be  verified  thyroid  extract  would  serve  as  a  ready  means  of 
diagnosis.  Sudden  and  fatal  attacks  of  tetany  sometimes  occur  in  cases 
of  dilatation  of  the  stomach. 

The  following  case,  which  I  saw  in  consultation  with  Dr.  Buckenham 
and  Dr.  Lawrence  Humphry,  the  latter  of  whom  has  kindly  given  me 
the  notes,  may  be  regarded  as  an  example  of  the  severe  form  of  tetany. 

A  pale,  thin,  anxious  looking  lad,  set.  13,  sitting  on  a  sofa  with  the 
head  bent  on  to  the  chest,  and  rigidly  fixed  in  that  position ;  knees 
firmly  extended,  and  rectus  abdominis  contracted,  mapped  into  squares, 
and   bending  the  body  forward ;    upper  limbs  stiff,  but  not  so  fixed 


TETANUS  783 


as  the  lower ;  muscles  of  back  rigid,  and  sterno-mastoid  and  trapezius 
especially  so ;  muscles  of  face  not  rigid ;  he  could  open  his  mouth  and 
put  out  his  tongue,  which  was  much  scarred ;  tenderness  over  fourth  and 
fifth  cervical  vertebrae,  which  were  rendered  prominent  by  the  bending 
of  the  neck ;  temperature  100°,  pulse  90.  Slight  spasms  during  the  day 
were  easily  brought  on  by  movement,  swallowing,  or  any  irritation.  At 
night  these  were  severe,  causing  him  to  bite  his  tongue  and  cry  out,  and 
his  respiration  was  then  difficult ;  no  loss  of  consciousness  during  the 
spasms,  or  at  other  times,  and  no  fits.  The  affection  began  three  weeks 
previously  without  apparent  cause,  with  spasms  of  the  jaw  causing  him 
to  bite  his  tongue.  The  spasms  extended  and  increased  in  severity. 
They  continued  in  spite  of  various  treatment,  and  he  died  in  a  month 
(seven  weeks  from  the  commencement  of  the  attack)  of  exhaustion. 
A  post-mortem  examination  could  not  be  obtained.  It  was  stated  that 
he  had  a  similar  attack,  not  so  severe,  three  years  before,  and  recovered. 

Among  the  many  features  which  liysteria  and  liystero-epilepsy  occasion- 
ally assume  are  spasmodic  or  convulsive  seizures  ;  these  may  present  some 
resemblance  to  tetanus,  but  can  scarcely  be  mistaken  for  it.  The  sex, 
appearance,  general  character  of  the  patient's  constitution,  and  the  char- 
acter of  the  seizures,  are  commonly  sufficient  to  indicate  the  nature  of  the 
malady.  The  writhing,  the  distortion  of  features,  the  laughing  or  crying, 
the  hallucinations,  the  more  or  less  complete  anaesthesia  or  paralysis  of 
parts  of  the  body,  the  affections  of  consciousness,  most  of  which  are  due 
to  influences  acting  on  the  cerebral  hemispheres,  are  very  unlike  the 
manifestations  of  spinal  excitement  which  we  witness  in  tetanus. 

Treatment.  —  With  regard  to  the  treatment  of  tetanus  it  is  necessary 
to  bear  in  mind,  firstly,  that,  like  most  other  diseases  caused  by  toxic 
agencies  in  the  blood,  it  runs  a  definite  course,  having,  as  it  were,  a 
certain  life-history  —  a  period  of  incubation  which  varies  from  a  few 
hours  to  several  weeks,  a  period  of  increase,  and  a  period  of  decline. 
These  may  not  be  defined  or  regular  as  to  their  time  of  occurrence  or 
duration,  but  they  clearly  exist ;  and  the  severity  and  impression  of  the 
attack  upon  the  system  may  be  taken  as  proportionate  to  the  amount 
and  virulence  of  the  admitted  poison  as  compared  with  the  resisting 
powers  of  the  individual.  Secondly,  as  already  mentioned,  the  symptoms 
of  tetanus  are  usually  seen  first  in  the  muscles  of  the  neck,  jaws,  and 
face.  This  early  condition  has  been  called  trismus ;  and  if  the  affec- 
tion go  no  further  the  patient  commonly  recovers.  TJiirdly,  we  have 
hitherto,  that  is  to  say  till  recently,  known  of  no  antidote  or  agency 
whereby  the  poison  could  be  neutralised  or  its  influence  upon  the  sys- 
tem mitigated.  Fourthly,  our  means  of  modifying  the  poison  being  very 
small,  the  contest  lies  between  the  strength  of  the  attacking  poison  and 
the  resisting  strength  of  the  tissues ;  and  the  treatment  resolves  itself 
mainly  into  the  adoption  of  measures  which  may  increase  the  latter 
and  enable  the  patient  to  hold  on  till  the  malady  runs  its  course  and 
terminates  by  resolution.  The  alleviation  of  particular  symptoms,  such 
as  the  spasms,  may  do  something  to  alleviate  the  distress,  but  little 


784  SYSTEM  OF  MEDICINE 

to  modify  the  progress  of  the  malady ;  and  the  drugs  employed  for  the 
purpose  have  often  done,  on  the  whole,  more  harm  than  good.  The  only 
hopeful  means  of  treatment  has  hitherto  consisted  in  the  endeavour  to 
maintain  the  strength  by  the  administration  of  nutriment  —  this  being 
especially  indicated  by  the  wasting  and  exhausting  influence  which,  as 
already  mentioned,  forms  so  prominent  a  feature  of  the  disease.  Un- 
fortunately, in  most  of  the  severe  cases  this  cannot  be  efficiently  carried 
out  owing  to  the  difficulty  of  swallowing ;  and  the  difficulty  of  giving 
enemata  is  often  such  that  they  cannot  be  continued,  though  in  some 
cases  they  are  well  borne  and  should  then  be  persevered  with.  When 
food  cannot  be  swallowed  recovery  rarely  takes  place,  and  nothing  can 
be  relied  on  even  to  postpone  the  fatal  event.  A  great  variety  of  drugs, 
chiefly  of  the  sedative  kind,  have  been  tried ;  some  have  been  thought, 
in  particular  cases,  to  have  done  good,  but  no  decidedly  good  results  have 
been  obtained.  Even  the  relief  from  distress  Avhich  may  be  produced 
by  them  does  not  seem  in  the  severe  cases  to  influence  the  progress 
of  the  malady  materially,  and  the  mild  cases  in  which  they  have  seemed 
beneficial  would  probably  have  recovered  without  them.  Electricity, 
antipyrin,  and  cold  baths  have  been  used,  as  well  as  injections  of  car- 
bolic acid,  phenol,  and  corrosive  sublimate  ;  but  the  cases  in  Avhich  benefit 
is  reported  have  been  of  the  mild  type.  In  short,  whenever  the  patient 
can  be  induced  to  swallow,  the  administration  of  nutriment  should  be 
regarded  as  the  sheet  anchor,  and  no  medicinal  treatment  should  be 
allowed  to  interfere  with  it.  Unhappily,  even  in  these  milder  cases 
it  will  often  fail,  but,  saving  the  antitoxin  method,  we  have  no  hopeful 
resource.  The  worst  case  in  which  I  ever  saw  recovery  was  that  of  an 
infant  from  whom  I  had  removed  a  large  adipose  or  fibro-adipose  tumour 
situated  in  the  back  of  the  neck.  The  spasms  were  frequent  and  so  se- 
vere that,  on  several  occasions,  we  thought  the  child  was  dead.  She  con- 
tinued, however,  in  the  intervals  to  swallow  milk.  I  did  not  allow  any 
medicine  to  be  given,  but  relied  exclusively  upon  the  milk.  Gradually 
the  spasms  became  weaker  and  less  frequent,  the  malady  ran  its  course, 
and  the  child  recovered.  I  once  went  several  miles  to  see  a  case  of 
tetanus  in  a  man,  employed  in  the  stables  of  a  horsedealer,  who  had  been 
accidentally  shot  in  tlie  back  of  the  thigh  by  his  master.  I  directed  the 
administration  of  port  wine,  beef-tea,  and  eggs,  as  much  as  he  could  take, 
and  prohibited  all  medicine.  It  was  rather  a  severe  case,  but  the  man 
got  well.  I  have  had  other  cases  treated  in  the  same  manner  and  with 
the  like  result.  All,  be  it  remarked,  were  able  to  swallow,  though  some 
with  difficulty,  and  were  therefore  of  the  milder  type.  It  is  surprising 
how  much  nourishment  can  be  taken  and  well  borne  in  these  cases,  which 
indicates  that  there  is  no  failure  in  the  digestive  and  assimilative  powers. 
In  the  earlier  years  of  my  practice  I  tried  a  variety  of  drugs  very 
perseveringly,  but  without  any  appreciably  good  effect.  In  some  in- 
stances I  thought  they  had  done  harm ;  and  I  came  to  the  conclusion, 
after  many  struggles  Avith  the  disease,  that  I  could  not  boast  of  any 
success  even  in  prolonging  life  by  these  means.     Most  if  not  all  of 


TETANUS  785 

these  drugs — such  as  morphia,  aconite,  Indian  hemp,  chloroform,  chloral 
—  were  given  with  the  view  of  lessening  the  spasms  which,  after  all,  as 
I  have  just  said,  are  but  a  symptom  of  the  disease ;  and  I  found,  in 
some  instances,  that  when  the  spasms  had  been  delayed  they  recurred 
after  the  interval  with  the  greater  severity.  In  one  case,  where  the 
wound  was  in  the  thigh,  I  kept  the  patient  continuously  under  the  influ- 
ence of  chloroform  for  several  hours.  Then  a  violent  spasm  occurred 
and  was  fatal.  In  another  case,  that  of  a  young  gentleman  who  had 
received  the  charge  of  a  gun  in  the  buttock,  and  in  whom  the  spasms 
were  frequent  and  se,vere,  at  the  request  of  himself  and  his  friends,  whom 
I  warned  that  it  would  do  no  good,  I  kept  up  the  influence  of  chloroform  ; 
and  though  the  spasms  were  in  great  measure  controlled  by  it,  I  thought 
that  it  rather  shortened  life.  In  yet  another  case  a  severe  and  nearly 
fatal  spasm  was  induced  by  the  administration  of  chloroform  before 
amputation  of  the  damaged  leg.  After  the  operation  and  the  chloroform 
there  was  a  temporary  cessation  of  spasm,  but  the  disease  ran  a  fatal 
course.  I  may  observe  that  the  effect  of  chloroform  varied  much  in 
different  cases  :  in  some,  as  in  the  case  just  mentioned,  its  administra- 
tion caused  violent  spasms ;  in  others  these  did  not  occur.  In  some  its 
administration  was  followed  by  a  period  of  quietude  and  relief  from  all 
distress  ;  in  others  the  spasms  seemed  to  be  rather  aggravated,  and  the 
patient  was  weaker,  as  though  the  chloroform  left  him  more  susceptible 
and  less  able  to  bear  the  attacks.  I  had  some  hope  from  tobacco  given 
in  the  form  of  an  enema-,  but  it  had  to  be  used  with  much  caution  on 
account  of  its  great  depressing  effect,  and  after  several  trials  I  was  not 
convinced  that  it  afforded  any  sufiicient  compensating  advantage.  One 
man  smoked  incessantly  and  got  well,  but  it  was  not  a  severe  case ;  in 
others  the  smoking  did  no  good.  Nicotine  also  proved  of  no  avail.  In 
so  far  as  these  sedatives  have  any  initial  action  of  stimulation  of  the 
ganglionic  and  other  nerves  they  may  indeed  do  harm.  Chloral  gives 
some  relief  and  sleep,  and  perhaps  enables  the  patient  to  swallow.  In 
the  case  of  the  chronic  ulcer  of  the  leg  I  have  mentioned  —  a  woman 
aet.  50  —  the  dyspnoea  from  closure  of  the  glottis  during  the  spasms  was 
so  urgent  that  I  performed  tracheotomy.  It  relieved  that  symptom, 
and  the  spasms,  for  a  time,  were  less  severe ;  but  she  became  weaker, 
and  died  on  the  twenty-second  day  from  the  commencement  of  the 
attack.  Opium  and  Indian  hemp  in  large  doses  did  no  real  good ;  and 
the  same,  on  the  whole,  has  been  the  experience  of  others.  The  extract 
of  Indian  hemp,  in  one  case  that  I  saw,  was  found  after  death  to  have 
accumulated  into  a  dangerous  mass  in  the  stomach,  where  it  had  not 
been  digested  or  absorbed.  I  came,  therefore,  long  ago,  to  the  conclusion 
that  the  administration  of  nutriment  was  the  only  hopeful  treatment; 
that  where  this  could  be  done  nothing  should  be  allowed  to  interfere 
with  it,  and  that  where  it  could  not  be  done  it  mattered  little  what 
measures  were  adopted,  the  result  being  almost  invariably  fatal.  It 
need  scarcely  be  added  that  the  patient  should  be  kept  quiet  and  pro- 
tected from  cold,  and  from  all  draughts  and  other  external  irritants. 

VOL.  I  3  E 


786  SYSTEM   OF  MEDICINE 


TJie  ivound  should  be  cleansed  from  all  foreign  substances,  and 
freely  soaked  with  antiseptic  solutions.  Removal  of  the  limb  by 
amputation,  also  division  or  stretching  of  the  nerves  connected  with 
the  wounded  part,  have  been  resorted  to,  but  rarely  with  good  result. 
The  poison  has  already  entered  the  system,  and  is  working  its  evil  way 
there;  and  as  in  the  case  of  hydrophobia,  and  of  primary  syphilitic 
sores  when  the  glands  are  affected,  the  further  progress  of  the  malady 
does  not  appear  to  be  much  influenced  by  the  removal  of  the  primary 
source  of  infection.  Where  a  good  result  has  followed,  the  same  would 
probably  have  ensued  had  there  been  no  surgical  interference.  Thus, 
in  a  lad  sdt.  13,  admitted  into  Addenbrooke's  a  fortnight  after  a  contused 
wound  of  the  fourth  and  fifth  fingers,  the  fourth  finger,  which  was  in  a 
foul  state,  was  ampiitated  under  chloroform,  a  bad  spasm  occurring 
when  he  was  being  anaesthetised.  The  spasms  were  not  very  severe, 
the  temperature  never  rose  above  100",  and  he  took  nourishment. 
Chloral  hydrate  and  bromide  of  potassium  were  given;  the  spasms 
diminished  in  frequency  and  severity  till  April  16th,  when  the  last 
occurred,  and  he  got  quite  well.  Gross  (i.  633)  relates  that  in  a  case 
of  tetanus  he  dissected  out  from  the  face  of  a  girl  a  tender  cicatrix 
which  had  followed  a  lesion  from  a  splinter  of  wood  a  month  before 
the  occurrence  of  tetanic  sjmiptoms ;  no  further  paroxysms  occurred. 
On  the  other  hand  I  have  seen  amputation  of  the  leg  in  four  cases  in 
which  tetanus  ensued  upon  injuries  to  the  foot,  but  without  good  effect 
in  any.  A  more  favourable  view  of  the  operation  seems  to  be  afforded 
by  the  Surgical  History  of  the  War  of  the  Rebellion  in  America  (vide 
Appendix),  where  it  is  stated  that  the  operation  was  resorted  to  in 
twenty-nine  cases  after  incipient  tetanic  symptoms,  with  favourable  re- 
sults in  ten.  It  is  not  stated  whether  in  these  cases  the  disease  was 
acute  or  chronic,  though  it  would  appear  to  have  been  acute  in  four  out 
of  the  seven  cases  related.  The  observation  that  the  bacillus  germinates 
chiefly  in  the  deeper  parts  of  the  wound,  and  disseminates  itself  in  the 
surrounding  tissues,  renders  free  excision  or  amputation  necessary  if 
any  local  measure  of  this  sort  is  attempted ;  and  of  no  less  importance 
for  the  prevention  of  tetanus  is  the  free  cleansing  of  the  wound  with 
antiseptic  solutions  in  all  cases  if,  as  appears  to  be  the  fact,  the  bacilli 
have  their  seat  and  residence  in  and  near  the  wound,  where  they  gen- 
erate the  toxin  which  enters  the  blood,  and  if  their  development  and 
increase  are  favoured  by  the  presence  of  pus.  « 

If  by  extraction  of  one  or  more  teeth,  or  by  the  nostril,  no  way  can 
be  made  for  the  passage  of  a  tube,  the  operation  of  r/astrostoiny  has  been 
rendered  comparatively  so  safe  and  simple  by  the  modern  appliances  of 
surgery,  that  it  might  be  resorted  to  in  some  of  those  cases  of  medium 
severity  in  which  swallowing  is  difficult  or  cannot  be  accomplished. 
The  requisite  steps  should  be  taken  to  open  the  stomach  at  once  and 
introduce  a  tube  through  which  nourishment' may  be  passed  with  a  free 
hand.  I  am  not  aware  that  this  proceeding  has  been  tried  or  even 
suggested;  but  I  think  it  deserves  consideration,  and  it  might  prove  an 


TETANUS  787 


assistant  to  the  treatment  with  antitoxin  by  maintaining  tlie  strength 
during  the  days  in  which  that  remedy  is  being  employed. 

For  a  new  hope  is  dawning  with  regard  to  the  treatment  of  this  and 
of  otlier  affections,  dependent  like  it  upon  a  toxic  infection  of  the  blood; 
a  hope  based  upon  a  method  which  is  really  antidotal,  and  consists  in  the 
introduction  into  the  system  of  a  material  engendered  by  the  poison  or 
toxin,  and  called  antitoxin.  Should  this  hope  be  realised  in  the  future 
application  of  the  method,  one  which  concerns  not  tetanus  only  but 
other  kindred  diseases  also,  we  shall  be  able  to  boast  of  the  most  impor- 
tant discovery  ever  made  in  therapeutics,  one  of  the  most  important 
ever  made  in  medicine — perhaps  the  greatest  and  most  beneficent  medi- 
cal discovery  of  our  generation.  In  what  manner  the  antitoxin  is  pro- 
duced, whether  by  the  toxin  stimulating  the  cells  or  other  tissues  of  the 
body  to  its  formation,  or  by  any  change,  such  as  an  increased  oxygena- 
tion, which  the  toxin  itself  undergoes,  or  from  the  disintegrating  bodies 
of  exhausted  or  dead  bacteria,  or  by  what  other  process,  is  not  clearly 
known.  It  seems  to  act,  like  the  toxin,  as  a  ferment.  Thus  we  have 
in  the  blood,  at  the  same  time,  the  two  ferments  —  the  poison  and  its 
antidote,  the  toxin  and  the  antitoxin  —  the  one  leading  to  the  production 
of  the  other ;  and  also,  somewhere  within  the  surface,  the  bacteria  which 
are  the  source  of  one  or  the  other,  of  the  poison  and  its  antidote,  or  of 
both.  In  the  case  of  diphtheria  this  therapeutic  method  is  so  far  gradu- 
ally gaining  ground.  In  tetanus  it  has  not  been  tried  in  a  sufficient 
number  of  severe  cases  to  enable  us  even  to  come  to  a  provisional 
conclusion ;  and  some  at  least  of  the  milder  cases  might  have  recovered 
equally  well  without  it.  The  general  opinion,  however,  seems  to  be 
that  in  many  of  the  cases  in  which  it  has  been  tried  it  has  so  far 
afforded  relief  as  to  justify  the  hope  that  further  experience  will  show, 
at  any  rate,  that  it  has  more  potency  in  resisting  and  overcoming  the 
malady  than  any  other  agent  which  has  yet  been  tried  (9).  We  read 
that  in  several  cases  of  the  milder  kind  where  it  has  been  tried  the 
spasms  have  been  mitigated,  and  the  amount  of  toxin  in  the  urine  has 
been  reduced ;  there  seems  to  be  no  record  of  any  acute  case  in  which  the 
antitoxin  treatment  was  even  of  temporary  benefit.  It  has  been  noted 
also  that  the  symptoms  have  returned  during  the  temporary  suspension 
of  the  injections,  to  be  mitigated  again  on  their  resumption.  We  read, 
too,  that  a  large  proportion  of  the  recorded  cases  in  which  it  has  been 
used  have  recovered,  though,  as  I  have  already  said,  these  were  chiefly 
of  the  milder  type  (10) ;  it  does  not  seem  to  have  been  productive  of 
ill  effects  in  any  of  the  cases.  In  most  cases  the  relief  afforded  by 
the  antitoxin  injections,  if  any,  was  soon  manifested.  In  some  there 
was  a  longer  interval,  the  symptoms  continuing  unabated  or  even  in- 
creasing at  first,  though  they  ultimately  yielded  to  the  influence.  In  two 
cases  of  "  kopftetanus "  referred  to  above  the  good  results  were  attrib- 
uted to  the  use  of  antitoxin.  These  and  other  variations  in  the  effects 
of  the  agent  may  not  improbably  have  depended  on  variations  in  its 
strength  and  quality  or  on  the  method  of  its  preparation.     Respecting 


788  SYSTEM   OF  MEDICINE 

all  this  there  is  much  to  be  learned,  and  we  must  look  for  practical 
information  concerning  the  antitoxin  treatment  of  tetanus,  in  the  main, 
to  those  countries  in  which  the  disease  is  more  frequent  than  happily  it 
is  in  our  temperate  regions.  In  our  own  country  the  cases  are  compara- 
tively few  and  sporadic,  and  they  occur  without  any  warning ;  there  is 
nothing  in  the  nature  of  the  local  lesion  to  give  intimation  of  the  prob- 
ability of  so  serious  a  complication.  Hence  the  practitioner  is  probably 
not  at  once  prepared  with  the  means  of  giving  trial  to  the  antitoxin 
treatment.  Happily  the  remedy  is  becoming  less  expensive  and  more 
easily  procurable  in  an  emergency.  It  may  now  be  obtained  from 
Messrs.  Allen  and  Hanbury,  in  Plough  Court,  E.G.,  at  a  moderate  cost, 
though  as  many  as  thirty  injections  or  more  may  be  required  in  the 
treatment  of  a  single  case.  It  must  be  used  early ;  the  cases,  therefore, 
in  which  it  can  be  tried  with  good  hope  of  success  are  few,  and  some  time 
must  elapse  before  we  can  form  a  true  estimate  of  its  value.  We  should, 
at  any  rate,  whether  we  resort  to  the  new  remedy  or  not,  persist  in  the 
plan  of  treatment  which  I  have  indicated,  and  maintain  the  strength  of 
the  patient  till  the  storm  is  overpast,  in  the  hope  that  the  vessel  may  be 
enabled  to  weather  its  blasts. 

When  the  disease  subsides  the  spasms  become  less  severe  and  less 
frequent,  the  face  more  natural,  and  the  periods  of  sleep  longer  and  less 
disturbed.  For  a  considerable  time  after  all  spasms  have  subsided  a 
sense  of  stiffness,  as  if  from  cold  or  rheumatism,  is  experienced  in  various 
parts ;  it  is  longest  felt  in  the  neck,  back,  and  loins,  and  is  liable  to  be 
increased  by  exposure  to  damp  or  cold,  or  by  fatigue.  It  is  in  some 
cases  felt  about  the  jaws  for  months.  Much  care  in  diet  and  in  the 
avoidance  of  cold  should  be  enjoined,  for  instances  have  occurred  in 
which  the  disease  has  returned  after  many  days  somewhat  in  the  man- 
ner of  relapsing  fever. 

Morbid  Anatomy.  —  The  examination  post-mortem  in  cases  of  tetanus 
has  commonly  revealed  to  the  naked  eye  no  trace  of  disease  in  any  part 
of  the  body.  Naturally,  attention  has  been  directed  chiefly  to  the 
nervous  system;  but  here,  for  the  most  part,  whether  in  the  brain, 
spinal  cord,  meninges,  or  nerves,  nothing  abnormal  has  been  discovered. 
In  a  few  cases,  it  is  true,  congestion  has  been  observed  in  the  spinal  cord, 
or  in  its  membranes,  or  in  both,  more  particularly  about  the  regions  con- 
nected with  the  nerves  of  the  injured  part.  This  congestion  has,  in  some 
instances,  been  attended  with  changes  or  degenerated  conditions  in  the 
gray  matter  of  the  cord,  and  some  swelling.  Thus  an  instance  is  related 
by  Dr.  Dickinson  (11),  in  which  there  was,  in  addition  to  the  congestion 
of  the  dura  mater  and  the  pia  mater,  swelling  of  the  cervical  and  lumbar 
portions  of  the  cord  caused  by  transparent  exudation  into  the  substance 
of  the  cord  with  consequent  lesion  of  the  substance.  Lockhart  Clarke 
and  Clifford  Allbutt  also  found  swelling  and  areas  of  disintegration  of  the 
gray  matter  of  the  cord  with  exudation  of  finely  granular  matter  and 
debris  of  blood  and  vessels.  The  nerves  in  the  neighbourhood  of  the 
wound  have  also  been  found  inflamed.     These  occasional  appearances 


TETANUS 


789 


confirm  the  view,  which  on  other  grounds  can  scarcely  be  doubted,  that 
the  tetanus  poison  vents  itself  in  an  esjjecial  manner  upon  the  spinal 
cord,  causing  functional  disturbance;  though  it  is  usually  attended 
with  little  or  no  gross  structural  lesion.  This  absence  of  actual  nerve 
lesion  formed  an  argument  (12)  against  the  supposition  that  the  real, 
at  any  rate  the  primary  seat  of  the  disease  was  in  the  nervous  system 
itself,  and  prepared  us  for  or  suggested  the  view,  since  confirmed  by  the 
bacteriological  investigations,  that  blood-poisoning  by  noxious  material 
introduced  into  the  system  must  be  the  essential  cause  of  the  malady. 
The  rUjor  mortis  is  said  to  persist  long  (13).  As  already  stated,  cer- 
tain muscles  have  been  found  ruptured,  and  even  bones  broken,  by  the 
force  of  the  spasmodic  contraction  of  the  muscles. 

Infantile  Tetanus  (TetMius  neonatorum) 

Is  commonly,  and  probably  with  reason,  attributed  to  some  infection 
taking  place  at  the  umbilicus.  I  have  only  seen  one  case:  the  child 
was  stiff  all  over,  persistently  so,  as  far  as  I  could  judge,  and  did  not 
live  long.  Eseherich  (14)  has  tried  the  antitoxin  treatment  in  four  of 
these  cases,  of  which  one  recovered.  In  case  1  the  doses  administered 
were  too  small  in  quantity;  in  case  4  the  disease  was  exceptionally 
severe,  so  that  a  good  result  could  not  be  expected;  in  case  3  the  injec- 
tions had  to  be  discontinued  in  consequence  of  the  onset  of  septic  pneu- 
monia. Inoculation  of  mice  from  two  of  the  cases  (1  and  4)  with  a  bit 
of  tissue  taken  from  near  the  umbilicus  caused  typical  tetanus ;  but  in 
the  other  cases  the  inoculation  was  without  result.  The  disease  is  said 
to  be  common  in  some  regions,  especially  in  India,  where  antitoxin  has 
been  tried,  at  least  in  one  case,  but  with  no  good  result  (15). 


APPENDIX 

History  of  War  of  Rebellion.  —  The  fullest  statistical  record  hitherto  pub- 
lished is  to  be  found  iu  that  marvellous  compilation  and  evidence  of  American 
work,  the  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  third  surgical 
vol.  p.  818.  Of  246,712  injuries  by  weapons  of  war  505  (0-20)  per  cent,  or  a 
little  over  2  in  1000,  were  followed  by  tetanus,  which  is  regarded  as  not  a  large 
profjortion.     The  seat  of  the  injury  and  the  result  are  tabulated  as  follows :  — 


Seat  of  Injury. 

Total  Cases. 

Kecoveries. 

Deaths. 

Katio  of 
Mortality. 

Head,  face,  neck  .... 

Trunk   

Upper  extremity   .... 
Lower  extremity  .... 
Aggregate 

21 

55 

137 

202 

1 

5 
18 
30 

20 

50 

119 

252 

95-2 
90-9 
86-8 
89-7 

505 

64 

451 

89-3 

"The  belief  that  wounds  of  the  foot  and  hand  are  particularly  liable  to 
cause  tetanus  is  not  confirmed  by  the  cases  recorded  during  the  war."     The 


790  SYSTEM  OF  MEDICINE 

rarity  of  tetanic  complication  of  chest-wonnds  is  noted ;  and  in  all  but  one  of 
the  17  of  these  there  were  injuries  to  scapula,  shoulder,  or  arm. 

In  131  instances  tetanus  followed  closely  upon  operations  in  the  extremities, 
namely,  in  116  cases  after  amputations,  and  in  15  after  excision. 

The  recoveries  were  chiefly  in  the  slighter  or  more  chronic  cases ;  and  the 
later  the  occurrence  of  the  disease  after  the  injury  the  greater  the  chance  of 
life. 

In  6  cases  the  disease  occurred  within  twenty-four  hours  after  the  injury. 
Few  on  the  second,  third,  and  fourth  days.  From  the  fifth  day  the  number 
rapidly  increased  until  the  eighth,  when  it  diminished  till  the  fourteenth  day ; 
after  which  it  "  appeared  irregularly  "  —  in  one  not  till  seven  months  after  the 
injury. 

In  203,  one  more  than  one-half,  the  duration  of  the  disease  did  not  exceed 
three  days ;  of  these  only  two  recovered.  The  longest  duration  of  the  fatal 
cases  was  twenty-seven  days. 

In  several  instances  the  removal  of  the  missiles  or  foreign  bodies,  or  pieces 
of  bone,  seemed  to  have  quieted  the  threatening  symptoms. 

Amputation  was  resorted  to  in  29  instances  after  incipient  tetanic  symptoms ; 
10  of  the  cases  resulted  favourably.  This  is  very  strong  evidence  in  favour  of 
the  proceeding ;  but  it  is  not  stated  whether  the  disease  was  acute  or  chronic. 
In  4  of  the  seven  cases  related  it  would  appear  to  have  been  acute.  Relief  was 
afforded  by  the  chloroform  and  continued  after  the  operation.  No  anatomical 
lesions  of  the  medulla  oblongata  cerebellum  or  spinal  cord  were  found  in  the 
cases  that  were  examined  post-mortem. 

George  Murray  Humphry. 

REFERENCES 

1.  Dr.  miCAisE  in  International  Endi/opsedia  of  Surr/ery,  in.  607.  —  2.  Gross.  Sys- 
tem  of  Surgery,  i.  (329.  —  3.  Le  Gros  Clark.  Diagnosis  of  Visceral  Lesions,  p.  176. — 
4.  British  Medical  Journal,  Oct.  21,  1892,  Epitome,  No.  352. — 5.  Q.VAi'^'s  Dictionary 
of  Medicine,  1894,  ii.  104. — (i.  Ihid.  p.  99.  —  7.  Dr.  Parry.  Cases  of  Tetanus  and 
Hydrophobia.  —  8.  Bi-it.  Med.  Journal,  March  o,  1892;  Epitome,  No.  199. — 9.  Ibid. 
Sept.  15,  1894. —  10.  Dr.  John  Marriott  of  Northampton.  Brit.  Med.  Journal,  Jane 
19,  1895.  — 11.  Medico-Chirurg.  Trans,  vol.  xli.  — 12.  Bowlby  in  St.  Bartholomeio's 
Hospital  Reports,  xix.  — 13.  Curling,  p.  77.  — 14.  Escherich.  Brit.  Med.  Journal, 
Sept.  23,  1893;  Epitome,  No.  253.  — 15.  Ibid.  Jan.  19,  1895.  — 16.  Lockhart  Clarke. 
Medico-Chirurg.  Trans.  1865.  — 17.  Clifford  Allbutt.  Path.  Titans.  1871. — 
18.  Leyden.  Virch.  Arch.  1863.-19.  Coats.  Medico-Chirurg.  Trans.  1878.-20. 
Poland  and  Hulke.  Holmes'  System  of  Surgery,  1882.  — 21.  Rose.  Pitha  u.  Billroth 
Handbuch  der  Chirurgie,  §63. — 22.  Caretti.  Brit.  Med.  Journal,  Epitome,  March 
16,  1895.-23.  Bramwell.  Bnt.  Med.  Journal,  June  22,  1895.  —  24.  Trevelyan. 
Brit.  Med.  Journal,  Feb.  8,  1896. 

G.    M.   H. 

1.  Behring.  Das  Tetanusheilserum,  Leipzig,  1892;  see  also  his  Infection  und 
Disinfection,  1894;  and  Berlin,  klin.  Wochenschr.  No.  4,  1893.  —  2.  Behring  and 
Kitasato.  Deutsch.  med.  Wochenschr.  No.  49,  Dec.  1890.  —  3.  Brieger  and  Cohn. 
Cf.  Centralbl.  f.  Bakteriologie  u.  Parasitenkunde,  Bd.  xiv.  1893,  p.  711,  and  Bd.  xv. 
1891,  p.  442. — 4.  Brunner.  Deutsch.  med.  Wochenschr.  No.  5,  1894.  First  paper  pub- 
lished in  1892.-5.  Buschke  and  Oergel.  Deutsch.  med.  Wochenschr.  16th  Feb.  1893. 
Nachtrag  von  Dr.  Buschke. — 6.  Carle  and  Rattone.  Giornale  della  R.  Academia  di 
Medicina  di  Torino,  vol.  xlvii.  March  1884. — 7.  Goldscheider.  Zeitschrift  f.  klin. 
Med.  Bd.  xxvi.  1894.  —  8.  Gumprecht.  Deutsch.  med.  Wochenschr.  No.  26,  1894. — 9. 
Kanthack.  The  Medical  Chronicle,  May  IS95.  — 10.  Kitasato.  Zeitschnftf.  Hygiene, 
Bd.  vi.  Nov.  1889;  also  Congress  of  Hygiene,  London,  1892;  and  Zeitschrift  f.  Hygiene, 


ENTERIQ  FEVER  791 


Aug.  1892. —11.  KiTASATO  and  Weyl.  Zeitschrift  f.  Hygiene,  Bd.  viii.  1890,  p.  41.— 
12.  Klipstein.  Hygien.  Bundschau,  Ja.u.  Iii9'.i.  — 13.  Knud  Faber.  Om  Tetanus  som 
Itifektloassygdom.  Dissert.  Copenhageu,  1890.  Also '•  Die  Pathogeiiese  des  Tetanus," 
Berliner  klin.  Wochenfschr.  1890,  No.  31.  —  14.  KtJJJLER.  Centraloi.  f.  Bakt.  u.  Parasi- 
tenkunde,  Bd.  xvi.  181J4,  p.  838.  — 15.  Makchesi.  Annaii  uelC  1st.  u'igiene  Sperim. 
d.  E.  Univ.  di  Roma,  vol.  ii.  fasc.  i.  1892,  pp.  47-lJl.  —  IG.  Nicolaier.  Beitrdge 
zur  ^Hologie  des  Wundstarrkrampfes.  Dissert.  Giittingen,  1885. — 17.  Rosenbach. 
Lungenbeck's  Archiv,  xxxiv.  1880.  — 18.  Roux  and  Vaillard.  Annates  de  I'Institut 
Pasteur,  No.  2,  Feb.  1893.  —  19.  Simpson.  Edinburgh  Monthly  Journal  of  Medical 
Science,  Feb.  1854,  p.  97.  —  20.  Tizzoni  and  Cattani.  La  liifornia  Medica ;  and 
Ceutratbl.  f.  Bakterlologle  u.  Pcu-asitenk.  from  1890  onwards ;  also  Deutsch.  med. 
Wochenschr.  No.  6,  1894;  and  Berliner  klin.  Wochenschr.  Nos.  49-52,  Dec.  1893, 
and  Nos.  3  and  32,  18i)4. — 21.  Vaillard  and  Rouget.  Annates  de  I'Institut  Pas- 
teur, t.  vi.  1892,  t.  vii.  189.3,  p.  755.-22.  Vaillard  and  Vincent.  Annates  de  I'Institut 
Pasteur,  t.  v.  1892.  —  23.  Worthington,  G.  V.  Digest  0/  Sixty-eight  Cases  of  Tetanus. 
Thesis  for  M.B.  degree.    Camb.  1895. 

G.  S.  W. 


ENTERIC    FEVER 

SYNONYMS.  —  Gastric  Fever,  Typhoid  Fever,  Pythogenic  Fever;  Fr. 
Dothien  entente,  Fi^vre  typJioide;  Germ.  Abdominaltyiihus,  Nervenfiehre. 

Definition.  — An  acute  infectious  fever,  due  to  a  specific  niicro-organ- 
ism,  occurring  endemically,  sometimes  epidemically ;  clinically  charac- 
terised in  ordinary  cases  by  a  gradual  onset,  followed  by  a  period  of 
continuous  fever  with  diarrhoea,  an  enlarged  spleen,  tympanites,  and  a 
roseolar  rash,  usually  lasting  three  weeks ;  cmatomically  characterised 
by  more  or  less  extensive  ulcerations  affecting  the  Peyer's  patches  in  the 
ileum,  with  swelling  of  the  mesenteric  glands  and  enlargement  of  the 
spleen. 

History,  — Enteric  fever  appears  to  have  been  known  to  the  ancient 
writers  (for  example,  Hippocrates  and  Galen) ;  but  it  was  not  until  the 
beginning  of  this  century  that  it  was  distinguished  from  other  acute 
febrile  affections,  especially  from  typhus. 

In  Germany  Von  Hildsbrandt  (1810)  clearly  distinguished  these 
two  affections;  in  France  Bretonneau  (1818)  proposed  the  name  of 
dothienenterite,  to  denote  the  specific  nature  of  its  intestinal  lesion; 
whilst  in  England,  after  some  older  writers,  the  observations  of  Perry 
(3836),  Barlow  (1840),  Stewart  (1840),  and  especially  the  classical  par- 
pers  published  by  Sir  Wm.  Jenner  (1849-53),  led  to  the  final  distinc- 
tion between  the  two  diseases,  which  ever  since  has  been  universally 
recognised.  Enteric  fever  having  then  been  recognised  as  a  specific 
fever,  its  etiology  was  made  the  subject  of  further  investigation.  Its 
infectious  nature,  and  its  propagation  by  the  faecal  discharges  of  the 
patient,  led  many  physicians,  headed  by  Budd,  to  look  upon  it  as  due 
to  one  specific  agent,  and  to  deny  its  origin  de  novo. 

The  advances  made  in  sanitary  science,  the  establishment  of  special 
sanitary  medical  officers,  and  the  interest  with  wliich  all  matters  relating 
to  public  health  were  considered  by  corporate  bodies,  a  movement  in 
which  England  took  a  prominent  part,  led  on  to  investigations  into  the 


792  SYSTEM  OE  MEDICINE 

cause  or  causes  of  enteric  fever ;  and  though  the  agent  was  not  discov- 
ered, yet  the  source  of  the  propagation  and  dissemination  of  outbreaks 
were  carefully  studied,  and  many  of  them  were  traced  to  contaminated 
water  or  milk  and  to  "sewer  gas."  This  led  to  the  improvements  in 
drainage  and  water-supply  of  many  English  towns,  with  the  result  of  a 
marked  diminution  in  the  prevalence  of  enteric  fever,  and  of  an  almost 
total  extinction  of  typhus  (see  Table  I.,  Appendix).  With  the  develop- 
ment of  bacteriology  the  history  of  typhoid  fever  entered  upon  a 
new  stage. 

Murchison,  whose  classical  writings  on  the  continued  fevers  of 
England  still  maintain  a  prominent  place  in  the  literature  of  enteric 
fever,  believed  in  the  origin  of  enteric  fever  from  decomposing  organic 
material,  and  also  in  its  spontaneous  origin.  The  observations  of  Stich 
and  later  of  Panum,  which  showed  that  the  ingestion  of  putrid  material 
may  produce,  amongst  other  symptoms,  fever,  diarrhoea,  and  intestinal 
lesions,  not  only  supported  this  opinion,  but  gave  rise  to  that  of  the 
autogenetic  origin  of  enteric  fever,  namely,  that  the  disease  may  be 
generated  in  the  system  from  decomposition  of  faeces  in  the  intestinal 
canal  without  any  infection  from  outside. 

Eberth  (1880)  discovered  a  peculiar  bacillus  in  the  organs  of  persons 
who  had  died  of  enteric  fever,  and  subsequent  investigations  not  only  con- 
firmed this  observer,  but  placed  the  pathogenetic  nature  of  this  organism, 
and  with  it  the  etiolog}^  of  enteric  fever,  on  a  fii'm  basis  ;  thus  the  pytho- 
genetic  theory  of  Murchison  and  the  autogenetic  theory  of  other  observers 
became  untenable.  The  discovery,  however,  of  another  micro-organism 
—  the  bacterium  coli  commune  —  which  occurs  in  the  normal  human 
body,  and  apparently  elsewhere  also,  which  is  seen  in  increased  numbers 
in  persons  affected  Avith  enteric  fever,  and  in  many  of  its  characters  and 
properties  resembles  the  bacillus  of  typhoid  fever,  has  led  authors  to 
review  the  older  theories :  some,  like  Roux  and  Rodet,  believe  that  the 
bacterium  coli  commune  may  be  converted,  under  suitable  circumstances, 
into  the  typhoid  bacillus ;  others,  like  Peter  (68),  hold  that  in  typhoid 
fever  we  have  simpl}^  an  intoxication  of  the  human  body  by  the  retention 
of  substances  elaborated  by  it.  The  majority  of  pathologists  and  clini- 
cians, however,  firmly  believe  in  the  specific  nature  of  enteric  fever,  as 
thus  only  is  its  infectious  nature  explained  —  though,  on  the  other  hand, 
the  mode  and  source  of  infection  in  many  cases  are  difficult  to  prove. 

In  sketching  the  history  of  enteric  fever  the  progi-ess  in  the  treat- 
ment of  the  disease  must  not  be  forgotten.  Whilst  depletion  and 
starvation  were  for  a  long  time  the  guiding  principles  in  the  treatment 
of  fever,  the  liberal  use  of  stimulants  was  advocated  chiefly  by  English 
physicians  (Alison,  Graves,  Todd,  and  Stokes) ;  but  in  the  course  of  time 
their  administration  was  again  restricted,  and  used  only  on  definite  in- 
dications. The  antipyretic  treatment  by  the  cold  bath,  however,  first 
recommended  by  Carrie  (1787)  and  resuscitated  by  Brandt  (1861),  is 
said  to  have  diminished  considerably  the  mortality  from  enteric  fever, 
and  is  now  widely  adopted.     The  various  antipyretic  drugs  and  their 


ENTERIC  FEVER  793 


application  in  febrile  diseases  have  scarcely  displaced  the  cold  water 
treatment.  With  the  discovery  of  the  typhoid  bacillus  new  methods  of 
treatment  have  been  tried:  the  antiseptic  treatment  proposed  by  Bou- 
chard (though  antiseptic  drugs  had  been  given  long  before  in  enteric 
fever),  and  subsequently  adopted  in  various  forms  by  many  English  and 
continental  observers ;  and  more  recently  a  quasi-specific  treatment,  con- 
sisting in  the  subcutaneous  injection  of  sterilised  cultures  of  typhoid  bacilli 
have  been  tried,  but  the  latter  method  is  yet  in  the  experimental  stage. 

Geographical  Distribution.  —  Enteric  fever  prevails  all  over  the  globe. 
It  is  endemic  in  Great  Britain,  but  is  less  common  in  Scotland  than  in 
England  or  Ireland ;  its  frequency  in  the  British  Islands  has,  however, 
considerably  diminished  during  the  last  ten  to  fifteen  years,  owing  to 
better  sanitary  arrangeinents.  It  is  met  with  throughout  the  whole  of 
Europe ;  it  is  widely  distributed  throughout  the  whole  of  the  United 
States  and  Canada;  it  is  met  with  in  India,  Africa  (Egypt,  Tunis),  and 
in  Central  and  South  America. 

Etiology.  —  The  s-pedfic  cause  of  enteric  fever  is  the  hadllus  of  typhoid, 
or  Ehertli's  hadllus.  This  organism  was  first  described  by  Eberth  (22),  who 
found  it  in  sections  of  the  mesenteric  glands  and  of  the  spleen  of  persons 
who  had  died  of  enteric  fever.  Koch  about  the  same  time  gave  photograj)hs 
of  the  same  organisms  present  in  the  tissues,  and  Coats  of  Glasgow  also 
described  and  figured  them.  Gaffky  prepared  pure  cultivations  of  the 
bacillus,  and  described  some  of  its  chief  morphological  properties.  Since 
then  numerous  observations  have  been  made  on  the  morphology,  life 
history,  distinctive  characters,  and  pathogenetic  nature  of  this  organism  ; 
the  more  important  of  these  features  will  be  described  in  the  following 
account,  in  the  working  out  of  which  I  have  been  greatly  assisted  by 
Mr.  James  Richmond,  who  for  many  months  has  studied  the  bacteriology 
of  enteric  fever  in  the  pathological  laboratory  of  the  Owens  College,  and 
has  tested  the  statements  of  other  observers  by  his  own  investigations. 

Character  and  Biology  of  the  Tyjyhoid  Bacillus. — The  appearance  of 
the  bacillus  may  be  studied  from  sections,  from  juices  and  scrapings  of 
the  organs,  and  from  pure  cultures. 

The  typhoid  bacillus  may  be  seen  in  sections  prepared  in  the  usual 
way,  stained  for  twenty-four  hours  in  Loeffler's  alkaline  methylene  blue 
solution,  or  in  Ziehl's  carbolic  fuchsin,  and  washed  subsequently  in  water 
so  as  to  wash  the  dye,  if  possible,  from  all  that  appears  in  the  sections 
except  from  the  bacteria  and  the  tissue  nuclei ;  they  are  then  dehydrated 
in  aniline  oil :  if  now  washed  in  alcohol,  or  treated  by  Gram's  method,  the 
colour  is  removed  from  the  bacteria,  but  if  the  section  be  placed  for  ten 
minutes  in  a  one-fifth  per  cent  solution  of  mercury  dichloride,  and  then 
stained  by  Gram's  method,  tlie  bacilli  take  the  stain  deeply  [Woodhead]. 
In  preparations  made  from  the  juices  of  the  organs  or  from  cultures  on 
cover-glasses,  watery  solutions  of  any  of  the  aniline  dyes,  especially 
fuchsin  or  Ziehl's  carbolic  fuchsin,  may  be  used  as  stains;  in  the  latter 
case  a  niucli  slioi'tcr  action  of  the  stain  is  necessary.  The  cover-glass  is 
rinsed  in  water,  dried,  and  mounted  in  xylol  balsam.     Washing  with 


794 


1  SYSTEM  OF  MEDICINE 


alcohol  or  the  use  of  Gram's  method  removes  the  stain  entirely.  They 
often  stain  at  the  ends,  leaving,  with  the  watery  dyes,  a  bright  unstained 
portion  in  the  centre. 

The  typhoid  bacillus  is  a  short,  thickish  bacillus  —  2-3  /a  long,  and 
0-7-0 -9 /A  in  breadth  —  having  rounded  ends;  cultivations  outside  the 
body  often  grow  in  threads  composed  of  bacilli  strung  end  to  end; 
in  sections  the  bacilli  are  single.  In  drop  cultivations  they  have  very 
lively  motions  of  progression ;  the  longer  threads  have  a  slower  sinuous 
motion.  AVhen  stained  by  Loeffler's  method  (60),  or  one  of  its  modifica- 
tions, they  are  seen  to  be  provided  with  a  number  of  (8-12)  fine  wavy 
flagella  having  a  length  twice  that  of  the  bacillus.  These  are  inserted 
at  the  sides  as  well  as  into  the  ends  of  the  bacillus. 

The  bacillus  grows  in  the  ordinary  nutritive  media.  Its  growth 
is  favoured  by  the  presence  of  oxygen  and  a  temperature  of  2o°-35°, 
although  growth  can  go  on  in  the  absence  of  oxygen  (Liborius  and 
Eoux)  and  at  lower  temperatures. 

In  plate  cultures,  on  nutrient  gelatine,  the  youngest  colonies  seen 
under  a  low  power  are  round  or  oval,  and  of  a  yellowish  colour  and 
sharp  outline.  The  older,  deeper  colonies  are  darker,,  with  regular 
borders  and  fine  irregular  linear  markings.  The  superficial  colonies 
grow  quickly  into  an  expansion,  which  may  attain  to  a  diameter  of 
3-4  mm.,  having  a  notched  border,  a  grayish  white  colour,  and  a  fur- 
rowed and  wrinkled  iridescent  surface.     The  gelatine  is  not  liquefied. 

Gelatine  stab  cultures  show  the  same  appearance  of  the  superficial 
and  deep  growths. 

On  agar  there  is  a  superficial  white  growth. 

On  solidified  blood  serum  a  white  superficial  growth  occurs,  without 
liquefaction  of  the  serum. 

On  ordinary  potato  the  growth  is  scarcely  to  be  distinguished  in  forty- 
eight  hours,  only  a  moist  appearance  being  noticeable.  The  area  of 
inoculation  when  touched  with  the  platinum  needle  has  a  feeling  of 
greater  resistance  than  the  uninoculated  part,  and  typhoid  bacilli  are 
found  in  the  part  which  offers  this  resistance  to  the  needle. 

On  alkalised  potato  older  cultures  have  a  dirty  yellow  appearance,  and 
cultures  of  typhoid  recently  isolated  from  faeces  give  a  thicker,  more 
pulpy  growth.     The  other  characters  are  given  in  tabular  form  below. 

The  bright  unstained  parts,  once  supposed  to  be  spores,  are  known 
now  to  be  due  to  retraction  of  the  protoplasm  to  the  poles  of  the  cells 
where  it  takes  on  the  stain.  This  retraction  is  a  sign  of  degeneration,  due 
to  unsuitability  of  the  medium,  either  from  exhaustion  of  the  nutriment, 
or  from  an  unsuitable  reaction  (acidity).  So  far  from  these  forms  being 
spores  they  are  on  the  contrary  more  easily  killed  by  heat,  drying,  and 
bactericidal  substances  than  bacilli  which  stain  uniformly. 

Vitality  of  Typhoid  Bacilli — Influence  of  Temperature. — The  bacilli  are 
killed  when  exposed  to  temperatures  of  60°  C.  for  twenty  minutes  (Pf  uhl), 
but  in  this  respect  the  various  cultures  show  a  somewhat  different  be- 
haviour; low  temperatures  do  not  readily  destroy  the  vitality  of  the 


ENTERIC  FEVER  795 


bacillus,  and  several  observers  (Chantemesse,Widal,  Janowsky,  Prudden) 
have  seen  cultures  of  bacilli  in  beef-tea  live  for  weeks,  although  re- 
peatedly exposed  to  a  freezing  temperature. 

By  cultivation  it  has  been  found  that  in  sterilised  stools  and  in  stools 
which  have  stood  for  some  time  the  bacilli  may  remain  alive  for  months  ; 
in  fresh  typhoid  stools  and  in  normal  stools  they  die  much  sooner.  In 
threads  soaked  in  cultures  they  remained  alive  one  year;  on  potato 
cultures  two  years ;  in  sterilised  garden  soil  twenty-one  days ;  on 
sterilised  linen  sixty  to  seventy  days ;  in  street  sweepings  thirty  days. 
When  dried  in  various  ways  by  more  or  less  active  agents  their  duration 
of  life  was  from  one  to  sixty -four  days ;  free  access  of  air  shortens  the 
duration.  Hydrochloric  acid  of  the  strength  in  which  it  occurs  in  the 
normal  gastric  juice  does  not  destroy  their  vitality  till  it  has  been  in 
contact  with  the  cultures  for  several  hours. 

Action  of  Antiseptics.  —  Seitz  found  that  quinine,  chlorate  of  potash, 
salicylic  acid,  and  calomel  destroyed  the  life  of  the  typhoid  bacilli.  Dr. 
A.  C.  Latham  experimented  with  calomel,  chalk  and  mercury,  /?  naphthol 
and  bismuth,  and  found  that  all,  except  bismuth,  killed  the  typhoid 
bacillus. 

Carbolic  acid  (2-3  per  cent  solution),  and  corrosive  sublimate  (1  in 
5000)  also  quickly  destroy  the  typhoid  bacilli.  From  a  prophylactic 
point  of  view  the  observations  of  Liborius,  confirmed  by  Richard  and 
Chantemesse,  are  important.  According  to  the  latter  observers  4  parts 
of  slaked  lime  (milk  of  lime)  in  a  1000  of  water  destroys  the  bacilli  in 
typhoid  stools  in  less  than  half  an  hour ;  the  same  result  could  not  be 
obtained  with  chloride  of  lime  (1  to  1000)  or  corrosive  sublimate  (1  in 
50,000). 

In  the  sunlight  they  are  killed  more  rapidly.  Cultures  in  a 
dish  exposed  to  sunlight  were  killed  in  one  to  seven  days ;  in  sterilised 
water  exposed  to  sunlight  they  were  killed  in  an  hour.  It  has  been 
shown  that  this  action  is  due  principally  to  the  chemical  rays :  all  the 
rays  have  this  bactericidal  action,  but  the  rays  having  the  smaller  wave 
lengths  have  the  greater  effect.  In  sterilised  distilled  water  few  have 
been  found  alive  in  twenty  days  after  their  immersion. 

In  sterilised  river  water  they  disappear  in  forty-three  to  eighty-one 
days.  In  ordinary  well  water  or  river  water  they  rapidly  diminish  in 
numbers,  whilst  the  water  bacteria  at  first  increase  and  then  diminish. 
Few  typhoid  bacilli  were  seen  in  one  case  on  the  thirtieth  day  ;  in  another 
none  were  seen  on  the  fourteenth  day.  In  some  cases  it  was  found  that 
whilst  living  typhoid  bacilli  had  disappeared  from  the  liquid  they  were 
still  to  be  found  in  the  sediment  at  the  bottom  of  the  vessel.  In  distilled 
sterilised  vxiter  the  bacilli  show  signs  of  degenerative  changes,  the  proto- 
plasm gradually  losing  susceptibility  to  stains,  and  the  organism  becom- 
ing thicker  and  plumper,  more  oval  in  shape  (Curt  Braeni.).  They 
have  been  found  alive  after  19G  days.  The  tyj)hoid  bacilli  can  also 
grow  in  milk,  and  live  on  various  food  stuffs,  as  in  butter,  where  they 
have  been  found  alive  a  week  after  the  date  of  inoculation. 


796 


SYSTEM   OF  MEDICINE 


Poison.  —  In  old  peptone  cultures  Brieger  by  his  method  found  that 
a  poison  is  present  which  produces  in  guinea-pigs  quickening  of  the 
respirations  and  increased  glandular  secretions  ;  the  limbs  are  weakened 
and  the  animal  lies  down,  the  pupils  become  dilated,  the  respiration 
becomes  feebler,  diarrhoea  comes  on,  and  death  occurs  in  twenty-four 
hours  from  the  beginning.  The  poison  causing  these  symptoms  is  a 
diamine,  having  a  provisional  formula  C7H17NO2.  It  is  not  always 
found  in  the  cultivation  of  the  typhoid  bacillus.  To  compare  with  this 
Lufl:  isolated  from  the  urine  of  typhoid  patients  a  ptomaine,  the  reac- 
tions of  which  are  given  in  a  tabular  form  alongside  those  of  the 
ptomaine  isolated  from  the  cultures  of  the  bacilli  (9a). 


Ptomaine  from  Tj'phoid  Urine  (Luff)  (61). 


Ptomaine  from  Cultures,  on  Meat  Peptone,  of 
Eberth's  Bacilli. 


Solutions  ffave 


With  phospho-molybdic 

acid 
Phospho-tungstic  acid 
Iodine  solution 
Tannic  acid  solution 

Chloride  of  gold 
Picric  acid 

Chloride    of    gold    and 

picric  acid 
Platinum  chloride 


A  white  precipitate 

Nil 

Brown  precipitate 
Yellowish  brown  precipi- 
tate 
Dense  yellow  precipitate 
Dense  yellow  precipitate 


Nil 


A  white  precipitate 

Nil 

Deep  brown  precipitate 

Deep  yellow  precipitate 

Gold  salt  soluble 
Not  stated  (in  the  refer- 
ence) 
Yellow  precipitate 


From  the  liver,  kidneys,  and  spleen  of  a  fatal  case  of  typhoid  Brieger 
and  Wassermann  (9&)  obtained  a  glycerine  extract  which,  after  filtration 
through  a  Berkfeld's  filter,  gave  a  precipitate  with  alcohol.  This,  being 
further  purified  by  reprecipitation  and  dried,  yielded  a  grayish  white 
powder  soluble  in  water,  giving  a  yellow  solution  which  frothed  on 
being  shaken  up  and  presented  the  chemical  reaction  of  albumin.  One 
decigramme  of  this  powder,  dissolved  in  1  c.c.  of  water,  when  injected 
into  the  peritoneal  cavity  of  a  guinea-pig,  caused  paralysis  of  the  hind 
limbs,  feebleness,  lowered  temperature,  and  death.  On  examination  the 
animal  was  found  to  be  emaciated,  the  liver  fatty,  and  the  peritoneum 
reddened,  its  cavity  containing  a  little  fluid.  The  same  results  were 
produced  by  the  injection  of  5  c.c.  of  the  blood  serum  obtained  after 
death  from  a  fatal  case  of  typhoid. 

Diagnosis  of  Typho  id  Bacillus  from  Bacterium  Coli  Commune.  — In  1885 
Escherich  pointed  out  that  in  the  normal  stools  of  infants  at  the  breast,  a 
straight  bacillus,  of  length  varying  from  1  /a  to  5  /x  and  of  a  breadth  of 
0-3-0-4  jx  was  constantly  found.  The  bacilli  stained  well  with  ordinary 
dyes,  but  not  with  Gram's  method.  In  peptone  sugar  culture  the  bacilli 
were  easily  obtained,  and  fermentation  took  place.  These  bacilli  when 
grown  on  gelatine  do  not  liquify  it.  The  deep  colonies  on  plates  have 
the  appearance  of  very  small  yellow  granular  discs;  the  superficial 


ENTERIC  FEVER 


797 


colonies  form  whitish  lateral  expansions  of  a  uniformly  granular  aspect, 
sometimes  iridescent ;  the  outline  is  sometimes  circular,  but  generally 
irregularly  notched  and  wrinkled. 

In  drop  cultivations  the  bacilli  have  a  slight  motility.  On  potato 
they  form  a  juicy  layer  varying  in  colour  from  a  greenish  yellow  to  a 
maize-yellow.  Milk  is  coagulated  by  these  bacilli.  Cultures  of  them 
are  pathogenetic  in  guinea-pigs  and  rabbits;  when  injected  into  the 
jugular  vein  they  produce  diarrhoea,  lowering  of  the  temperature,  and 
death  in  three  days.  On  post-mortem  examination  the  small  intestine 
is  in  its  upper  part  hyperaeraic ;  the  caecum  normal.  The  contents  of 
the  small  intestine  consist  of  a  serous  alkaline  fluid,  and  the  mucous 
membrane  of  the  injected  part  is  hyperaemic,  soft  and  swollen;  the 
Peyer's  patches  are  swollen  as  in  typhoid  fever. 

This  bacillus  being  constantly  found  in  the  stools  of  persons  in  health 
was  termed  the  bacterium  coli  commune.  On  account  of  its  great 
similarity  in  size,  shape,  mode  of  staining,  and  growth  on  gelatine,  to 
the  bacillus  described  by  Eberth  (typhoid  bacillus),  other  differential 
tests  were  sought  for  than  those  given  by  Escherich  as  distinctive  of 
his  bacillus  (46). 


Tijphoid  Bacillus  {Eberth,  Gaffky). 

Siz<i,  len2;th  2-3  ix,  breadth  0-7-0-8  ^ 

(Gaffky). 
Has  active  movements. 
Has  10-12  flagella  (Nicolle  and  Morax), 
18-24  (Remy  and  Sugg). 


4.   Produces   no  indol    in    peptone  water 
inoculated  with  it  when  kept  at  35' 
for  forty-eight  hours. 
(To  10  c.c.  of  the  culture  1  c.c.  of  a  0-02 
per    cent     solution     of     potassium 
nitrite  is  added,   and    one  or  two 
drops   of   pure  sulphuric  acid ;    ia 
the  presence  of  indol,  a  violet-pink 
colour  is  produced  (Kitasato)  ). 
•"».   Causes  no  formation   of  gas  in  media 
containing  sugar,  for  example,  2  per 
cent  sugar  liouillon,  2  per  cent  sugar 
agar,  etc.  (Smith). 
(!.    NoevoJuiion  of  gas  in  gelatine  "shako 
cultures"  (Klein). 


Bacterium  coli  commune  (Escherich). 

1.  Size,  1-5  iJL  length,  Q-^-O-i  ij-  breadth. 

2.  MoA'eraents  more  sluggish. 

3.  Has  8-10  flagella  more  fragile   than 

those  of  typhoid  (Nicolle  and  Morax) . 

1-3  (Luksch) .  4-6  (Remy  and  Sugg) . 
Note  to  3.  —  Some  of  my  specimens  of 
bacteria  coli  commune  have  six  fla- 
gella, most  have  only  two  or  three. 
They  appear  to  be  very  easily  broken 
off.  The  bacilli  adhere  very  tena- 
ciously together  in  agar  cultures. 
In  drop  cultivations  a  better  result 
is  obtained,  but  even  then  the  num- 
ber of  flagella  varies  much  more 
than  in  the  specimen  of  typhoid. 
The  bacillus  was  from  a  diarrhoeal 
stool.  The  diagnosis  by  flagella  may 
be  made  from  my  specimen.  — J.  R. 

4.  Indol  pi'oduced  in  forty-eight  hours  at 

37°  in  peptone  water. 


5.  Causes  abundant  evolution  of  gas  in 
media  containing  sugar. 


G.   Bubbles  surrounding  the  colonies  in 
gelatine  "  shake  cultures." 


79^ 


SYSTEM   OF  MEDICI  ATE 


10. 
11. 


Does  not  curdle  sterilised  milk  (Chan- 
temesse  and  Vidal) . 

In  cultivations  in  neutral  whey  an 
acidity  equal  to  2-3  per  cent  in 
volume  of  j'oth  normal  sodium  hy- 
drate solution  is  produced  (Pet- 
rusehky). 

Growth  typical  on  potato  acidified 
with  O'A-1  per  cent  solution  of  tar- 
taric acid  or  monosodium  phosphate 
(Ferrati). 

Grows  more  slowly  on  gelatine. 

Does  not  split  up  amygdaline  in  bouil- 
lon (Pe're). 


12.   In  fresh  bouillon  an  acid  reaction  re- 
mains for  some  days  (Fere). 


13. 


14. 


Does  not  grow  in  bouillon  containing 
To'uoth  part  of  formalin  (by  volume) 
(Schild). 

The  surface  of  gelatine  upon  which 
typhoid  bacilli  have  already  grown 
no  longer  grows  them  when  again 
inoculated  (Wurtz). 


7.  Curdles  sterilised  milk. 

8.  In    similar    cultivations    an    acidity 

equal  to  7-8  per  cent  of  alkali   is 
produced. 


9.   Growth  on  potato  thus  acidified  —  a 
thick  yellow  layer  (Ferrati). 


10.  Grows  more  quickly  on  gelatine. 

11.  In    bouillon    cultures    amygdaline    is 

split  up  into  glucose  and  hydrocy- 
anic acid  (Fere). 

12.  In  fresh  bouillon  the  reaction,  at  first 

acid,  becomes  alkaline  in  five  days 
(Fe're'). 

13.  Grows  in  bouillon    containing  T^im^'h 

part  (by  volume)  of  formalin  (Schild) . 

14.  Will  grow  on  a  stratum  of  gelatine  on 

which  typhoid  bacilli  have  previously 
grown  (Wurtz). 


Klein  says  the  colonies  of  typhoid  bacilli  are  iridescent,  those  of 
bacillus  coli  communis  are  not,  and  that  the  latter  bacillus  is  much 
smaller  than  the  former. 

For  practical  purposes  the  distinction  of  the  two  bacilli  must  be 
made  by  means  of  the  tests  4,  5,  6,  7,  9,  and  13.  By  these  tests  we  can 
ensure  the  similarity  of  the  conditions  of  growth ;  and,  if  a  micro- 
organism similar  to  that  of  Eberth  in  its  morphology  and  gelatine  plate 
cultures  gives  also  these  reactions  of  Eberth's  bacillus,  it  is  extremely 
probable  that  the  bacillus  in  question  is  identical  with  that  of  Eberth.' 

Examination  of  Stools.  —  Three  volumes  of  the  stool  are  mixed  with 
one  volume  of  1  per  cent  solution  of  phenol  in  order  to  provide  a  mixture 

1  Since  the  above  paragraph  went  to  press  a  method  has  recently  been  published  by 
Eisner  [Zeitsch.f.  Hi/giene  und  Infections  Kr.  vol.  xxi.  1805),  which  appears  to  fulfil  the 
long-felt  want  of  easily  isolating  the  bacillus  of  enteric  fever  and  to  distinguish  it  from  the 
bacterium  coli.  As  the  cultivating  medium  acid  potato  gelatine  is  vised,  after  Holz  {Zeitsch. 
f.  Bacteriologie,  vol.  xiii.),  to  which  1  per  cent  of  iodide  of  potassium  is  added.  On  this 
medium  very  few  microbes  grow ;  among  them  are  both  the  bacillus  of  enteric  fever  and 
the  bacterium  coli ;  they  grow,  however,  in  so  different  a  manner,  that  in  the  course  of 
forty-eight  hours  the  two  can  be  readily  distinguished.  The  colonies  of  Eberth's  bacillus 
appear  as  small  shining  masses  like  drops  of  water ;  those  of  bacterium  coli  appear  as 
coarsely  granular,  brown  coloured  collections  of  larger  size.  When  the  colonies  are  very 
closely  set  it  may  happen  that  the  colonies  of  bact.  coli,  being  checked  in  their  growth, 
resemble  those  of  the  Eberth's  bacillus,  but  if  so,  further  plate  cultivation  will  show  the 
difference  at  once.  In  fifteen  out  of  seventeen  cases  of  enteric  fever  the  bacillus  was  easily 
isolated  from  the  fteces  in  the  various  stages  of  the  disease.  The  importance  of  this  method 
for  clinical  purposes,  as  it  enables  an  observer,  without  being  an  expert  bacteriologist,  tn 
isolate  the  bacillus  of  enteric  fever  from  the  f  neces  within  forty-eight  hours  after  inoculation . 
is  shown  by  the  observations  of  LB.za,Tns(Berlinerklinisrhe  iroc/;e«.?c/i. 1895, December  i'th) 
and  Brieger  (Deutsche  med.  Wochensch.  189.5,  December  12th).  The  latter  found  numerous 
bacilli  in  the  dejections  of  patients  suffering  from  enteric  fever  at  a  time  when  the  symptoms 
were  still  very  obscure.  During  convalescence  the  bacilli  rapidly  diminished  ;  in  two  cases 
they  persisted  after  the  fever  had  disappeared,  and  both  cases  were  followed  by  a  relapse. 


ENTERIC  FEVER  799 


containing  a  quarter  per  cent  of  phenol.  This  is  left  for  three  hours  at 
a  temperature  of  21°  C.  Plate  cultivations  are  now  made  in  Petri's 
dishes  (four  plates  of  various  dilutions)  from  this  mixture,  using  a 
moderately  large  amount  of  the  sample  for  the  first  inoculation.  The 
gelatine  used  should  contain  0-25  per  cent  of  phenol. 

The  plates  when  set  are  kept  for  forty-eight  hours  in  an  incubator 
at  22°.  At  least  ten  of  the  colonies,  which  present  a  superficial  irregu- 
larly bordered  expansion  somewhat  like  a  fig-leaf,  are  chosen;  and  each 
is  inoculated  into  a  tube  containing  2  per  cent  of  sugar  as  a  stab  culture 
(or  made  into  shake  cultures  with  gelatine) ;  the  former  are  kept  at 
37°  C.  for  twenty-four  hours,  and  no  bubbles  should  be  produced  if 
typhoid  bacilli  are  present ;  the  latter  are  kept  at  21°  C.  for  two  or  more 
days.  The  growth  of  the  typhoid  bacillus  takes  place  along  the  track  as 
well  as  on  the  surface.  If  the  growth  takes  place  only  superficially,  or 
is  very  slow,  or  if  bubbles  are  produced,  the  typhoid  bacillus  is  excluded. 

The  tubes  which  may  contain  the  typhoid  bacilli  are  next  inoculated 
(a)  in  peptone  solution  (2  per  cent  peptone,  0-5  per  cent  sodium  chloride), 
kept  at  37°  C  for  forty-eight  hours.  To  each  is  then  added  twenty  drops 
of  0-02  per  cent  solution  of  potassium  nitrite,  and  one  or  two  drops  of 
pure  sulphuric  acid  when  no  violet-pink  colour  should  be  produced.  (6) 
In  sterilised  fresh  milk ;  this  should  not  be  coagulated  after  some  days' 
stay  in  a  temperature  of  35°.  (c)  On  a  half  of  a  potato,  the  other  half 
of  which  is  inoculated  with  an  authentic  typhoid  bacillus.  These  should 
show  no  difference  after  incubation.  By  using  this  method  Mr.  Eich- 
mond  did  not  succeed  in  finding  typhoid  bacilli  in  the  stools  of  convales- 
cence from  typhoid  fever  in  seven  cases  at  periods  of  5,  7,  8, 10,  15,  16, 
23,  24,  and  30  days  after  a  normal  temperature  had  been  reached.  In 
the  course  of  the  investigation  it  was  noticed  that  some  apparently 
typical  colonies  produced  gas  formation  in  saccharine  media,  others  did 
not ;  of  those  which  produced  no  gas  some  gave  the  indol  reaction,  but 
three  did  not.  These  three  coagulated  milk  so  that  the  typhoid  bacillus 
was  excluded.  Thus  either  organisms  must  have  been  present  in  the 
stools  very  like  Eberth's  bacillus  in  all  their  reactions  except  that  of 
coagulation  of  milk,  or  Eberth's  bacillus  may  under  certain  circum- 
stances acquire  the  property  of  coagulating  milk,  a  property  possessed  in- 
deed by  some  of  the  recent  cholera  vibrios,  but  not  possessed  by  the  young 
cultivations  of  the  older  specimens  and  some  of  the  recent  specimens. 

Phenol  kills  those  organisms  which,  by  producing  liquefaction  of  the 
gelatine,  would  interfere  with  the  plate  cultures,  but  does  not  hinder 
the  growth  of  typhoid  and  some  other  bacteria. 

The  results  of  the  examination  of  stools  based  upon  the  diagnosis  of 
the  typhoid  l)acillus  before  the  introduction  of  the  indol  and  fermenta- 
tion tests  are,  therefore,  not  so  valuable  as  those  made  afterwards. 

PatJiorjaacUc  Nature  of  the  Bacilli.  —  The  typhoid  bacilli  fulfil  the 
necessary  conditions  as  the  veritable  cause  of  enteric  fever,  namely  — 
they  are  found  in  living  organisms,  and  in  the  organs  of  persons  who 
have  died  of  enteric  fever,  and  in  no  other  disease ;  they  can  be  cultivated 


8oo  SYSTFAI   OF  MEDICh\'R 


outside  the  body ;  when  inoculated  into  animals,  lesions  like  those  of 
typhoid  fever  are  produced,  and  they  are  found  in  the  organs  of  the 
animal  so  inoculated. 

It  now  remains  to  give  briefly  the  results  of  observations  on  these 
points. 

1.  Typhoid  Bacilli  in  the  Living  Patients. 

In  the  stool  of  the  patient  they  are  constantly  found  (Strpolansky  and 
Stroganoff).  Wratch  found  them  in  90  out  of  96  cases  examined.  It 
must  be  noted,  however,  that  they  are  rarely  found  before  the  9th  day 
of  the  disease  (Karlinski),  they  may  disappear  from  the  stools  before 
the  end  of  the  fever  and,  according  to  the  observation  of  Mr.  J.  Eich- 
mond  (see  above),  they  quickly  disappear  after  convalescence  has  set  in. 
Strpolansky  and  Stroganoff  have  in  two  cases  observed  them  in  the  stool 
nine  days  and  fifteen  days  after  the  temperature  had  become  normal. 

In  the  blood,  taken  from  the  finger  tip  or  from  a  vein  by  inserting 
the  nozzle  of  a  small  syringe,  bacilli  have  very  rarely  been  found,  and 
cultivations  have  either  given  negative  results,  or  have  shown  the  pres- 
ence of  streptococci  or  staphylococci,  indicating  a  mixed  infection.  In 
the  blood  taken  from  the  roseolar  eruption  some  observers  (Neuhans  in  9 
out  of  15  cases,  Roux,  Meisels)  have  found  bacilli  like  those  of  Eberth. 

The  blood  from  the  spleen,  drawn  off  by  means  of  a  small  syringe, 
has  often  given  positive  results  (Meisels  found  them  from  the  9th  to 
the  18th  day  of  fever,  Buschelt  in  8  out  of  15  cases;  in  2  of  these 
streptococci  also  were  present). 

In  the  foetus,  after  abortion  or  premature  labour  in  typhoid  patients, 
the  bacillus  has  repeatedly  been  found.  They  were  present  in  various 
organs  of  the  foetus  (iSTeuhans,  Hildebrandt,  and  Ernst). 

In  the  nrine  Eberth's  bacillus  has  been  found  by  Leitz  in  2  cases  out 
of  7  examined.  Newman  found  them  in  some  cases  on  the  10th,  16th, 
and  21st  day  of  convalescence ;  they  were  present  in  8  cases  out  of  48 
cases  examined.  Bouchard  found  them  in  21  out  of  65  cases ;  the  urine 
in  these  cases  contained  albumin,  which  on  precipitation  settled  at  the 
bottom  of  the  test-tube  (retractile  albuminuria) ;  9  out  of  these  21  cases 
were  fatal,  and  the  bacilli  were  found  in  the  kidney.  As  early  as  the 
3rd  day  of  fever  they  were  found  in  the  urine  by  Karlinski. 

In  the  sputum  of  typhoid  patients  suffering  from  pneumonia  they 
may  occur  (Chantemesse). 

Lastly,  in  the  sequeke  of  typhoid.  There  are  already  a  great  many 
cases  recorded  where  the  pus  of  abscesses,  chiefly  in  connection  with 
periosteum  or  bone,  which  appeared  long  after  the  patient  had  recovered 
from  the  fever,  contained  living  typhoid  bacilli.  In  Sultan's  case  (86) 
they  were  cultivated  from  the  pus  of  an  abscess  opened  six  years  after 
recovery  from  typhoid,  and  in  a  case  recorded  by  Buschke  (11)  twenty- 
seven  years  had  elapsed.  In  many  of  the  cases  recorded  other  micro- 
organisms, chiefly  streptococci  and  staphylococci,  were  found  in  addition 
to  the  typhoid  bacilli. 

2.  Typhoid  Bacilli  in  the  Organs  after  Death. — They  have  been  con- 


ENTERIC  FEVER  8oi 


stantly  found  in  the  Peyer's  patches,  mesenteric  glands,  spleen  and  liver; 
occasionally  in  the  myocardium  (Chantemesse),  kidney  and  meninges, 
and  very  often  in  areas  concerned  in  the  various  complications  of 
typhoid  fever :  instances  will  be  given  under  Symptomatology. 

3.  Inoculation  on  Animals.  —  As  animals  do  not  suffer  from  enteric 
fever  (there  is  some  doubt  whether  the  well-known  outbreak  of  enteric 
fever  at  Kloten  in  Switzerland  was  really  due  to  meat  derived  from  a 
calf  suffering  from  enteric  fever),  it  is  not  easy  to  produce  a  disease  in 
its  symptoms  like  enteric  fever  in  animals  by  inoculation,  as  was  found 
by  Murchison  and  others  who  fed  animals  with  matter  containing 
dejections  from  typhoid  fever.  Now,  however,  we  have  abundant  evi- 
dence that  under  certain  conditions  a  disease  not  unlike  enteric  fever, 
with  lesions  resembling  those  seen  in  it  and  presenting  typhoid  bacilli 
in  the  various  organs,  can.  be  produced  by  inoculating  animals  with 
pure  cultures  of  typhoid  bacilli.  Positive  results  were  first  obtained  by 
E.  Frankel  and  Simmonds  by  intra-peritoneal  injections  in  mice,  guinea- 
pigs  and  rabbits ;  and  they  found  consequently  enlargement  of  spleen, 
hypertrophy  of  mesenteric  glands  and  of  Peyer's  patches,  and  typhoid 
bacilli  in  the  spleen.  Sirotinin  and  Beumer  and  Peiper,  on  repeating 
the  experiments,  came  to  the  conckxsion  that  the  animals  died,  not  from 
an  infection,  but  from  an  intoxication  by  the  soluble  product  of  the 
bacillus,  and  that  no  growth  or  multiplication  of  the  typhoid  bacilli 
had  taken  place.  Numerous  experimenters  (A.  Prankel,  Fodor,  Leitz, 
Chantemesse  and  Vidal,  Sanarelli,  Cygnoeus,  Gilbert  and  Girode)  have, 
however,  since  confirmed  the  observations  of  Prankel  and  Simmonds. 
The  experimental  methods  were  varied,  some  (A.  Prankel)  injected  the 
bacilli  directly  into  the  stomach  or  duodenum  after  laparotomy,  as  done 
by  Koch  in  cholera  inoculations ;  others  (Chantemesse  and  Vidal)  used 
small  doses  of  very  virulent  cultures,  or  diminished  the  resistance  of 
the  animal  by  injecting  at  the  same  time  into  the  peritoneal  cavity  ster- 
ilised cultures  of  other  micro-organisms  —  streptococci  (Chantemesse), 
bact.  coli  commune  (Sanarelli) ;  but  all  obtained  positive  results :  the 
bacilli  were  found  in  the  various  organs,  and  even  in  the  foetus  after  an 
abortion,  thus  showing  conclusively  that  an  infection,  and  not  an 
intoxication  only  must  have  taken  place. 

Cygnoeus  used  a  virulent  culture  which  he  injected  into  animals  in 
various  ways  —  intra-venous,  intra-peritoneal  —  and  into  the  duodenum 
or  ileum  after  laparotomies ;  he  also  introduced  the  culture  by  the 
mouth  and  by  inhalation.  Many  of  the  inoculated  animals  (mice,  rab- 
bits, dogs)  died,  and  at  the  post-mortem  the  spleen  and  mesenteric 
glands  were  found  swollen,  and  the  Peyer's  patches  reddened.  Bacilli 
were  found  in  the  spleen,  the  liver,  the  intestines,  the  kidney,  and  the 
medulla  of  bone.  Positive  results  were  also  obtained  with  some  of  the 
mice  which  had  inhaled  cultures  of  bacilli. 

The  results  of  the  experiments  where  other  micro-organisms  were 
introduced  in  order  to  weaken  the  resisting  power  of  the  organism  re- 
ceive a  fuiiher  confirmation  by  recent  observations  of  Alessi,  who  found 

voj..  I  3  p 


802  SYSTEM  OF  MEDICINE 


that  g-uinearpigs  made  to  breathe  the  effluvia  from  cesspools  were  killed 
by  feeble  cultures  of  typhoid  bacilli  which  had  no  action  upon  animals 
of  the  same  size  kept  under  more  favourable  conditions. 

Relation  between  B.  GoU  Com.  and  Typhoid  Infection.  —  Pisenti  and 
Biancho-Mariotti  found — -1.  On  simultaneously  injecting  into  animals 
cultures  of  typhoid  bacillus  and  B.  coli  com.  (which  latter  had  been 
proved  to  be  inactive),  that  B.  coli  com.  increased  in  virulence,  so  as  to 
act  like  very  virulent  B.  typh.  on  animals. 

2.  That  if  sown  in  gelatine  mixed  up  with  filtered  cultures  of  B. 
typh.,  B.  coli  also  gains  in  virulence,  which  is  due  to  typho-toxin  acting 
on  the  B.  coli. 

3.  Tliat  healthy  intestinal  epithelium  hinders  infection  from  the 
intestine ;  but  that  if  Beyer's  patches  undergo  changes  this  defence  is 
in  abeyance.  Filtrates  from  typhoid  cultures  exert  an  influence  on 
Beyer's  patches,  as  proved  by  experiments  (nature  not  stated),  so  that 
in  typhoid  fever  the  toxin  in  the  blood  alters  the  Beyer's  patches,  and 
thus  B.  coli  are  permitted  to  get  into  the  body  and  add  to  the  virulence 
of  the  typhoid  infection. 

4.  That  the  virulence  of  B.  coli  is  increased  by  simultaneous  injec- 
tions of  streptococci  pyo.  aur.  (explaining  Vincent's  observation  that 
typhoid  is  more  severe  when  streptococci  are  present  in  the  blood). 

5.  That  with  very  virulent  cultivations  of  B.  coli  they  could  get 
similar  results  (such  as  thermometric  curves,  for  instance)  to  those 
obtained  by  very  virulent  B.  typhoides,  and  could  immunise  animals 
against  B.  typhoides ;  at  the  same  time  they  guard  against  any  expres- 
sion of  opinion  as  to  the  identity  of  the  two. 

Waijs  of  Infection.  —  Having  shown  that  the  typhoid  bacillus  is  the 
immediate  cause  of  enteric  fever,  we  may  now  consider  by  what  chan- 
nels it  may  be  conveyed.  The  general  conclusions  as  to  the  etiology  of 
enteric  fever  arrived  at  by  ma,ny  years  of  experience  and  observation 
before  the  discovery  of  the  typhoid  bacillus  were  —  that  it  occurs  in 
sporadic  cases  or  in  epidemics ;  that  the  poison  is  contained  in  the 
alvine  discharges  of  the  typhoid  patients,  contact  with  which  may  com- 
municate the  disease  to  a  healthy  person ;  that  an  outbreak  of  enteric 
fever  implies  poisoning  of  air,  soil,  drinking  water,  milk,  or  other 
ingesta  with  the  fever  poison.  In  s"ome  cases  the  source  of  the  poison 
cannot  be  traced,  hence,  as  I  have  already  said  in  the  short  historical 
sketch  at  the  outset  of  this  article,  many  have  believed  that  typhoid 
fever  may  arise  spontaneously. 

In  some  instances  it  is  no  doubt  very  difficult,  often  even  impossible, 
to  trace  the  origin  of  a  case  of  enteric  fever,  or  to  explain  the  source 
of  an  outbreak  of  the  disease ;  but  considering  the  long  vitality  of  the 
typhoid  bacillus  under  certain  conditions,  its  probably  wide  distribu- 
tion, its  rapid  multiplication,  the  great  dilution  to  which  it  may  be  sub- 
jected without  losing  its  potency  —  as  shown  in  some  epidemics,  where 
the  source  of  infection  was  undoubtedly  proved,  as  in  the  outbreak  at 
Lausen  (12)  —  and  the  influence  which  the  presence  of  other  micro- 


ENTERIC  FEVER  803 


organisms  and  impurities  of  the  air  have  either  in  favouring  its  develop- 
ment, or  in  diminishing  the  power  of  resistance  of  the  individual,  we  can 
quite  understand  that  it  may  often  be  difficult  to  trace  the  source  of 
infection.  Is  there  not  the  same  difficulty  in  other  infectious  diseases, 
such  as  small-pox  or  scarlet  fever ;  yet  no  one  believes  in  the  spontaneous 
origin  of  these  affections  ? 

The  typhoid  bacillus  is  contained  in  the  dejections  of  the  typhoid 
fever  patient,  and  "typhoid  fever"  is  chiefly  propagated  by  these. 

It  is  stated  by  most  observers  that  fresh  typhoid  stools  are  not 
infectious  (Murchison,  Caley),  and  that  they  only  become  so  after  one  or 
more  days.  If  this  be  so,  it  could  be  explained  readily  by  the  observa- 
tions of  Hiippe,  who  found  that  the  typhoid  bacilli  in  recent  stools  being 
anaerobic  when  leaving  the  body,  were  more  influenced  by  external 
agents  than  bacilli  found  in  stools  that  have  stood  for  some  time  and 
have  thus  become  aerobic  (41). 

We  have  seen  that  the  bacilli  are  occasionally  contained  in  the  sputum 
and  in  the  urine ;  these  secretions,  therefore,  cannot  be  neglected  as 
sources  of  infection,  and  should  be  thoroughly  destroyed. 

The  paths  of  conveyance  are  — 

1.  Direct  contact  with  particles  of  dried  faeces  contained  in  the 
clothes  of  the  patient,  bed  linen,  etc. ;  many  instances  have  been  recorded 
where  washerwomen,  nurses,  and  others  have  been  infected  in  this  way. 

It  is  also  quite  possible  that  insects,  such  as  flies,  may  carry  infectious 
particles  from  typhoid  patients  to  fruit  and  vegetables.  This  mode 
of  infection  may  explain  the  occurrence  of  some  sporadic  cases.  We 
know  that  the  bacillus  grows  well  on  many  vegetables  besides  potatoes 
and  other  articles  of  food  (39) ;  and  on  the  other  hand,  experimental  obser- 
vations by  Hoffman  and  others  have  shown  that  both  cholera  bacilli  and 
tubercle  bacilli  may  be  conveyed  by  flies ;  Burgess  has  recently  given 
further  proof  how  easily  micro-organisms  may  be  conveyed  by  flies. 
With  other  articles  of  food  taken  raw  —  such  as  milk,  oysters,  watercress 
—  which  are  now  known  to  be  a  source  of  infection,  contamination  is  due 
to  the  water.  Infection  by  oysters  has  been  recently  observed  in  London 
and  elsewhere  (10),  and  cases  like  those  observed  by  Sir  Wm.  Broadbent 
seem  to  prove  that  oysters  not  infrequently  act  as  carriers  of  the  poison. 

2.  Water  into  which  the  excretions  find  their  way.  This  may  be 
drinking  water,  or  water  used  for  rinsing  milk-cans,  etc.,  which  may  thus 
give  rise  to  epidemics,  when  the  disease  is' propagated  by  milk  ;  or,  as  in 
one  or  two  outbreaks  recently  recorded,  by  ice  cream  :  vegetables,  again, 
may  be  washed  in  contaminated  water ;  or  oysters  may  contain  it  (see 
above). 

3.  Air.  This  is  now  known  to  be  a  very  rare  mode  of  infection.  It 
is,  however,  not  impossible  that  dried  bacilli  may  be  suspended  in  the  air. 
Tryde  and  Salomonson  found  typhoid  bacilli  on  the  floor  of  a  barrack 
where  enteric  fever  was  prevalent.  (It  is  doubtful,  however,  whether 
these  were  proved  to  be  tyj)lioid  bacilli.)  Lassurie  (54)  passed  a  pulver- 
ising spray  of  water  over  a  quantity  of  dried  typhoid  bacilli,  and  found 


8o4  SYSTEM  OF  MEDICINE 

that  the  particles  of  spray  carried  the  bacilli  some  distance.     The  part 
played  by  sewer  air  will  be  alluded  to  later. 

4.  Food  from  animals  affected  with  the  fever.  Several  such  epi- 
demics have  been  recorded,  whether  actually  enteric  fever  or  not.  In 
the  one  at  Kloten  the  affected  person  not  only  partook  of  the  meat 
(supposed  to  have  been  derived  from  a  calf  suffering  from  typhoid),  but 
also  partook  of  wine  and  other  drinks.  It  is  very  probable  that  the 
beverages  consumed  contained  the  active  agent,  the  action  of  which 
would  be  assisted  by  the  putrid  condition  of  the  veal.  Enteric  fever, 
moreover,  has  not  been  recognised  in  animals. 

It  would  be  beyond  the  scope  of  this  article  to  go  fully  into  the 
various  outbreaks  of  enteric  fever  and  their  respective  sources,  which 
subject  is  fully  treated  in  works  on  hygiene  and  in  larger  treatises  on 
enteric  fever,  as  in  one  just  published  (9c). 

The  facts  ascertained  with  regard  to  the  outbreaks  of  typhoid  fever 
are,  briefly,  that  in  very  few  cases  is  there  any  evidence  of  direct  con- 
tagion from  the  sick  to  the  healthy ;  in  a  considerable  number  of  cases, 
especially  of  isolated  cases,  no  direct  or  indirect  contagion  can  be  proved ; 
in  a  large  number  of  cases,  especially  in  large  epidemics,  the  disease 
arises  among  persons  who  drink  unfiltered  and  unboiled  water  or  milk 
contaminated  with  typhoid  stools. 

Enteric  fever  due  to  milli  contamination  is  chiefly  confined  to  houses 
served  by  a  particular  dairy  ;  the  attacks  are  simultaneous,  and  confined 
at  first  to  those  members  of  the  family  who  had  partaken  largely  of 
unboiled  milk,  especially  the  younger.  As  a  rule  the  cases  have  not  a 
high  mortality.  In  many  of  them  it  has  been  proved  that  enteric  fever 
existed  at  the  farms  from  which  the  milk  was  derived ;  that  the  water- 
supply  of  the  farms  was  infected  with  the  stools,  and  that  the  milk 
cans  were  washed  with  the  infected  water.  As  fresh  warm  milk  is  a 
favourable  medium  for  the  growth  of  the  typhoid  bacillus,  a  small 
amount  of  infected  material  would  contaminate  a  large  amount  of  milk. 

In  epidemics  from  the  use  of  contaminated  tvater,  the  cases  arise  to 
a  much  greater  extent  among  those  who  use  the  suspected  water  than 
among  those  who  have  another  water-supply  (6),  the  percentage  of  at- 
tacks not  being  very  high;  or  severe  outbreaks  arise  in  connection  with 
the  consumption  of  water  from  a  particular  well  contaminated  with 
typhoid  stools,  as  in  Budd's  Cowbridge  case,  where  of  140  persons  who 
possibly  might  have  drunk  of  water  from  a  well  polluted  with  typhoid 
stools  forty  or  fifty  had  typhoid  fever  —  some  after  a  very  short  period  • 
of  incubation.  In  the  Tees  valley  outbreak  a  large  body  of  water  was 
contaminated :  in  the  former  one  a  small  body  was  more  intensely  in- 
fected, and  a  very  large  percentage  of  consumers  were  attacked.  In  these 
cases  bacteriological  examination  of  the  water  may  be  carried  out  in  the 
way  recommended  for  the  examination  of  stools ;  or  the  first  step  by  which 
the  liquefying  organisms  are  got  rid  of  may  be  attained  by  Parietti's 
method.  In  this  method  three,  six,  and  nine  drops  of  a  solution  of  5 
per  cent  phenol  and  4  per  cent  of  hydrogen  chloride  in  distilled  water  are 


ENTERIC  FEVER  805 


added  to  tubes,  each  of  which  contains  10  c.c.  of  neutral  bouillon.  These 
are  capped  and  kept  at  37°  in  the  incubator  for  twenty-four  hours.  The 
tubes  which  have  become  turbid  are  now  excluded.  To  each  clear  tube 
are  then  added  one  to  ten  drops  of  the  suspected  water,  according  to  the 
amount  of  impurity.  The  tubes  are  capped,  shaken,  and  incubated  for 
twenty-four  hours.  Plate  cultures  are  now  made  from  the  turbid  tubes. 
Other  methods  have  also  been  formulated  and  described  in  bacterio- 
logical text-books :  when  the  infecting  material  is  largely  diluted,  or 
the  examination  is  made  some  time  after  the  fouling  has  occurred,  the 
typhoid  bacillus  may  not  be  detected,  and  bacterium  coli  only  found. 
In  these  cases  a  much  larger  quantity  of  water  must  be  examined ;  this 
can  be  effected  by  passing  a  large  quantity  of  the  water  through  a  ster- 
ilised Chamberland's  porcelain  tube  contained  in  a  sterilised  stoppered 
vessel,  as  suggested  by  Professor  Delepine ;  the  scum  collected  on  the 
outside  of  the  tube  is  afterwards  to  be  examined  bacteriologically. 
Typhoid  bacilli  have  often  been  found  in  water  which  has  been  con- 
sumed by  persons  who  have  suffered  from  enteric  fever :  in  some  of 
these  cases  the  water  has  been  derived  from  wells  into  which  cesspools 
containing  such  stools  have  drained;  in  others  the  water  of  rivers  or 
brooks  has  been  contaminated  by  sewage,  by  drainage  from  fields  manured 
by  privy  refuse,  or  by  drainage  from  laundries  where  clothes  soiled  by 
typhoid  stools  have  been  washed.  In  conducting  bacteriological  exami- 
na.tion  of  water,  it  must  be  borne  in  mind  that  a  number  of  bacilli  may 
occur  in  water,  which  closely  resemble  the  typhoid  bacillus  both  in 
appearance,  in  the  character  of  the  colonies,  and  even  in  some  of  the 
reactions ;  so  that  it  becomes  necessary  to  use  every  one  of  the  differ- 
ential tests  given  above  :  indeed  in  the  present  state  of  our  knowledge, 
even  if  the  organism  do  present  the  various  test  reactions  we  can  then 
only  say  that  it  is  like  the  typhoid  bacillus.  For  further  references  on 
the  subject  we  refer  to  Lustig's  treatise  (63).  In  many  of  the  cases  in 
which  enteric  fever  has  been  associated  with  the  use  of  a  particular  water- 
supply,  some  of  the  persons  exposed  to  the  infection  have  escaped ;  in 
other  cases  persons  living  in  particular  districts  have  scarcely  suffered, 
whilst  in  other  districts  having  the  same  water-supply  the  fever  has 
been  very  prevalent.  Thus  there  is  a  local  immunity  as  well  as  an 
individual  immunity.  Chantemesse  points  out  that  the  20th  arrondisse- 
ment  had  in  the  ten  weeks  beginning  with  the  20th  Pebruary  1894  a 
mortality  from  enteric  fever  of  0-5  per  10,000 ;  whilst  in  the  17th,  18th, 
and  19th  arrondissements,  inhabited  by  the  same  classes  of  people,  and 
where  the  same  water  was  drunk,  the  mortality  was  0-88  per  10,000. 
The  same  arrondissement  for  the  last  thirty  years  has  had  a  lower  mortal- 
ity from  enteric  than  the  mean  mortality  of  the  other  arrondissements  of 
Paris  {T){)).  The  Tourelles  barracks  did  not  present  a  single  case.  The 
water-supply,  examined  on  the  0th  April,  yielded  bacilli  coli  commune  — 
prol)ab]y,  but  perhaps  not  necessarily,  due  to  faecal  contamination — but 
no  typhoid  bacilli.  The  20th  arrondissement  has  a  less  crowded  popula- 
tion and  more  open  spaces  than  the  otherS;  except  in  Belleville  which, 


8o6  SYSTEM  OF  MEDICINE 

though  thickly  populated,  is  situated  on  a  well-ventilated  and  elevated 
site.  On  this  subject  Mr.  Hart's  articles  on  Water-borne  Typhoid  in  the 
British  Medical  Journal  for  1895  may  be  consulted. 

Fodor  found  that  the  mortality  from  typhoid  fever  in  Buda-Pesth 
was  greater  in  those  houses  which  were  supplied  by  well  water  than  in 
those  supplied  by  pipe  water  (filtered) ;  and  greater  in  those  houses 
where  the  ground  water  was  more  impure,  and  where  the  ground  was 
more  polluted  with  organic  matter  which  did  not  present  evidence  of 
active  oxidation. 

In  Dublin,  which  has  a  pure  water-supply,  but  where  the  soil  is  satu- 
rated with  the  filth  from  privies  and  ashpits  formerly  in  use,  those  living 
on  clay  suffered  much  less  from  enteric  fever  than  those  living  on  the 
porous  gravel ;  and  Sir  C.  Cameron  believes  this  difference  to  be  due  to 
emanations  from  the  filthy  soil.  At  Stockport  the  grouping  of  cases  of 
enteric  was  noticed  in  three  particular  areas,  the  three  highest  points 
in  the  town  at  which  the  sewers  were  ventilated.  This  association  has 
been  noted  elsewhere.  In  many  cases  insanitary  conditions  allowing 
sewer  gas  to  pass  into  houses  are  found  where  this  fever  occurs.  In- 
stances might  be  infinitely  multiplied.  Thus  impurity  of  the  soil  and 
the  breathing  of  sewer  air  are  often  found  in  connection  with  enteric 
fever,  but  there  is  no  exact  evidence  that  these  act  otherwise  than  as 
accessory  agents.  There  is  no  evidence  that  sewer  air  contains  typhoid 
bacilli ;  it  is  found  that  in  well-ventilated,  well-constructed  sewers  the 
air  contains  fewer  bacteria  than  the  outside  air;  but  where  the  sewage 
is  stagnant  it  is  possible  that  gas  abundantly  produced  by  the  formation 
and  the  bursting  of  bubbles  may  disseminate  solid  particles  in  the  air, 
and  some  of  these  may  be  wafted  up  into  those  houses  where  the  soil- 
pipes  act  as  sewer  ventilators,  or  into  the  air  about  the  ventilating  grids. 
In  some  of  these  ways  it  is  possible  to  explain  the  origin  of  cases  which 
appear  obscure  without  invoking  the  action  of  any  miasma,  except  as  an 
adjuvant  cause  as  in  Alessi's  experiments. 

This  brings  us  to  the  consideration  of  remoter  causes  which  favour 
the  occurrence  of  the  disease.     Of  these  may  be  mentioned  — 

1.  Age. — Enteric  fever  occurs  much  more  frequently  amongst  the 
young,  and  adult  persons  under  35.  It  is  not  uncommon  in  children, 
but  very  rare  in  infants.  This  will  be  evident  from  some  of  the  tables 
which  accompany  this  article. 

2.  Sex.  —  The  male  sex  appears,  from  the  number  of  cases  admitted 
into  hospitals,  somewhat  more  disposed  to  the  disease  than  females. 
Thus  there  were  admitted  into  Metropolitan  Asylum  Board's  Hospitals 
in  the  years  1871-1892,  3293  males  and  3030  females  between  the  ages 
of  10  and  35  years.  But  probably  more  males  are  admitted  into  hospi- 
tal than  females,  so  that  the  liability  to  enteric  fever  may  be  the  same 
in  the  two  sexes. 

3.  Season.  —  Though  enteric  fever  occurs  at  all  seasons,  it  is  much 
more  prevalent  in  autumn  and  beginning  of  winter,  especially  after  a  dry 
and  hot  summer.     In  London  the  maximum  mortality  is  in  November; 


ENTERIC  FEVER  807 


in  England  the  maximum  prevalent  in  October.  This  seasonal  prev- 
alence must  be  due  to  some  meteorological  influence ;  but  the  favouring 
conditions  of  temperature,  atmospheric  pressure,  and  rainfall  are  not 
definitely  known. 

Pettenkofer  and  Buhl  pointed  out  that  in  Munich  the  maximum 
prevalence  of  enteric  coincided  with  the  lowest  recession  of  the  ground 
water  from  the  surface  of  the  soil,  and  was  especially  marked  when  the 
ground  water  was  previously  high.  These  are  just  the  circumstances 
favourable  for  the  pollution  of  wells  by  filthy  soil,  as  Buchanan  has 
pointed  out.  Fodor  showed  that  at  Buda-Pesth  the  maximum  of  the 
prevalence  of  the  fever  coincided  with  the  maximum  height  of  the  ground 
water,  that  is  with  the  highest  level  of  the  Danube.  The  same  observation 
was  made  by  Thorne  Thorne  in  an  outbreak  of  the  disease  in  Jerliug, Essex. 

In  many  places  Pettenkofer's  observations  have  been  conlirmed,  in 
many  they  have  not ;  moreover,  as  Flllgge  (27)  points  out,  the  number 
of  cases  in  the  quarter  of  the  year  in  which  the  ground  water  is  at  the 
lowest  level,  compared  with  the  average  number  of  cases  in  the  other 
quarters,  shows  only  a  difference  amounting  to  10-20  per  cent  of  the 
total  number  of  cases  (17  per  cent  in  Berlin);  so  that  the  sinking  of  the 
ground  water  only  increases  the  number  of  cases  by  a  small  fraction  of 
the  whole,  the  rest  occurring  during  the  rising  and  the  high  level  of  the 
ground  water. 

English  observations  have  led  to  the  conclusion  that  a  permanent  low 
level  of  the  ground  water  (at  depth  of  15-20  feet)  is  the  best  for  health. 

4.  Defective  drainage  and  seAverage,  accumulation  of  filth,  over- 
crowding and  disregard  of  ventilation,  in  fact,  all  shortcomings  in  sani- 
tation of  the  individual  and  of  the  community  are  most  important  agents 
in  favouring  the  power  of  the  typhoid  bacillus,  and  in  lessening  the 
resistance  of  the  individual.  The  improved  sanitary  condition  of  most 
of  the  English  towns  as  regards  water-supply,  sewerage,  open  air  spaces, 
etc.,  is  the  chief  cause  of  the  diminished  mortality.  This  diminution 
amounted  to  45-4  per  cent  in  twenty-one  out  of  twenty-four  English 
towns;  in  three  towns  where  the  typhoid  mortality  was  increased,  the 
sewerage  arrangements  were  manifestly  faulty.  (See  accompanying  table 
giving  the  annual  mortality  from  typhus  and  typhoid  per  million  persons 
living,  in  England,  Table  I.,  Appendix.) 

5.  Other  less  potent  causes  are  peculiarities  of  constitution  (see  under 
Prognosis),  and  recent  residence  in  an  infected  district.  Occupation  and 
station  of  life  have  no  influence. 

Immunity.  —  We  will  confine  ourselves  entirely  to  a  few  facts  in 
relation  to  this  subject,  the  general  consideration  of  which  is  dealt  with 
elsewhere. 

Some  persons  show  a  natural  immunity  from  enteric  fever;  acquired 
immunity  is  a  well-established  fact  in  this  as  in  some  other  infectious 
fevers.  Of  over  2000  cases  of  enteric  fever  which  came  under  obser- 
vation at  the  Hamburg  General  Hospital,  only  fourteen  persons  were 
affected  twice,  and  only  one  person  three  times  by  enteric  fever.     Of  the 


8o8  SYSTEM  OF  MEDICINE 


experimental  investigations  we  may  briefly  allude  to  the  observations  of 
AVidal  and  Chantemesse,  Brieger,  Kitasato,  Wasserniann,  and  Stern. 

In  the  course  of  these  investigations  it  was  found  that  when  cultures 
of  typhoid  bacilli  which  were  virulent,  or  which  had  been  sterilised  by 
heat,  were  used  to  infect  animals,  and  the  animals  survived  the  action  of 
the  virus,  that  these  animals  were  more  or  less  immune  to  the  action  of  a 
stronger  virus.  By  regulated  doses  of  the  weakened  virus  injected  sub- 
cutaneously  (or  in  some  cases  into  the  veins)  guinea-pigs  were  rendered 
immune  from  the  action  of  a  stronger  virus.  The  blood  serum  of  these 
guinea-pigs  was  then  found  to  confer  immunity  upon  other  animals  when 
used  in  the  same  way,  and  to  retard  the  disease  in  animals  already 
affected.  According  to  E,.  PfeifEer,  if  the  serum  of  a  highly  immunised 
guinea-pig  be  injected  with  a  small  dose  of  typhoid  bacilli  into  the 
peritoneal  cavity  of  a  normal  guinea-pig,  and  drops  of  the  peritoneal 
exudation  then  removed  for  examination,  the  bacilli  are  seen  rapidly  to 
undergo  degenerative  changes,  and  finally  to  disappear.  Other  bacteria 
when  subjected  to  the  same  process  remain  unaffected.  Hence  this 
"  specific  immunising  power  "  of  the  serum  in  question  may  be  used  as  a 
diagnostic  test  for  the  typhoid  bacilli  (6Sa).  Dunbar  confirms  Pfeiffer's 
results  (21&).  It  is  obvious,  however,  that  if  moderate  doses  of  the 
bacilli  to  be  tested  will  not  grow  in  the  peritoneal  sac  of  a  normal 
guinea-pig  the  reaction  will  not  be  available.  The  blood  serum  of  men 
who  have  enteric  fever,  and  of  some  who  have  not  had  it,  has  the  same 
property  (Stern).  The  serum  of  protected  guinea-pigs  injected  sub- 
cutaneously  in  the  enteric  fever  patients  gave  no  important  results 
(Chantemesse). 

Prankel  and  Simmond's  observations  with  sterilised  cultures  of 
typhoid  bacilli  will  be  referred  to  under  Treatment. 

Portah  of  Entrance  into  the  Human  Body  of  the  Tijphoid  Bacilli.  — 
The  digestive  tract  forms  the  principal  channel  along  which  the 
typhoid  bacilli  find  their  way  into  the  body.  This  is  evident  from  the 
well-established  fact  that  from  the  post-mortem  appearance  most  out- 
breaks can  be  traced  to  contaminated  water  or  milk.  Chantemesse 
quotes  a  case  of  Klebs,  where  a  man  died  on  the  second  day  of  the  dis- 
ease, and  in  the  mucous,  submucous,  and  muscular  coat  of  the  intestines 
masses  of  typhoid  bacilli  were  found.  Prom  what  has  been  stated  before, 
it  is  evident  that  typhoid  bacilli  may  find  their  way  into  the  air,  and 
may  thus  enter  by  the  respiratory  tract.  Yet  it  is  quite  possible  that 
they  may  be  arrested  in  the  pharynx,  and  thence  find  their  way  into  the 
digestive  tract.  Wyssokowitch  Avas  not  able  to  find  typhoid  bacilli  in 
animals  which  had  inhaled  dried  culture  of  typhoid  bacilli,  or  in  which 
he  had  injected  typhoid  bacilli  into  the  trachea.  The  occurrence  of  pneu- 
monia at  the  very  onset  of  entric  fever,  and  the  presence  of  typhoid 
bacilli  in  the  lungs  in  these  cases,  make  it  not  improbable  that  occasion- 
ally, though  no  doubt  very  rarely,  the  bacilli  may  enter  the  system 
through  the  respiratory  tract. 

Recently  Anderson  described  two  cases  of  enteric  where  the  fever 


ENTERIC  FEVER  .  809 


was  contracted  in  the  hospital,  and  where  there  was  presumptive  evi- 
dence that  tlie  infection  was  conveyed  by  an  enema  syringe ;  the  en- 
trance in  this  case  would  be  per  rectum. 

Symptomatology.  —  The  symptoms  of  enteric  fever  vary  considerably 
in  individual  cases  both  as  regards  character  and  intensity ;  this  is  due 
partly  to  the  intensity  and  localisation  of  the  poison,  and  partly  to  a 
mixed  infection  by  septic  organisms.  It  will  be  well  to  describe  at  first 
an  ordinary  case,  then  to  give  an  analysis  of  the  symptoms  and  of  the 
complications,  and  the  sequelae.  In  each  case  of  enteric  fever  we  may 
take  certain  periods  to  represent  the  several  stages  of  the  affection. 
The  following  stages  are  recognised  by  most  clinicians :  incubation, 
onset  or  invasion;  the  fever  period  itself,  which  is  divided  into  the 
first,  second,  and  third  week  of  the  fever  —  or,  according  to  Murchison, 
into  the  stage  of  glandular  enlargements  extending  to  the  12th  or  14th 
day,  the  stage  of  ulceration  or  sloughing  of  the  intestinal  glands  extend- 
ing to  the  end  of  third  week  —  lysis,  or  gradual  diminution  of  the  fever, 
and  convalescence. 

The  incuhation  period  varies  considerably ;  it  seems  in  most  cases  to 
be  about  fourteen  days ;  in  some  cases,  however,  it  has  been  ascertained 
to  be  as  short  as  four  or  five  days,  or  even  shorter ;  in  others  it  may 
extend  over  three  or  four  weeks.  During  the  period  the  patient  may 
either  experience  no  symptoms  whatever,  or,  as  is  most  commonly  the 
ease,  towards  the  end  of  this  period,  he  may  complain  of  headache,  loss 
of  appetite,  sleeplessness,  and  a  sense  of  fatigue  ;  this  stage  may  gradu- 
ally pass  into  the  next  stage. 

The  Onset.  —  In  many  ordinary  cases  the  onset  is  insidious.  The 
patient  complains  of  pain  in  the  limbs,  of  excessive  fatigue,  of  cold  and 
chilly  sensations,  of  headache  often  very  severe,  of  loss  of  appetite,  and 
of  sleeplessness  :  epistaxis  is  a  very  common  symptom,  and  generally 
occurs  about  the  second  or  third  day  of  the  disease.  These  symptoms 
become  more  severe,  the  patient  has  to  take  to  his  bed,  and  from  this  day 
we  generally  reckon  the  duration  of  the  fever.  In  many  cases,  however, 
as  shown  by  the  changes  after  death,  the  beginning  of  the  morbid  process 
must  be  dated  from  the  very  first  symptom.  The  tongue  becomes  furred, 
and  is  at  first  moist ;  there  is  a  steady  rise  of  temperature,  the  evening^ 
temperature  being  generally  one  and  a  half  degree  (F.)  higher  than  the 
morning  temperature,  so  that  about  the  fourth  day  the  temperature 
reaches  103°  F.  or  104°  F. ;  the  pulse  rises  to  90  or  100,  rarely  higher 
except  in  very  severe  cases,  or  in  very  young  or  debilitated  subjects,  is 
dicrotic  and  indicative  of  low  blood  pressure ;  there  is  increased  thirst ; 
the  abdomen  is  slightly  distended  and  tender  on  pressure;  diarrhoea 
may  as  yet  be  absent,  and  there  may  be  constipation,  or  there  may  be  two 
or  three  fluid  stools  from  the  first.  Beyond  the  headache,  which  persists 
for  a  few  days,  and  sleeplessness,  there  are  as  yet  no  other  symptoms ; 
the  skin  is  dry,  but  there  are  paroxysms  of  profuse  perspiration.  The 
spleen  is  as  yet  l)ut  little  enlarged,  and  there  are  as  yet  no  roseolar  spots, 
though  when  perspiration  is  profuse  sudamina  are  noticed;  the  urine  has 


8io  SYSTEM   OF  ■  MEDICINE 


febrile  characters  and  as  yet  does  not  show  the  diazo  reaction.  This  stage 
lasts  about  seven  days,  and  constitutes  the  lirst  week  of  enteric  fever. 

During  the  second  iveek  more  characteristic  symptoms  appear.  The 
fever  remains  high  and  steady,  the  morning  remissions  being  less ;  the 
pulse  is  quicker;  the  skin  remains  moist;  the  tongue  becomes  dry  and 
brown,  and  the  lips  likewise;  the  roseolar  rash  appears,  between  the 
seventh  and  twelfth  day,  in  the  form  of  isolated,  circular,  rose  coloured 
spots,  slightly  elevated,  and  about  the  size  of  lentils,  from  two  to  four 
millimetres  in  diameter,  disappearing  on  pressure,  and  reappearing  with 
the  removal  of  the  pressure ;  they  appear  chiefly  on  the  abdomen  and 
back,  occasionally  on  the  arms  and  thighs ;  they  may  be  very  few  in 
number,  or  at  times  very  numerous,  and  they  appear  in  successive  fresh 
crops,  Avhile  the  old  ones  gradually  fade :  the  appearance  of  the  spots 
continues  up  to  the  end  of  the  second  week,  and  often  to  the  middle  or 
end  of  the  third  week,  or  even  during  convalescence.  In  some  cases  a 
minute  vesicle  may  be  seen  at  the  apex  of  the  roseolar  spot.  During 
this  stage  the  abdomen  becomes  more  distended,  gurgling  in  the  right 
iliac  fossa  is  noticed,  and  the  abdomen  may  be  painful  on  pressure.  The 
diarrhoea  is  now  more  profuse,  and  the  motions  have  the  characteristic 
pale  yellow  ("  pea-soup  ")  colour,  and,  especially  in  children,  are  highly 
offensive.  The  spleen  is  now  considerably  enlarged,  is  often  to  be  felt 
below  the  costal  margin,  and  is  occasionally  painful  on  pressure.  The  res- 
piration is  quickened,  but  not  as  quick  as  in  pneumonia ;  still  there  may 
be  some  bronchial  affection  with  mucous  expectoration.  The  temj^erature 
during  the  first  few  days  of  the  second  week  continues  high,  with  marked 
evening  exacerbations.  About  the  middle  of  the  second  Aveelc,  in  moder- 
ately severe  cases,  the  morning  temperature  is  lower  than  it  was  before  ; 
in  others  the  morning  remission  is  but  slight,  and  the  fever  has  a  less 
remittent  character;  in  very  mild  cases  the  fever  may  disappear  about 
the  end  of  the  second  week.  The  urine  is  scanty,  high  coloured,  and  of 
high  specific  gravity ;  occasionally  it  contains  albumin,  and  in  most  cases 
gives  the  "  diazo  reaction."  The  headache  usually  disappears  during 
the  second  week  if  not  before ;  there  is  often  marked  and  increasing 
deafness.  The  patient  in  the  second  week,  except  in  very  slight  cases, 
assumes  a  somewhat  characteristic  appearance.  He  is  dull,  apathetic, 
and  has  a  heavy  look ;  the  face  is  pale,  the  cheeks  occasionally  flush,  the 
pupils  dilate,  and  the  lips  are  dry.  In  severer  cases  there  is  delirium, 
especially  at  night,  and  in  still  more  severe  cases  other  nervous  symptoms 
(constant  delirium,  somnolence,  subsultus  tendinum)  may  supervene,  and 
death  may  take  place  during  the  second  week.  Haemorrhage  from  the 
bowel  occasionally  occurs  towards  the  end  of  the  second  week. 

During  the  third  iveek,  in  mild  cases,  the  symptoms  gradually  subside. 
In  moderately  severe  cases  most  symptoms  remain  the  same  as  during 
the  second  week ;  but  the  temperature  shows  marked  morning  remissions, 
and  the  fever  gradually  declines,  and  may  show  for  a  few  days  an  inter- 
mittent fever  type,  —  the  morning  temperature  being  normal,  the  evening 
temperature  still  reaching  100°  F.  or  101°  F. ;  in  more  severe  cases  the 


ENTERIC  FEVER  8ii 


temperature  may  remain  high,  and  even  increase,  the  pulse  becomes 
smaller  and  quicker,  the  tongue  quite  dry  and  brown  and  often  fissured, 
the  lips  covered  with  sordes,  the  diarrhoea  persistent,  and  the  perspira- 
tion profuse :  the  delirium  is  now  constant,  and  often  of  a  low,  mutter- 
ing, or  sometimes  of  a  violent  maniacal  character ;  the  loss  of  flesh 
becomes  particularly  apparent  during  this  week,  and  bed-sores  may 
appear  if  the  nursing  be  inefficient.  Haemorrhage  from  and  perforation 
of  the  intestines  are  apt  to  occur  during  the  week.  Pulmonary  compli- 
cations and  failure  of  the  heart's  action  are  to  be  feared,  and  would  show 
themselves  by  quick  and  small  pulse,  cyanosis  of  the  face,  clammy  per- 
spiration, and  the  like ;  other  unfavourable  symptoms  relating  to  the 
nervous  system  may  also  occur  towards  the  end  of  the  third  week,  such 
as  retention  of  urine,  or  involuntary  discharge  of  urine  and  faeces. 

With  the  fourth  iveeTc  convalescence  commences  in  ordinary  cases,  in 
very  severe  cases  later.  The  evening  temperature  now  falls  gradually 
to  the  normal,  or  nearly  so ;  save  a  fcAV  exceptions  (Fagge,  Morris),  there 
is  no  crisis,  but  a  gradual  defervescence  ;  the  alvine  evacuations  become 
formed,  the  pulse  improves,  and  the  tongue  begins  to  clean,  Avhile  the 
appetite  returns  and  becomes  almost  ravenous  ;  the  pulse  becomes  slower 
and  firmer ;  there  is  often  polyuria,  the  urine  having  a  low  specific  grav- 
ity;  the  nervous  symptoms  quickly  disappear;  the  sleep  becomes  more 
natural,  and  though  the  patient  feels  excessively  weak,  often  complains 
of  vertigo  and  palpitation,  and  is  pale  and  anaemic,  the  strength  gradu- 
ally returns  and  is  maintained ;  unless  the  convalescence  be  interrupted 
by  relapses,  or  some  of  the  sequelae  to  be  mentioned  below  ensue.  In 
very  severe  cases  the  fourth  week  often  brings  not  only  no  relief,  but 
even  an  aggravation  of  the  symptoms  of  the  third  :  the  pulse  may  reach 
140  or  more,  the  respirations  become  laboured,  the  face  is  dusky  and  cov- 
ered by  clammy  perspiration,  urine  and  faeces  pass  involuntarily,  and 
coma  gradually  sets  in,  soon  followed  by  death :  some  few  patients,  how- 
ever, in  spite  of  the  severity  of  the  symptoms,  take  a  favourable  turn, 
and  eventually  recover.  Convalescence  begins  in  the  majority  of  cases 
with  the  fourth  week  :  in  not  a  few  cases,  however,  the  fever  does  not 
subside  till  the  end  of  the  fourth  week ;  whilst  in  some  protracted  cases 
it  may  continue  during  the  fifth  or  even  the  sixth  week. 

The  above  is  a  brief  description  of  the  symptoms  in  ordinary  cases 
of  enteric  fever.  Certain  variations  both  in  the  onset  and  course  of  the 
disease  are,  however,  sometimes  noticed. 

As  regards  the  onset,  it  is  well  to  know  that  occasionally  this  may 
be  sudden,  in  one  of  the  following  ways  —  (a)  Symptoms  resembling  an 
ordinary  febrile  cold:  repeated  shivers,  with  headache  and  rise  of  tem- 
perature ;  but  a  single  rigor,  so  characteristic  of  pneumonia,  is  very  rarely 
seen  in  enteric  fever,  (h)  Symptoms  resembling  acute  gastritis :  such  as 
frequent  vomiting,  which  may  persist  for  a  few  days,  and  be  soon  fol- 
lowed by  diarrhfBa;  the  gradual  increase  of  the  temperature,  which  on 
the  fourth  day  may  reach  10.'->°  or  more,  assists  us  in  diagnosing  such  a 
case  from  gastro-intestinal  catarrh,     (c)  In  other  cases  the  patient  at 


8i2  SYSTEM  OF  MEDICINE 

first  complains  of  sore  throat,  and  the  tonsils  may  be  so  swollen  as  to 
interfere  with  breathing  and  swallowing ;  the  accompanying  headache, 
epistaxis  and  pyrexia  here  assist  us  to  make  an  early  diagnosis,  (d)  The 
first  symptoms  may  be  those  of  pneumonia,  and  only  after  some  days  the 
typhoid  symptoTus  (diarrhoea,  enlargement  of  spleen,  roseola)  present 
themselves.  These  cases  are  known  as  pneumo-typhoid,  and,  as  in 
some  of  them  the  typhoid  bacillus  has  been  found  in  the  pneumonic 
lung,  we  have  probably  here  to  do,  in  some  cases  at  least,  with  enteric 
fever  in  which  the  typhoid  bacillus  established  itself  first  in  the  lungs ; 
in  other  cases  we  probably  have  to  do  with  two  coincident  affections  — 
pneumonia  and  enteric  fever  (Chantemesse).  (e)  The  fever  may  set  in 
with  severe  headache  and  vomiting,  soon  followed  by  delirium,  retrac- 
tion of  the  head,  and  photophobia,  —  indeed  with  all  the  symptoms  of 
meningitis ;  and  it  is  only  after  five  to  six  days  that  the  true  nature  of 
the  case  reveals  itself :  this  onset  is  not  rare  in  children.  (/)  Symp- 
toms of  acute  nephritis  (nephro-typhoid)  (see  below),  (g)  In  very 
rare  cases  laryngeal  symptoms  (laryngo-typhoid). 

During  the  stage  of  glandular  enlargement  the  temperature  may  not 
show  the  characteristic  curve ;  it  may  be  normal,  or  but  little  above 
normal,  throughout  the  whole  course  (apyrexial  type),  or  slightly  febrile 
(in  mild  cases),  or  it  may  show  great  variations ;  again  diarrhoea  may 
be  absent  throughout  the  whole  course,  or  there  may  even  be  obstinate 
constipation.  Grave  nervous  symptoms  may  persist  throughout  the 
whole  period,  as  in  the  form  of  constant  delirium  or  drowsiness  ;  the 
presence  of  the  other  syjnptoms  characteristic  of  the  disease  helps  us 
in  the  recognition  of  these  aberrancies.  As  the  symptoms  vary  consider- 
ably in  some  cases,  I  will  now  give  a  brief  analysis  of  the  symptoms 
relating  to  the  various  organs. 

Temperature  in  Typhoid.  —  For  the  majority  of  cases  the  observations 
of  Wunderlich  on  the  temperature  curve  in  enteric  fever  still  hold  good. 
With  the  onset  the  temperature  rises  gradually  during  the  first  four  days, 
an  evening  exacerbation  of  about  1-5°  to  2°  F.,  being  followed  by  a  remis- 
sion next  morning  of  about  1°  F.,  so  that  there  is  a  gradual  mean  rise 
with  a  daily  zig-zag,  the  summit  of  which  reaches  about  103-5°  to  104°, 
on  the  fourth  day.  This  is  followed  by  the  fastigium,  lasting  for  about 
seven  days,  during  which  time  the  temperature  is  more  uniform  and  of 
continuous  type,  the  morning  temperature  being  102°  to  103°,  evening 
temperature  103°  to  104°  F.  In  many  cases  there  is  on  the  seventh 
day  a  distinct  but  only  temporary  fall  of  a  few  degrees.  From  this 
poi:it  to  the  end  the  temperature  varies  with  the  severity  of  the  case 
(excluding  such  accidents  as  haemorrhage) ;  in  ordinary  moderately 
severe  cases  the  temperature,  after  the  eleventh  or  twelfth  day,  has  for 
three  to  four  days  a  remittent  character,  the  morning  temperature  now 
falling,  and  more  rapidly  than  the  evening  temperature;  during  the 
remaining  days  (from  about  the  sixteenth  to  the  twenty-first)  it  assumes 
an  intermittent  character,  the  morning  temperature  being  about  normal, 
,the  evening  temperature  reaching  101-5°  to  101°,  and  coming  somewhat 


ENTER TC  FEVER  813 

rapidly  down  to  the  normal  on  the  twenty-first  day :  in  mild  cases  the 
tejuperature  may  fall  more  rapidly  at  the  end  of  the  second  week,  and 
]nay  reach  the  normal  soon  after;  in  severe  cases  the  morning  tem- 
perature remains  high  after  the  second  week,  between  103°  and  104°, 
and  the  evening  temperature  reaches  105° ;  or  we  have  irregular  tempera- 
tures for  several  days  after  the  twelfth  day  (the  "  amphibolic  stage  "  of 
Wunderlich,  the  "  stage  of  changing  fortunes  "  of  Murchison).  Defer- 
vescence thus  takes  place  more  or  less  gradually ;  but  sometimes  the  fever 
may  terminate  by  sudden  crisis  on  or  before  the  end  of  the  third  week. 
"For  the  majority  of  cases,  then,  Wunderlich's  observations  on  the  tempera- 
ture hold  good,  and  from  a  diagnostic  point  of  view  it  is  well  to  remember 
his  general  rule :  —  Any  fever  which  on  the  second  day  reaches  to  104° 
F.  is  not  enteric  fever,  nor  is  it  enteric  if  the  fever  does  not  approach 
104°  F.  on  the  evening  of  the  fourth  day  ;  on  the  other  hand,  enteric  fever 
may  be  diagnosed,  if  in  a  middle-aged  person  suffering  from  an  acute 
febrile  attack  the  evening  temperature  on  the  fifth  day,  or  within  the 
first  week,  is  between  103°  and  105°,  and  alternates  with  morning 
temperatures,  which  are  1-4°  to  1-7°  lower,  unless  some  other  disorder 
can  be  discovered  to  explain  the  height  of  the  fever.  It  is  well  to  state 
that  by  morning  temperature  we  mean  the  temperature  about  9  a.m., 
by  evening  temperature  that  about  6  p.m.  If  the  temperature  be 
taken  every  two  hours  greater  differences  are  sometimes  noticed  during 
the  twenty-four  hours. 

There  are,  however,  many  variations  of  the  temperature  curve. 
Thus,  sometimes,  especially  if  pneumonia  intervene,  or  even  in  simple 
cases  there  may  be  a  very  high  temperature  on  the  second  day  ;  again,  we 
occasionally  meet  with  hyperpyrexia,  which  may  reach  109°,  and  even  110°. 
Such  temperatures  generally  occur  during  the  third  week,  and  are  quickly 
fatal ;  but  temperatures  between  105°  F.  and  106°  F.  may  be  met  with 
even  towards  the  end  of  the  second  week  in  cases  which  recover,  espe- 
cially in  young  subjects.  Again  the  temperature  may  undergo  sudden 
alterations  from  incidents  which  arise  during  the  fever ;  thus  an  attack 
of  pneumonia,  occurring,  as  it  often  does,  towards  the  end  of  the  fever, 
causes  a  sudden  rise  of  temperature ;  various  septic  affections,  which 
so  often  complicate  enteric  fever,  considerably  disturb  the  fever  curve ;  ^ 
haemorrhage  from  the  ulcers  causes  a  sudden  fall  of  the  temperature ; 
perforation  of  the  bowel  often  has  a  similar  effect ;  and  even  nervous 
symptoms,  or  failure  of  the  heart,  may  be  ushered  in  by  a  fall.     Again 

1  It  is  stated  by  many  observers  that  in  persons  who  have  had  malaria  the  temperature 
in  typhoid  shows  a  distinctly  intermittent  type,  accompanied  by  rigors  and  sweating,  and 
the  typiif)-m;i,larial  fever  of  the  tropics  has  been  looked  upon  by  some  as  enteric  fever. 
Osl<;r  and  otiier.s  liave  described  cases  where  malarial  fever  came  on  during  an  attack  of 
typln)id  witliout  tlie  temperature  becoming  intermittent;  and  other  observers  (Purjez, 
Weil)  (!)fi)  desi;ril)e  a  true  intermittent  temperature  in  enteric  fever  without  any  malaria, 
whicli  may  persist  throughout  the  wliole  course.     (F/cfe  art.  "  Fevers  in  India.") 

Ill  a  few  cases  f>scillatiori  between  high  and  very  low  temperatures  has  been  recorded  ; 
thus  in  a  child  suffering  from  entericr  ffsver  tin;  lem))eratni'e  U^W  from  104°  F.  to  i)l°  F.,  and 
tiieri  i;radu;illy  rose  to  normal.  Wilh  tlie  rapid  fall  of  temperature  signs  of  pneumonia 
appeared  (71aJ. 


8i4  SYSTEM   OF  MEDICINE 

the  fever,  instead  of  terminating  at  the  end  of  the  third  or  fourth  week, 
may  run  on  for  weeks,  protracted  by  a  variety  of  causes,  such  as  continued 
ulcerations,  septic  complications,  etc. 

Some  cases  of  enteric  fever  may  run  their  whole  course  without  any 
rise  of  temperature,  or  with  a  temperature  but  slightly  above  normal,  or 
even  with  a  subnormal  temperature.  Su.ch  cases  have  been  described  by 
Gerhardt  (34,  97)  and  myself  (21).  Even  epidemics  of  such  cases  have 
been  described  (30).  In  two  of  the  cases  observed  by  me,  not  only  were  all 
the  prominent  symptoms  of  enteric  fever  present,  with  the  exception  of 
pyrexia,  but  there  was  also  a  distinct  relapse,  lasting  in  one  case  exactly 
three  weeks,  during  which  there  was  marked  haemorrhage  from  the 
intestines.  The  prognosis  of  these  cases,  in  spite  of  their  apyrexial 
nature,  is  as  grave  as  that  of  ordinary  enteric  fever ;  one  of  my  patients 
died  from  perforation,  and  the  two  cases  described  by  Wendland  termi- 
nated fatally. 

Post-Typhoid  Pyrexia.  —  Apart  from  the  cases  which  are  mentioned 
above,  in  which  the  temperature,  on  account  of  some  complication  or 
continued  ulcerations,  does  not  come  to  the  normal  for  many  weeks,  we 
may  note  a  rise  of  temperature  lasting  a  short  time ;  this  occasionally 
happens  during  convalescence,  and  is  sometimes  referred  to  errors  in  diet, 
or  too  nitrogenous  a  diet,  or  to  constipation  (in  one  case  the  temperature 
ran  to  105°  after  having  been  normal  for  three  days,  and  quickly  sub- 
sided again  after  an  enema).  Slight  elevations  of  temperature  during 
convalescence  are  often  noticed  in  very  anaemic  persons  or  in  those  of 
highly  nervous  temperament  (Osier). 

From  these  post-typhoid  temperatures  must  be  distinguished  the 
fever  of  the  relapse,  which  will  be  described  hereafter. 

Symptoms  on  the  Surface  of  the  Body.  —  The  roseolar  eruption  has 
already  been  described.  It  is  present  in  about  77  per  cent  of  the  cases ; 
it  is  more  often  wanting  in  children,  but  may  be  even  copious  in  them. 
Of  other  eruptions  which  are  met  with  we  have  to  notice  :  — - 

(a)  Maculae  caeruleae,  taches  bleuatres,  peliomata,  blue  tinted  spots 
of  indefinite  size,  situated  chiefly  over  the  abdomen  ;  these  appear  to  be 
caused  by  the  irritation  of  pediculi,  and  occur  in  other  febrile  affections. 

(&)  Petechiae  or  Purpura  Spots.  —  In  rare  cases  the  typical  typhoid 
rash  may  be- accompanied  by  petechiae ;  at  other  times,  in  badly  nourished 
and  debilitated  persons,  or  when  septic  complications  occur,  petechiae 
may  appear  at  the  height  of  the  disease. 

(c)  Miliaria  and  sudamiria  are  not  unfrequently  met  with ;  they 
appear  sometimes  early,  but  generally  in  the  second  and  third  week  of 
the  disease ;  they  are  very  numerous,  and  principally  situated  on  the 
front  and  back  of  the  chest  and  on  the  abdomen  ;  the  sudamina  are  small 
vesicles,  filled  with  clear  fluid,  and  are  not  likely  to  be  mistaken  for  any 
other  affection.    This  eruption,  of  course,  occurs  in  many  other  diseases. 

(d)  Erythema.  —  A  rash  of  vivid  red  colour,  not  unlike  the  scarlet 
fever  rash,  sometimes  appears  during  the  first  week,  chiefly  on  the 
chest  and  abdomen.     I  have  twice  noticed  a  similar  rash  occurring 


ENTERIC  EEVER  815 


luring  the  third  week,  and  chiefly  affecting  the  arms.  This  rash  may 
ui  some  cases  be  due  to  the  administration  of  drugs  —  quinine,  salicylate 
of  sodium,  antipyrin,  etc.  It  has  been  observed,  however,  quite  inde- 
pendently of  such  drugs  {^o,  100),  and  is  probably  of  septic  origin. 

(e)  Morbilliform  rash,  resembling  measles  (58,  66),  in  larger  or 
smaller  patches,  with  a  dark  hsemorrhagic  centre  and  a  lighter  coloured 
periphery,  affects  the  neck  and  trunk,  spreads  rapidly,  but  does  not 
extend  to  the  mucous  membrane,  and  appears  not  materially  to  affect 
the  course  of  the  fever.  ISTeumann  found  the  streptococcus  pyogenes 
on  the  arms  of  a  patient  during  the  existence  of  this  rash. 

(/)  Urticaria  is  occasionally  observed,  but  is  probably  in  most  cases 
a  drug  eruption. 

icf)  Herpes,  so  common  in  pneumonia,  is  very  rare  in  enteric  fever ; 
it  has  been  observed  sometimes,  however,  during  the  first  week.  In 
two  cases  in  which  I  noticed  it  the  enteric  fever  was  complicated  by 
pneumonia. 

(/i)  Desquamation  in  fine  branny  scales  is  often  observed  towards 
the  end  of  the  fever  or  during  convalescence. 

GSdema  of  the  skin  is  noticed  sometimes  towards  the  end  of  the 
febrile  period  (from  thrombosis  of  a  vein),  or  during  convalescence 
(from  anaemia  and  nephritis). 

Erysipelas.  —  This  is  occasionally  noticed  as  a  complication.  I  have 
seen  it  twice  in  children ;  it  occurred  when  the  fever  symptoms  were 
subsiding.  It  commenced  in  the  usual  way  —  the  face,  forehead,  and 
ears  being  chiefly  affected,  and  it  ran  a  favourable  course.  Silvestrini 
(81),  in  a  case  of  erysipelas  complicating  enteric  fever,  found  the 
typhoid  bacillus  in  the  erysipelatous  eruption. 

Bed-Sores.  —  The  marked  improvement  which  has  taken  place  in  the 
nursing  and  management  of  fever  patients  has  almost  abolished  bed- 
sores ;  yet  in  a  few  very  protracted  cases  in  very  debilitated  persons, 
whatever  the  j)recautionary  measures,  they  may  perhaps  be  unavoidable  ; 
and  several  factors,  besides  mechanical  pressure  —  such  as  the  condition 
of  the  blood,  and  trophic  changes  due  to  central  nervous  causes  —  help 
in  their  production.  They  are  noticed  over  the  sacrum,  or  over  the 
trochanters,  knees,  elbows,  ankles,  shoulder,  head,  etc.  At  first  the 
skin  reddens,  then  small  superficial  erosions  or  fissures  ap]3ear,  and 
these  deepen,  giving  rise  to  gangrenous  patches,  which  may  slough  off, 
leaving  the  subjacent  parts  bare ;  occasionally  the  destruction  of  tissue 
extends,  and  may  be  accompanied  by  suppuration  and  the  appearance 
of  septic  symptoms.  We  may  thus  have  extensive  destruction  of  bone, 
which,  when  it  affects  the  sacrum,  may  lead  to  septic  meningitis,  or 
when  tlie  bed-sore  is  situated  over  a  joint  may  lead  to  opening  of  the 
joint  (;avity,  and  further  changes. 

During  convalescence  one  notices  occasionally  loss  of  hair,  which, 
liowever,  in  most  cases  grows  again.  As  in  other  fevers  and  severe 
diseases,  a  transverse  ridge  of  the  nails,  from  interference  with  nuti'ition, 
is  noticed  after  recovery  from  enteric  fever.     There  is  an  opaque  white 


Si 6  SYSTEM  OF  MEDICINE 

line,  followed  usually  at  some  little  distance  by  a  depression ;  starting 
close  to  the  bed  of  the  nail,  gradually  with  the  growth  of  the  nail  it 
advances  forward  till  eventually  it  disappears ;  in  older  people,  how- 
ever, it  may  remain  visible  for  a  long  time. 

Tlie  circulatory  system  presents  important  symptoms,  especially  from 
a  prognostic  point  of  view.  As  in  other  febrile  infectious  diseases,  the 
continued  high  temperature,  the  toxic  products  of  the  micro-organism, 
and  the  presence  of  the  typhoid  bacilli  in  the  myocardium  (Chante- 
messe),  and  especially  also  secondary  infection,  exert  a  deleterious 
effect  on  the  heart  muscle,  and  are  often  the  cause  of  death  in  typhoid ; 
the  blood  itself  presents  important  changes  which  differ  somewhat  from 
those  seen  in  other  acute  febrile  affections,  and  lead  to  further  disturb- 
ances, especially  noticed  in  the  post-febrile  period. 

Pulse.  —  During  the  first  week,  and  during  the  whole  period  of  the 
fever  in  cases  which  are  likely  to  end  in  recovery,  the  pulse,  except  in 
children,  ranges  from  86  to  100  in  men,  and  from  100  to  120  in  women ; 
it  is  distinctly  and  markedly  dicrotic,  indicating  a  paresis  of  the  arterial 
muscular  coat  and  low  blood  pressure.  The  force  of  the  pulse  varies, 
of  course,  with  the  age  and  strength  of  the  individual  and  the  condition 
of  the  heart;  according  to  Potain,  the  blood  pressure  in  the  arteries  is 
always  diminished,  see  on  this  subject  also  Moser  (65a).  Daring  the 
second  and  third  week  the  pulse  generally  becomes  a  little  quicker  and 
less  dicrotic,  and  during  convalescence  may  be  very  slow.  A  small  and 
quick  pulse  is  of  bad  omen ;  Liebermeister  found  that  when  the  pulse 
reached  140  pulsations  per  minute  death  occurred  in  50  per  cent,  and 
when  over  140  the  mortality  Avas  80  per  cent.  Equally  unfavourable  is 
the  prognosis  when  the  pulse  becomes  irregular  and  intermittent,  even 
if  not  very  frequent ;  such  a  pulse  is  often  followed  by  pulmonary  or 
cerebral  thrombosis,  with  sudden  death  at  a  later  period,  and  it  indicates 
myocarditic  changes.  In  some  cases  of  enteric  fever  a  slow  pulse  (50- 
40)  has  been  noticed  throughout  the  disease,  which  returned  to  its 
normal  frequency  during  convalescence  (Murchison).  There  is  no  defi- 
nite relation  between  the  temperature  and  the  pulse,  though  often  with 
rise  of  temperature  the  pulse  also  increases.  The  physical  examination 
of  the  heart  in  ordinary  uncomplicated  cases  reveals  nothing  abnormal ; 
in  severe  cases  the  first  sound  may  be  very  feeble  or  quite  inaudible,  as 
pointed  out  by  Stokes ;  or  the  first  and  second  sound  become  very  simi- 
lar in  timbre  and  duration ;  sometimes  a  systolic  murmur  is  heard  at 
the  apex  or  over  the  area  of  the  pulmonary  artery.  With  these  signs 
dilatation  of  the  heart,  cyanosis,  and  venous  pulsatioij  may  be  noted. 
French  observers  have  described  a  cardiac  form  of  enteric  fever. '  These 
cases  are  characterised  from  the  first  by  quick,  small,  and  irregular 
pulse,  a  low  temperature,  pallor  of  the  face  and  extremities,  and  retro- 
sternal pain.  The  prognosis  of  these  cases  is  always  very  grave,  and 
death  often  occurs  from  collapse  or  syncope. 

As  further  complications,  especially  during  the  last  stage  of  and 
during  convalescence  from  enteric,  blocking  of  arteries  and  of  veins 


ENTERIC  FEVER  817 


occurs,  the  latter  being  imich  more  common.  The  aifection  of  the  arte- 
ries has  been  described  by  Landouzy  and  Siredey  as  an  arteritis,  of 
which  they  distinguish  a  parietal  and  an  obliterating  form.  This  affec- 
tion, if  it  occur,  is  almost  always  met  with  during  convalescence;  it 
affects  the  large  trunks,  and  is  ushered  in  by  fever  and  by  pain  over  the 
affected  artery,  which  can  be  felt  as  a  cord-like  mass  ;  the  pulse  in  the 
vessels  below  the  obstruction  is  very  much  diminished,  oedema  appears 
in  the  peripheral  part  of  the  affected  limb,  and  in  some  cases  dry  gan- 
grene follows :  the  surface  temperature  of  the  affected  part  is  most  usu- 
ally diminished.  In  a  case  reported  by  Sydney  Phillips  (69),  in  which 
blocking  of  the  left  common  femoral  artery  took  place,  the  surface 
temperature  of  the  affected  limb  showed  an  increase  of  5°  F. 

Thrombosis  of  veins  is  of  much  more  frequent  occurrence.  It  affects 
most  commonly  the  left  femoral  vein,  but  may  affect  other  veins,  as  of 
the  upper  extremity;  it  is  ushered  in  by  slight  rise  of  temperature, 
severe  local  pain,  often  lasting  several  days,  and  marked  swelling  of 
the  limb ;  occasionally  several  attacks  of  thrombosis  may  occur  during 
convalescence.  In  one  case  under  my  own  observation  each  attack  was 
preceded  by  a  rigor,  very  high  temperature,  very  quick  pulse,  and  pro- 
fuse sweating.  In  the  clot  obstructing  the  vein  micro-organisms  have 
been  found  (Vaquez).  The  thrombosis  may  extend  into  other  veins ;  it 
may  lead  to  pygemic  symptoms,  and  sometimes  it  causes  sudden  death 
from  pulmonary  embolism.  If  by  the  thrombosis  of  the  vein  the  adja- 
cent artery  be  much  compressed,  or  if  clotting  in  the  artery  be  associated 
with  it,  gangrene  of  the  distal  part  of  the  limb  ensues. 

Infarcts  of  the  spleen,  kidney,  and  lungs  are  sometimes  seen  post- 
mortem. Unless  these  infarcts  are  very  extensive,  they  cannot  often 
be  diagnosed  during  life. 

The  blood  in  enteric  fever  shows  some  marked  changes.  Por  the 
literature  on  this  subject  I  must  refer  to  the  paper  by  W.  S.  Thayer  in 
the  Hospital  Reports  of  the  Harvard  University,  vol.  iv.  ISTo.  21,  p.  83. 
The  older  writers  state  that  the  clot  obtained  by  blood  letting  in  this 
fever  shows,  by  an  absence  of  the  buffy  coat,  that  the  fibrin  is  diminished. 
The  histological  examination  of  the  blood  has  not  always  given  uniform 
results,  but  the  majority  of  observers  are  agreed  upon  the  following 
broad  facts:  —  the  number  of  red  blood  corpuscles,  normal  at  first,  falls 
gradually  during  the  fever,  but  not  to  a  very  large  extent ;  with  the 
cessation  of  the  fever  the  number  falls  still  lower,  and  may  fall  to  a  very 
low  degree  (post-typhoid  anaemia).  The  red  blood  corpuscles  may 
undergo  temporary  changes  in  number  during  the  fever;  thus  profuse 
diarrhfca  may  cause  a  temporary  increase,  haemorrhage  a  decrease.  The 
amount  of  ha;moglobin  falls  and  rises  with  the  number  of  the  red  blood 
cells.  The  leucocytes  are  stated  by  most  recent  observers  to  be  not  only 
not  increased,but  rather  diminished  in  enteric  fever — amarkeddifference 
between  enteric  fever  and  inflammatory  affections  and  other  infectious 
fevers.  Some  observers,  however,  have  noticed  a  slight  increase  at  the 
beginning  of  the  attack.     With  convalescence  the  number  gradually 

VOL.    1  3   G 


8i8  SYSTEM  OF  MEDICINE 

returns  to  tlie  normal.  In  post-typhoid  ansemia  certain  changes  in  the 
relative  proportion  of  the  various  forms  of  leucocytes  have  been  noted 
by  Thayer,  namely,  a  great  increase  of  the  large  mononuclear  leucocytes, 
and  a  diminution  of  the  multinuclear  neutrophiles.  Eichhorst  found  in 
one  case  large  granular  cells  containing  several  red  blood  corpuscles. 
The  specific  gravity  of  the  blood  taken  after  the  method  of  Schmelz 
shows  considerable  diversity.  The  glycogen  of  the  blood  has  been  found 
increased.  Typhoid  bacilli  have  repeatedly  been  found  in  blood  dravs^n 
from  the  spleen  by  a  syringe,  but  very  rarely  in  blood  drawn  from  the 
finger  or  a  superficial  vein,  or  from  the  roseolar  eruption.  Streptococci 
and  staphvlococci  have  been  found  in  the  blood  in  mixed  infection  [see 
"Mixed  Infection,"  p.  832]. 

Respiratory  System. — Epistaxis  as  an  early  symptom  has  already 
been  mentioned.  In  severe  cases  of  the  so-called  "  haemorrhagic 
typhoid"  profuse  epistaxis,  haemorrhages  from  the  stomach,  kidneys, 
and  other  organs,  and  cutaneous  and  subcutaneous  haemorrhages,  have 
been  observed  at  a  late  stage  of  the  fever. 

Laryngeal  Affections. — The  larynx  is  not  unfrequently  found  affected 
in  enteric  fever.  About  the  proportion  of  cases  affected  authors  vary 
considerably.  In  many  cases  there  are  no  subjective  symptoms,  and 
laryngoscopic  examination  only  can  reveal  the  nature  and  extent  of  the 
affection;  in  others  the  symptoms  are  dryness  and  tickling  of  the  throat, 
hoarseness,  cough ;  while  some  affections,  like  oedema  and  perichondritis, 
may  give  rise  to  alarming  and  sometimes  quickly  fatal  symptoms.  The 
various  affections  are  — 

1.  Catarrhal  Affection.  —  This,  according  to  Landgraf,  Lewin,  and 
others,  is  a  simple  hyperaemia  of  the  mucous  membrane. 

2.  Ulcerations,  which,  according  to  some  observers,  are  due  to  the 
typhoid  bacillus,  and  may  thus  be  looked  upon  as  a  typical  form  of 
typhoid,  "  laryngo-typhoid."  These  ulcerations  are  situated  in  the 
parts  of  the  larynx  provided  with  adenoid  tissue,  namely,  the  base  of 
the  epiglottis,  the  posterior  wall  of  the  larynx,  especially  the  inner  sur- 
face of  the  arytenoid  cartilages,  and  the  false  vocal  cords.  These  ulcers 
may  be  simple  erosions  and  heal  readily,  or  they  may  become  necrotic 
and  leave  sharply-defined  defects,  or  they  may  lead  to  extensive  peri; 
chondritis  and  exfoliation  of  the  cartilages.  As  yet  typhoid  bacilli  have 
not  been  found  in  these  ulcers,  and  some  therefore  look  upon  them  as 
allied  to  the  next  class,  namely, 

3.  Ulcerations  due  to  an  epithelial  necrosis,  and  caused  by  strepto- 
cocci and  staphylococci  (Eppinger,  Landgraf).  They  appear  at  first 
in  the  form  of  yellowish  spots,  which  break  up  into  smaller  masses. 
These  masses  slough  and  become  detached,  leaving  more  or  less  deep 
ulcers,  which  may  lead  to  further  changes. 

4.  True  Diphtheritic  Affection.  —  This  is  extremely  rare,  and  but  few 
undoubted  cases  (35)  are  recorded.  In  one  case  the  diphtheritic  mem- 
branes extended  to  the  bronchi,  and  the  soft  palate  Avas  also  affected. 

5.  Perichondritis  with  exfoliation  of  the  cartilages,  which  may  lead 


ENTERIC  FEVER  819 


to  marked  narrowing  of  the  larynx,  or  in  rare  cases  to  subcutaneous 
emphysema  of  the  neck,  must  be  looked  upon  in  nearly  all  cases  as 
secondary  to  the  ulceration.  It  is  chiefly  noticed  during  convalescence  ; 
it  may  lead  to  suppuration  and  extensive  destruction,  and  to  alarming 
symptoms  of  suffocation.  In  several  cases  small  portions  of  cartilage 
have  been  coughed  up,  and  recovery  has  taken  place ;  in  many  trache- 
otomy is  necessary,  though  this  is  not  unfrequently  followed  by  fatal 
results  (62).  Some  authors  (Dietrich,  Eichle)  have  looked  upon  the 
laryngeal  ulcers  in  enteric  fever  as  allied  in  their  origin  and  nature  to 
bed-sores,  and  due  partly  to  pressure  and  partly  to  disturbance  in  the 
circulation  and  innervation  of  the  parts :  they  have  accordijigly  pro- 
posed for  these  ulcers  the  name  of  "  decubitus  ulcers." 

Lastly,  we  have  to  notice  paralysis  of  the  vocal  cords,  which  has 
occasionally  been  observed  during  convalescence,  or  some  time  after.  In 
some  cases  it  has  been  found  due  to  pressure  on  the  recurrent  laryngeal 
nerve,  either  by  enlarged  glands  or  thickened  pleura  (Schrotter)  ;  in 
others  it  is  probably  the  result  of  changes  in  the  muscles  or  nerves  due 
to  the  toxic  effect  of  the  poison.  Thus  in  one  case  paralysis  of  the 
vocal  cord  was  noticed  with  multiple  peripheral  neuritis. 

For  a  more  detailed  account  of  the  laryngeal  affections  see  (52,  28). 

Bronchitis  is  very  often  noticed  in  enteric  fever,  especially  in  the 
older  subjects.  It  may  occasionally  become  very  severe,  and  extend  to 
the  smallest  bronchi. 

Broncho-pneumonia  occurs  chiefly  in  the  disseminated  form,  and  may 
lead  to  small  foci  of  suppuration. 

Hypostatic  congestion  occurs  frequently  in  enteric  fever  owing  to 
the  enforced  and  prolonged  recumbent  posture  of  the  patient ;  it  may 
lead  to  hypostatic  pneumonia  or  collapse. 

Croupous  or  Lobar  Pneumonia.  —  It  has  now  been  clearly  demon- 
strated that  in  most  cases  the  pneumococcus  of  Frankel  is  the  cause  of 
pneumonia  in  typhoid.  In  others  (septic  pneumonia)  a  streptococcus 
has  been  found.  Some  few  cases  are,  however,  recorded  where  the 
typhoid  bacillus  has  been  detected  in  the  inflamed  lung,  and  such  cases 
must  be  regarded  as  a  specific  localisation  of  the  disease  (pneumo- 
typhoid)  (70a).  Clinically  considered,  it  must  be  noted  that  in  some 
cases  pneumonia  occurs  at  the  outset  of  the  disease,  and  masks  the  enteric 
symptoms  for  some  days,  till  in  the  second  week,  on  the  subsidence  of  the 
pneumonic  symptoms,  but  slight  abatement  of  the  fever  follows,  and  the 
enteric  symptoms  become  more  pronounced ;  in  others,  and  this  is  more 
frequent,  pneumonia  sets  in  at  the  end  of  the  second  or  third  week  of 
the  fever.  The  usual  symptoms  —  such  as  rigor,  pain,  and  rusty  sputum 
—  are  often  absent,  and  the  affection  is  often  to  be  recognised  only  by 
increased  frequency  of  breathing,  by  rise  of  temperature,  and  by  the 
y)hysical  signs ;  in  some  few  cases,  however,  acute  pleuritic  pain  and  rusty 
sputum  may  be  noticed.  Of  the  combination  of  septic  pneumonia  and 
enteric  fever  T  have  hitoly  seen  a  case  in  which  the  pneumonia  was  of 
the  creeping  kind,  attacking  first  the  base  and  then  the  apex  on  each 


820  SYSTEM  OF  MEDICINE 

side ;  the  sputum  contained  masses  of  streptococci  but  no  pneumococci. 
During  the  influenza  epidemic  the  combination  of  influenza  pneumonia 
with  enteric  fever  was  occasionally  noticed  (93).  The  association  of 
pneumonia  with  true  enteric  fever  must  be  distinguished  from  the 
"  typhoid  pneumonia,"  in  which  diarrhoea  and  all  the  symptoms  known 
as  the  "typhoid"  state  occur  —  namely,  great  prostration,  low  muttering 
delirium,  etc.  In  many  cases  the  diagnosis  cannot  be  made  imtil  the 
disease  has  lasted  some  days  by  the  marked  enlargement  of  the  spleen, 
the  appearance  of  roseolar  spots,  the  persistence  of  the  fever  and  the 
occurrence  of  intestinal  haemorrhage. 

Pleurisy  and  empyema  have  occasionally  been  noticed  during  the 
course  of  enteric.  Milder  attacks  of  pleurisy,  in  ^n^hich  spontaneous 
absorption  of  exudation  takes  place,  are  not  uncommon.  Extensive 
exudations  occur  much  less  frequently,  and  are  to  be  considered  as  the 
result  of  a  mixed  infection,  due  to  streptococci  or  pneumococci.  The 
typhoid  bacillus  has  been  found  in  a  very  few  cases  only  (Weintrand, 
Belfanti). 

Tuberculosis  of  the  lung  has  occasionally  been  observed  during  con- 
valescence or  some  time  after ;  probably  the  disease  in  these  cases  was 
already  present  in  the  patient  before  he  caught  typhoid.  Acute  tuber- 
culosis following  enteric  fever  has  been  noted  especially  in  some  of  the 
epidemics  of  enteric  in  soldiers  during  war  (38). 

The  Month.  —  The  state  of  the  tongue,  as  already  indicated  in  the 
general  description,  varies  with  the  severity  of  the  disease  and  the  stage 
of  the  disease.  At  the  onset  it  is  covered  with  a  white  fur,  which 
gradually  thickens,  but  is  still  moist ;  and  in  milder  cases  this  condition 
may  not  alter  throughout  the  whole  of  the  course :  in  the  ordinary  cases 
after  the  first  week  the  tongue  becomes  dry,  and  is  covered  by  a  brown 
fur;  later  the  dryness  still  further  increases,  and  the  centre  of  the 
tongue  is  covered  by  a  deep  brown,  almost  black,  dry  fur,  which  may 
form  crusts  and  leave  fissures.  The  gums  and  lips  become  likewise 
covered  by  brown,  dry  masses  of  sordes.  With  the  beginning  of  con- 
valescence the  tongue  becomes  moist  again  and  quickly  cleans.  The 
secretion  of  saliva  is  in  most  cases  very  much  diminished,  as  indeed  is 
the  case  in  most  fevers. 

Parotitis  is  occasionally  observed  during  the  later  course  or  as  a 
sequela ;  it  gives  rise  to  more  or  less  extensive  swelling,  and  is  usually 
unilateral ;  the  exudation  may  gradually  become  absorbed,  or  suppura- 
tion may  ensue,  which  not  unfrequently  leads  to  other  septic  symptoms 
and  death.  It  is  more  frequently  noticed  in  some  epidemics  than  in 
others,  and  is  either  due  to  an  extension  of  the  inflammation  from 
Steno's  duct  or  to  a  metastatic  inflammation.  Murchison  recorded  six 
cases  of  which  five  terminated  fatally ;  Osier  noticed  some  cases  which, 
however,  all  terminated  favourably. 

Cancrum  oris  occurs  chiefly  in  children,  and  appears  to  be  much  less 
frequent  now  than  formerly.  It  is  observed  during  the  latter  stage  of  en- 
teric, and  its  commencement,  as  it  begins  without  pain  as  a  small  necrotic 


ENTERIC  FEVER  821 


patch  on  the  mucous  surface  of  the  cheek,  is  not  likely  to  be  noticed. 
The  necrotic  patch  extends  in  depth,  and  soon  a  hard,  brawny,  shining, 
indurated  patch,  at  first  pale  and  gradually  deepening  in  colour,  appears 
on  the  outside  of  the  cheek ;  the  patch  softens,  a  deep  slough  forms,  and 
on  separation  a  hole  may  form  through  which  the  gums  and  teeth  can  be 
seen ;  at  the  same  time  the  process  extends  on  the  mucous  surface,  causing 
extensive  ulcerations  of  the  gums,  and  even  of  the  tongue.  The  gangrene 
may  now  spread  farther,  affecting  the  greater  part  of  the  cheek,  the  jaw 
may  be  laid  bare,  the  teeth  become  loosened  and  fall  out,  and  necrosis 
of  the  alveoli  follow.  There  is  marked  salivation,  and  the  breath  is 
very  foetid.  In  spite  of  the  extensive  spreading  of  the  necrosis  there 
is  rarely  any  haemorrhage,  and  there  is  no  pain  throughout  the  whole 
course  of  the  disease.  In  most  cases  the  patient  dies  from  septic  pneu- 
monia or  other  septic  complication.  Recovery  is  very  rare,  and  in  this 
event  a  marked  disfiguration  of  the  face  remains.  The  affection  is  of 
the  nature  of  gangrene,  and  is  not  due  to  typhoid  bacilli ;  long  threads 
of  small  bacilli  have  been  found  in  the  spreading  edge  by  Lingard. 

Pharynx.  —  Catarrhal  affection  of  the  pharynx  is  often  observed, 
and  during  the  latter  stage  of  severe  cases  there  is  occasionally  a  thick 
deposit  on  the  fauces,  which  can  be  detached,  and  is  found  to  consist 
of  debris,  particles  of  food,  masses  of  epithelial  cells,  leucocytes,  and 
numerous  micro-organisms.  In  some  cases  a  deposit  roughly  resembling 
a  diphtheritic  membrane  is  seen  ;  this  owes  its  origin  probably  to 
streptococci  and  staphylococci,  which  are  found  in  large  numbers 
together  with  necrotic  tissue  and  fibrin.  This  is  usually  a  complication 
of  very  severe  and  fatal  cases. 

A  peculiar  ulceration  has  been  described  by  several  French  and 
German  observers  (Bouveret,  Devignac,  Duguet,  "Wagner,  Cahn)  (9), 
and  is  looked  upon  as  specific  of  enteric  fever.  It  has  been  named 
pharyngo-typhoid.  The  ulcers  are  superficial,  circumscribed,  cleanly 
cut,  and  occur  principally  on  the  soft  palate,  close  to  the  hard  palate. 
From  the  observations  of  Renon  it  appears,  however,  that  they  are  not 
due  to  typhoid  bacilli,  but  to  streptococci  and  staphylococci. 

Gastro-Intestincd  Symptoms.  —  Nausea  and  vomiting,  as  already 
noticed,  may  be  present  at  the  onset  and  continue  for  some  days.  In 
most  cases  these  symptoms  disappear  after  the  first  week,  so  that  the 
patient,  as  a  rule,  has  no  difficulty  in  taking  large  quantities  of  milk ; 
the  secretion  of  gastric  juice  is  very  much  diminished,  and  free  hydro- 
chloric acid,  as  in  most  febrile  affections,  is  absent.  In  cases  where 
severe  nephritis  is  noticed  during  the  course  of  the  fever,  persistent 
vomiting,  probably  ursemic,  has  been  noted.  Epigastric  pain  and 
vomiting,  due  to  inflammatory  changes  and  ulceration  of  the  stomach, 
have  also  been  recorded  (A.  Chauffaro). 

DiarrhfjBa  is  one  of  the  characteristic  symptoms  of  enteric  fever.  It 
may  be  present  from  the  first,  and  persist  throughout  the  whole  course, 
continuing  sometimes  even  when  the  temperature  has  reached  the 
normal.     In  other  cases  there  is  constipation  at  first,  and  diarrhoea 


SYSTEM  OF  MEDICINE 


begins  about  the  end  of  first  week ;  in  otliers  diarrhoea  may  be  absent 
throughout,  and  even  obstinate  constipation  may  exist.  Profuse  diarrhoea 
is  noticed  principally  in  severe  cases,  but  there  is  no  relation  between 
the  diarrhoea  and  the  ulceration  of  the  intestines,  and  even  in  constipated 
patients  extensive  nf cerations  have  been  found.  The  number  of  stools, 
usually  four  to  ten  in  twenty-four  hours,  varies  considerably ;  sometimes, 
however,  the  stools  occur  even  more  frequently.  With  each  evacuation 
a  fairly  large  quantity  is  discharged.  The  stool  is  thin  at  first,  but  of 
ordinary  brown  colour;  soon  it  becomes  yellowish,  of  the  colour  and 
consistency  of  pea-soup :  it  is  often  uniform,  but  in  children,  and  some- 
times in  adults  when  very  large  quantities  of  milk  are  taken,  it  contains 
curds.  With  the  approach  of  convalescence  I  have  frequently  noticed 
the  colour  of  the  stool  to  become  greenish  and  less  uniform,  showing 
small  solid  particles.  The  stool,  especially  in  children,  has  a  very  foul 
smell.  On  standing,  a  clear  upper  stratum  separates,  which  is  very  rich 
in  albumin.  Microscopically  examined  the  stool,  besides  the  partly 
digested  particles  of  food,  contains  a  large  quantity  of  triple  phosphates, 
desquamated  epithelial  cells,  embryonic  cells,  blood  corpuscles,  necrotic 
tissue  elements,  and  granular  detritus.  Numerous  micro-organisms  are 
found,  micrococci  and  larger  and  smaller  bacilli.  The  typhoid  bacillus 
has  not  been  found  in  the  alvine  discharges  before  the  ninth  day ;  its 
detection,  especially  its  distinction  from  the  bacterium  coli  which  occurs 
constantly  in  the  faeces,  both  in  health  and  in  disease,  has  already  been 
described ;  and  it  has  been  seen  that  at  present  no  clinical  diagnosis  can 
be  based  upon  it.  Careful  examination  of  the  stool  on  the  third  week 
often  reveals  the  presence  of  small  shreds^  probably  sloughs  from  Peyer's 
patches.  There  is  usually  no  pain  either  before  or  after  the  discharge. 
Haemorrhage  from  the  bowels  in  any  marked  quantity  occurs  in  from 
3  to  7  per  cent  of  the  cases  (Murchison,  Liebermeister).  It  is  much 
rarer  in  children.  In  some  cases  it  may  occur  at  the  end  of  the  first 
week,  and  is  then  probably  due  to  intense  congestion ;  most  commonly 
it  occurs  after  the  second  week  ;  it  may  occur  only  once,  and  is  then 
not  a  very  unfavourable  symptom,  or  repeatedly,  and  there  may  be  eight 
to  ten,  and  even  more  discharges  in  twenty-four  hours,  consisting  of 
almost  pure  liquid  blood.  In  two  very  severe  cases  (husband  and  wife) 
the  haemorrhage  was  so  profuse  that  pressure  on  the  abdomen,  or  any 
movement  on  the  part  of  the  patient,  was  followed  by  a  discharge  of 
blood,  but  both  patients  recovered.  In  less  severe  cases  the  stool  is 
black  and  tarry.  Slight  haemorrhage  does  not  give  rise  to  any  subjective 
symptoms.  Profuse  haemorrhage  is  indicated  by  a  sensation  of  faintness, 
rapid  fall  of  temperature  (from  2°  to  5°  F.),  pallor  of  the  face,  smallness 
and  rapidity  of  the  pulse,  and  extreme  prostration.  According  to 
Ztllzer,  whose  statement  is  confirmed  by  Moore,  profuse  haemorrhage, 
by  filling  several  coils  of  intestines,  may  give  rise  to  a  dull  percussion 
note  where  previously  the  note  was  tympanitic.  Such  abundant  haemor- 
rhage during  the  later  stage  of  typhoid  is  due  either  to  erosion  of  the 
vessels  on  the  separation  of  a  slough,  or  to  an  increased  diapedesis  from 


ENTERIC  FEVER  823 


the  small  arteries,  whose  walls  are  degenerated  (72).  As  to  the  prog- 
nostic importance  of  the  haemorrhage  authors  differ  somewhat.  Graves, 
Trousseau,  and  Griesinger  are  of  opinion  that  the  occurrence  of  haemor- 
rhage is  not  an  unfavourable  symptom.  This  is  probably  correct  when 
haemorrhage  occurs  only  once  and  early,  as  by  the  haemorrhage  some  of 
the  toxic  material  accumulating  in  the  blood  may  be  got  rid  of.  Profuse 
haemorrhage,  on  the  other  hand,  occurring  at  a  later  period,  must  always 
be  looked  upon  as  a  very  serious  event,  and  the  mortality,  from  syncope 
chiefly,  is  very  high  (30  to  40  per  cent). 

In  haemorrhage  typhoid,  with  petechial  eruption,  and  abundant  epis- 
taxis,  intestinal  haemorrhage  is  a  prominent  symptom,  and  may  occur 
earlier  in  the  disease. 

Tympanites  is  almost  a  constant  symptom  in  enteric  fever,  and  when 
excessive  is  of  grave  omen.  It  may  favour  perforation,  or  by  displace- 
ment of  the  diaphragm  upwards  cause  cardiac  disturbances.  Of  gur- 
gling and  pain  on  pressure  we  have  already  spoken.  Abdominal  tender- 
ness is  sometimes  observed  for  the  first  week  or  later ;  it  is  sometimes 
diffuse,  at  other  times  limited  to  the  region  of  the  umbilicus,  or  the 
right  iliac  region.  Persistent  and  localised  pain  is  probably  due  to 
slight  peritonitis. 

Perforation  of  an  intestinal  ulcer  is  one  of  the  most  terrible  of  acci- 
dents. It  seems  to  occur  in  about  2-5  to  3  per  cent,  and  was  noticed 
114  times  in  2000  fatal  cases  (42).  It  is  rarer  in  children,  and  occurs 
more  frequently  in  men  than  in  women.  It  may  occur  any  time  after 
the  second  week,  and  it  has  been  observed  after  all  fever  symptoms 
have  subsided.  Osier  observed  one  case  as  early  as  the  eighth  day. 
In  Hoelscher's  table,  of  the  114  fatal  cases,  no  case  is  recorded  in  the 
first  two  weeks  of  the  fever.  As  accessory  causes,  indigestible  food, 
excessive  tympanites,  obstinate  vomiting,  movements  on  the  part  of  the 
patient,  and  the  presence  of  intestinal  worms,  are  cited;  but  occasion- 
ally perforation  may  occur  without  any  such  aids.  It  may  occur  in  mild 
cases,  and  I  have  noticed  it  in  apyrexial  typhoid.  The  perforation, 
setting  in  suddenly,  quickly  gives  rise  to  the  symptoms  of  perforative 
peritonitis :  severe  pain,  at  first  situated  over  the  right  iliac  fossa  (or 
referred  pain  over  the  left  iliac  region),  soon  becomes  general.  The 
pain  may  be  persistent,  or  more  like  colic ;  in  some  few  cases  it  has 
been  entirely  absent.  Vomiting  usually  occurs  early ;  the  patient  shows 
symptoms  of  collapse ;  the  features  become  pale  and  pinched,  the  pulse 
small  and  threadlike,  the  abdomen  more  distended,  and  the  liver  dulness 
can  no  longer  be  made  out  on  percussion  (Wagner,  Flint).  In  some 
cases  the  abdomen,  instead  of  being  distended,  may  be  retracted,  with 
marked  rigidity  of  the  walls  (Wagner).  The  breathing  becomes  thoracic, 
and  the  temperature  suddenly  falls,  though  it  may  afterwards  rise  again 
considerably.-  There  is  often  suppi'ession  of  urine.  Soon  the  prostra- 
tion becomes  extreme,  the  voice  husky,  cold  clammy  perspiration  covers 
the  face  and  body,  and  the  patient  gradually  sinks,  the  sensorium  often 
remaining  clear  to  the  end.     In  some  cases  death  may  occur  at  a  latei 


824  SYSTEM  OF  3IEDICT.VE 

period  from  subacute  peritonitis.  Thus  a  patient  was  admitted  into  the 
Manchester  Infirmary  with  symptoms  of  intestinal  obstruction  which 
had  lasted  for  some  days ;  the  patient  died  soon  after  admission.  At 
the  autopsy  typical  typhoid  ulcers  were  found,  one  of  which  was  perfo- 
rated, and  fsecal  extravasation  had  taken  place.  There  was  extensive 
peritonitis  and  a  small  quantity  of  fsecal  matter  lay  free  in  the  abdo- 
men. Recovery  does  occasionally,  but  very  rarely,  occur.  If  the  per- 
foration be  a  tiny  one  the  symptoms  may  not  be  very  characteristic :  the 
pulse,  however,  will  rise  over  120,  and  the  temperature  may  fall.  The 
area  of  liver  dulness  may  also  be  diminished,  and  the  respiration  be 
thoracic.  There  may  be  a  disposition  to  vomit,  and  a  little  increasing 
pain.  Yet  even  in  such  a  case  laparotomy  can  scarcely  be  advisable,  as 
the  enfeebled  heart,  extensive  intestinal  ulceration,  and  febrile  prostra- 
tion, prevent  much  hope  of  success. 

Perforative  peritonitis,  apart  from  the  perforation  of  an  ulcer,  may 
occur  from  ulceration  of  the  gall-bladder,  rupture  of  a  suppurating  mes- 
enteric gland  or  of  abscess  of  spleen,  rupture  of  spleen,  etc. 

The  occurrence  of  peritonitis  without  perforation  may  occur  from 
extension  of  the  inflammation  to  the  serous  coat  of  the  intestine.  It  is 
then  generally  circumscribed,  and  tends  to  form  adhesions.  Occasion- 
ally it  may  give  rise  to  a  local  suppuration. 

Complications  relating  to  the  Liver  and  Biliary  Apparatus.  —  Recent 
experimental  investigations  have  shown  that  in  microbic  diseases  the 
liver  plays  an  important  part,  the  vessels  with  their  endothelial  lining, 
and  probably  also  the  liver  cells,  being  actively  concerned;  but  these 
changes  do  not  give  rise  to  symptoms  which  can  be  clinically  recognised, 
and  the  changes  which  we  notice  are  due  not  so  much  to  the  typhoid 
bacillus,  as  to  a  mixed  or  secondary  infection,  and  to  complications. 

Jaundice  is  very  rare  in  the  enteric  fever  of  our  climate.  It  has  been 
noticed  late  in  the  disease,  or  even  during  convalescence,  and  is  most 
commonly  due  to  catarrhal  secretions  blocking  up  the  bile  duct.  In  other 
cases  the  jaundice  is  due  to  micro-organisms  which  have  been  found  in 
the  biliary  passages,  such  as  the  bacterium  coli  commune,  streptococcus 
pyogenes,  etc.,  which  give  rise  to  inflammation  of  the  biliary  ducts  (cho- 
langitis) with  or  without  formation  of  abscesses.  Such  cases  usually  run 
a  fatal  course,  with  symptoms  of  pyaemia.  The  gall-bladder  from  a 
similar  cause  may  be  the  seat  of  suppuration,  and  may  even  be  raptured. 
Some  observers  draw  attention  to  the  formation  of  gall-stones  after 
recovery  from  enteric  fever,  and  Dufourt  collected  nineteen  cases  where 
gall-stone  colic  occurred  thereafter.  Chantemesse  gives  a  case  where 
a  woman  eight  months  after  enteric  began  to  suffer  from  hepatic  colic, 
jaundice,  and  fever.  The  gall-bladder,  removed  by  operation  during  life, 
showed  the  presence  of  biliary  catarrh  and  living  typhoid  bacilli.  I 
may  here  draw  attention  to  the  not  unfrequent  coexistence  of  gall-stone 
and  ulcerative  endocarditis  [see  article  on  "  Ulcerative  Endocarditis  "]. 

Spleen. — The  enlargement  of  the  spleen  is  a  constant  symptom  in 
enteric  fever,  and  its  gradual  increase  can  often  be  demonstrated  during 


ENTERIC  FEVER  825 


the  course  of  the  disease.  During  the  second  week,  especially  in  chil- 
dren, the  edge  of  the  spleen  can  often  be  readily  felt,  particularly  on 
deep  inspiration.  The  enlargement  continues  to  the  end  of  the  third 
week,  when  it  gradually  subsides.  The  spleen  is  found  increased  in  its 
various  dimensions,  and  the  enlargement  can  be  readily  made  out  by 
percussion.  When  there  is  great  distension  of  the  abdomen,  or  when 
the  stomach  or  colon  are  inflated  and  displaced,  the  splenic  enlargement 
cannot  easily  be  made  out ;  in  other  cases  the  area  of  splenic  dulness, 
though  not  enlarged,  is  increased  in  intensity.  Palpation  of  the  spleen 
is  occasionally  painful.  xVbscesses  and  rupture  of  the  spleen  have  been 
occasionally  noticed ;  they  are,  however,  extremely  rare,  and  more  of 
pathological  than  clinical  interest. 

Genito-  Urinary  System.  —  The  urine  in  enteric  fever  presents  the 
ordinary  character  of  febrine  urine.  It  is  decreased  in  quantity,  high- 
coloured,  very  acid,  and  of  high  specific  gravity.  Uric  acid,  kreatinin, 
and  ammonia  are  increased ;  urea  is  usually  increased,  though  sometimes 
it  is  diminished  during  the  first  few  days.  Chloride  of  sodium^  and 
phosphoric  acid  (Zuelzer)  are  found  diminished  —  the  potash  salts  and 
relative  sulphuric  acid  (Zuelzer)  increased.  Of  abnormal  constituents, 
albumin  is  found  in  70-80  per  cent  of  the  more  severe  cases.  Of  the 
various  forms  of  albumin  serumalbumin  is  constantly  found,  and  with 
serumalbumin  globulin  often,  hemi-albuminose  or  prepeptone  occasion- 
ally. In  several  cases  the  urine  has  given  the  reactions  of  hemi-albu- 
minose for  one  or  two  days,  which  was  then  replaced  by  serumalbumin. 
The  urine  may  contain  blood  when  heemorrhagic  nephritis  complicates 
enteric  fever,  and  in  petechial  typhoid.  In  some  severe  cases  heemoglo- 
binuria  has  been  observed.  Mucus  occurs  when  cystitis  is  present.  In 
some  cases  acetone  and  aceto-acetic  acid  are  found  in  the  urine  without 
the  presence  of  sugar.  Microscopic  examination  may  reveal  the  presence 
of  various  forms  of  casts,  as  will  be  presently  pointed  out.  In  very  severe 
cases  of  enteric  fever  leucin  and  tyrosin  have  been  found  in  the  urine. 

EhrlicKs  Diazo  Reaction.  —  Ehrlich  described  this  test  in  1882,  and 
since  then  a  large  number  of  observations  have  appeared  on  the  subject 
(40).  The  peculiar  reaction  is  probably  due  to  the  presence  of  some 
nitrogenous  products  in  the  urine.  To  carry  out  the  test  we  use  two 
solutions  :  No.  1,  a  saturated  solution  of  sulphanilic  acid  in  dilute  hydro- 
chloric acid  (1  in  20) ;  No.  2,  a  solution  of  sodium  nitrite  in  water  (i  per 
cent  solution).  The  urine  to  be  tested  is  put  into  a  test-tube,  and  a 
quantity  of  the  solutions  1  and  2  equal  to  that  of  the  urine  is  added 
(about  40  c.c.  of  the  sulphanilic  acid  and  1  c.c.  of  sodium  nitrite  solu- 
tion), the  mixture  is  well  shaken,  and  then  some  drops  of  liquor  am- 
moniae  are  allowed  to  slip  down  the  side  of  the  tube.  At  the  junction  of 
the  two  a  deep  brownish  red  ring  appears  ;  if  again  shaken  the  whole 

1  Ten-ay  (88)  comparerl  the  quantity  of  sodium  cliloride  in  the  food  with  that  voided 
by  the  urine  and  the  fasces  in  four  (iases  of  enteric  fever,  and  found  the  chloride  diminish 
dnririK  tlie  w}if)le  fever  period,  and  also  for  some  days  after  the  fever  had  disappeared. 
The  ditniniition,  accordirif(  tf)  Leyden,  is  duo  to  the  retention  of  water  in  the  system 
during  the  fever. 


826  SYSTEM  OF  MEDICINE 


fluid  mass  appears  red,  and  if  the  diazo  reaction  be  present  the  foam 
appears  also  rose  tinted.  This  test  has  undoubtedly  some  diagnostic 
value  (87).  It  is  certainly  present  in  a  very  large  majority  of  cases  of 
enteric  fever  both  in  adults  and  in  children,  and  even  in  the  apyrexial 
type ;  according  to  Taylor,  it  does  not  often  appear  before  the  end  of  the 
first  week  (Hewetson  noticed  it  in  77  per  cent  of  his  cases  in  the  first 
week),  and  it  often  disappears  during  the  third  and  fourth  week.  The 
reaction,  however,  is  also  seen  in  other  febrile  affections  (typhus,  measles, 
scarlet  fever,  pneumonia,  acute  tuberculosis),  and  in  some  apyrexial  dis- 
eases (chronic  hepatitis,  carcinoma,  leukaemia,  etc.),  and  its  diagnostic 
value  is  thereby  somewhat  lessened. 

Albumin  in  the  urine  is  an  important  symptom ;  it  is  not  always  due 
to  the  same  cause,  and  from  analogy  with  other  infectious  diseases,  and 
from  a  consideration  of  the  pathological  changes  in  the  kidney  found 
after  death,  we  may  distinguish  the  following  forms  of  albuminuria:  — 

1.  Febrile  Albuminuria.  —  The  albuminuria  is  here  due  to  the 
pyrexia,^  though  the  retention  of  toxic  products  in  the  blood  cannot  be 
overlooked  as  a  probable  cause.  Clinically  this  albuminuria  is  charac- 
terised by  the  small  amount  of  albumin  in  the  urine  without  blood,  and 
often  without  casts ;  if  casts  be  present  they  are  hyaline  and  few  in 
number.  This  albuminuria  may  be  noted  early,  sometimes  even  in  the 
first  week.  It  occurs  in  children  as  well  as  in  adults ;  it  is  sometimes 
absent  for  a,  day  or  two,  and  it  disappears  with  convalescence.  It  does 
not  give  rise  to  very  serious  symptoms,  and  is  not  followed  by  any  per- 
manent damage  of  the  kidney. 

2.  Albuminuria  due  to  Acute  Bright's  Disease  (Hsemorrhagic  Neph- 
ritis, Nephro-typhoid).  —  The  albumin  is  here  often  abundant;  the  urine 
contains  also  blood,  and  granular,  fatty,  and  blood  casts  are  seen.  Vari- 
ous micro-organisms,  amongst  them  the  typhoid  bacilli,  have  been  found 
occasionally  in  the  urine  during  life,  or  in  the  kidneys  after  death  in  this 
affection.  This  complication,  if  stress  be  laid  on  the  free  admixture  of 
blood,  is  of  rare  occurrence  —  the  presence  of  large  quantities  of  albumin 
and  casts  without  any  blood,  or  with  but  a  small  quantity  of  blood,  is  of 
more  frequent  occurrence  (Osier  and  Mason's  figures  give  about  10  per 
cent  of  the  observed  cases  of  enteric  fever).  This  complication  is  usually 
observed  in  the  second  week,  but  sometimes  (Gubler,  Robin)  it  may  be 
an  early  symptom.  It  may  last  for  several  days,  and  end  in  recovery ; 
or  uremic  symptoms,  low  delirium  and  convulsions  may  set  in.  When 
this  complication  occurs  early  with  pain  in  the  back  and  the  passage  of 
urine  containing  much  blood,  and  is  followed  by  uraemic  symptoms, 
the  primary  disease  is  difficult  to  recognise.  The  affection  is  most 
likely  due  to  the  action  of  bacterial  products  on  the  kidney,  products 
which  either  circulate  in  the  blood  or  pass  to  the  kidney  from  another 

1  As  it  has  been  demonstrated  by  means  of  Roy's  oakometer  that  with  an  increase  of 
the  body  temperature  the  kidneys  decrease  in  size  considerably,  the  diminished  quantity 
of  urine  passed  and  the  presence  of  albumin  in  the  urine  are  readily  explained  ((i4) ;  asrain 
experimental  investigations  have  shown  that  albumin  may  appear  in  the  urine  of  animals 
exposed  to  high  temperatures. 


ENTERIC  FEVER  827 


part  of  tlie  urinary  tract  (67)  :  thus  it  is  allied  to  the  nephritis  seen  in 
other  infectious  fevers,  and  scarcely  deserves  the  designation  of  nephro- 
typhoid. 

3.  As  septic  infection  is  a  common  complication  of  enteric  fever,  we 
notice  sometimes  an  acute  suppurative  nephritis,  an  earlier  stage  of 
what  is  probably  Wagner's  lymphatic  nephritis.  This,  gives  rise  to  no 
diagnostic  symptoms,  except  perhaps  the  presence  of  multinuclear  leuco- 
cytes in  the  urine  not  due  to  any  other  complication  in  the  urinary 
cracts,  such  as  cystitis. 

4.  During  convalescence  albuminuria  may  be  observed  with  other 
symptoms  of  nephritis,  and  be  followed  by  oedema.  It  is  allied  to  the 
post-febrile  nephritis  seen  in  other' infectious  fevers  (Osier). 

Of  other  complications  we  may  notice  :  — 

Pyelitis,  cystitis,  when  there  has  been  retention  of  urine,  hcemorrJiage 
from  the   bladder,  urethritis. 

Orchitis,  followed  by  epididymitis,  occurs  during  convalescence.  The 
patient  becomes  again  feverish,  the  testicle  is  very  painful  and  swells 
rapidly.     Resolution  sets  in  quickly,  or  suppuration  ensues. 

Ovaritis  and  salpingitis  have  also  been  occasionally  noticed.  Changes 
in  the  menstrual  period  occur  sometimes  during  convalescence. 

Symptoms  relating  to  the  Nervous  System.  —  The  nervous  system  is 
often  profoundly  implicated  in  enteric  fever  throughout  the  fever  period 
and  even  after ;  so  much  so  that  in  Germany  the  popular  designation  of 
typhoid  is  nervous  fever  (Nervenfieber).  The  nervous  symptoms  vary 
considerably  in  individual  cases. 

At  the  onset,  and  sometimes  even  during  the  incubation  period, 
headache  and  insomnia  are  the  principal  features ;  these  usually  sub- 
side after  the  first  week.  In  milder  cases  there  may  be  no  other 
symptoms  within  the  nervous  sphere ;  in  the  more  severe  cases  there 
are  symptoms  of  irritation,  and  in  the  most  severe  cases  of  paralysis  of 
the  higher  centres.  Some  of  these  have  already  been  alluded  to  in  the 
general  description  of  the  disease. 

Delirium  is  common  in  the  ordinary,  and  especially  in  the  severer 
cases.  In  the  milder  cases  it  may  only  occur  at  night,  when  the  patient 
awakes  from  a  slight  slumber ;  in  the  more  severe  cases  it  is  persistent, 
but  varies  in  its  manifestations.  We  have  the  quiet  delirium,  when 
the  patient  is  easily  roused,  answers  questions  fairly  rationally,  but  soon 
lapses  into  delirium  again  :  violent  delirium,  when  the  patient  gets  very 
excited,  talks  or  sings,  or  may  even  become  violent ;  this  may  lead  gradu- 
ally to  acute  maniacal  delirium,  which  sometimes  occurs  in  paroxysms, 
during  which  the  patient  must  be  carefully  watched,  as  he  may  attempt 
to  escape  or  do  himself  some  bodily  injury.  It  must  be  remembered 
that  even  without  showing  marked  signs  of  delirium  patients  in  enteric 
fever  may  manifest  suicidal  tendencies.  Low  muttering  delirium  is 
seen  in  the  more  severe  cases :  the  patient  is  restless,  mutters  con- 
stantly, and  trembles  and  twitches;  equally  serious  is  the  delirium  in 
which  the  patient  is  quiet,  lies  with  his  eyes  open,  but  is  quite  uncon- 


828  SYSTEM  OF  MEDICINE 

scions.  The  more  severe  forms  often  lead  to  coma.  In  tipplers  the 
delirium  often  takes  the  form  of  delirium  tremens  —  the  patient  con- 
verses with  imaginary  people,  fancies  himself  at  his  usual  avocations, 
gives  orders,  or  serves  customers,  etc. 

In  some  cases,  especially  in  women,  the  delirium  has  more  the  char- 
acter of  lipemania;  the  patient  imagines  himself  the  subject  of  some 
persecution,  he  refuses  to  speak,  keeps  himself  wrapped  up  in  his 
blankets,  appears  terrified  when  any  one  approaches  him,  and  is  often 
absorbed  in  one  fixed  idea  (4).  The  fixed  idea  from  which  the  fever 
patient  suffers  sometimes  persists  for  a  while  during  convalescence. 
In  one  case  a  patient  fancied  he  had  received  a  commission  in  Her 
Majesty's  service,  and  after  he  recovered  from  the  fever  he  searched 
over  all  the  newspapers  to  see  if  he  had  not  been  gazetted. 

In  most  cases  the  delirium  occurs  during  or  after  the  second  week, 
but  occasionally  it  is  an  early  symptom,  and  when  preceded  by  head- 
ache, and  accompanied,  as  it  sometimes  is,  by  retraction  of  the  head  and 
neck,  convulsions,  taches  cerebrales,  etc.,  —  and  these  occur  more  par- 
ticularly in  children,  —  the  diagnosis  from  meningitis  is  often  difficult ; 
in  some  cases,  indeed,  the  post-mortem  examination  has  shown  the 
existence  of  meningitis  besides  the  lesions  of  enteric  fever.  The  men- 
ingitis may  be  the  result  of  a  mixed  infection ;  the  typhoid  bacillus, 
however,  has  been  found  in  the  meningeal  exudation  (Ferult). 

Convulsions  are  noticed  sometimes  in  children,  both  at  the  onset 
and  during  the  course  of  the  disease ;  in  adults  they  occur  sometimes 
in  the  meningeal  form,  or  from  uraemia  in  the  so-called  nephro-typhoid ; 
or  they  may  precede  death  when  myocarditis  complicates  enteric  fever. 
Severe  nervous  symptoms  are  seen,  especially  in  those  patients  who 
have  a  marked  neurotic  disposition,  either  acquired  or  inherited ;  though 
the  toxic  effects  of  the  fever  poison  cannot  be  excluded. 

The  deep  reflexes  (knee-jerks)  have  been  found  increased,  but  this, 
from  numerous  observations  I  have  made,  is  not  invariably  the  case.  I 
have  found  the  knee-jerks  absent  in  a  few  cases,  though  there  were  no 
indications  of  peripheral  neuritis ;  in  this  latter  case  the  knee-jerks  are 
absent. 

The  muscles  often  show  increased  irritability,  and  when  marked  ema- 
ciation is  present  they  exhibit  idiopathic  contractions  on  being  tapped. 
Muscular  tremors  affecting  the  limbs  (the  upper  extremity  more  than  the 
lower  extremity),  the  tongue,  and  sometimes  the  muscles  of  the  face,  often 
accompany  other  severe  nervous  symptoms ;  and  subsultus  tendinum  in 
enteric  as  well  as  in  other  affections  is  a  grave  though  not  a  fatal  omen. 

B-etraction  of  the  head  and  rigidity  of  the  muscles  of  the  neck,  back, 
or  extremities,  may  occur  in  severe  cases,  and,  if  associated  with  coma- 
tose symptoms,  may  suggest  epidemic  cerebro-spinal  meningitis. 

There  is  scarcely  any  other  febrile  affection,  except  perhaps  epidemic 
influenza,  which  is  followed  by  so  many  nervous  sequelae  as  enteric  fever. 
Some  of  these  are  observed  during  the  decline  of  the  fever  and  during 
convalescence,  others  occur  some  time  after.    Of  these  we  may  mention  — 


ENTERIC  FEVER  829 


Mental  Diseases.  —  Loss  of  memory  and  feebleness  of  intelligence, 
leading  to  dementia,  melancholia,  monomania,  and  other  forms  of  in- 
sanity, may  appear.  Some  of  these  symptoms,  probably  due  to  malnu- 
trition, are  of  short  duration ;  others,  probably  due  to  the  toxic  effect 
on  the  nerve  elements,  are  of  longer  duration ;  in  some  cases  recovery 
takes  place  after  many  months,  whilst  others  remain  incurable. 

Aphasia  has  often  been  observed  in  children,  and  is  generally  a  tem- 
porary affection. 

Neurasthenia  in  its  various  forms  may  supervene  —  cerebro-spinal, 
spinal,  sympathetic,  and  visceral.  Under  the  name  of  "  typhoid  spine," 
cases  of  spinal  neurasthenia,  characterised  by  severe  pain  in  the  ba,ck 
and  sometimes  in  the  legs,  have  been  described  (67). 

Local  pain,  allied  to  local  neurasthenia  (topalgia  of  Blocqui),  is  occa- 
sionally noticed.  The  affection  described  as  tender  toes  (acroparaesthe- 
sia  of  Schulze),  that  is,  an  excessive  tenderness  on  the  slightest  pressure 
of  the  toes,  sole  of  the  foot,  and  sometimes  dorsal  surface  of  the  foot, 
also  belong  to  this  group ;  the  opposite  of  this,  more  or  less  persistent 
anaesthesia  of  a  circumscribed  area,  not  due  to  peripheral  neuritis,  is 
occasionally  seen.  Local  vaso-motor  neurosis,  consisting  of  redness 
with  slight  swelling  of  parts  of  the  extremities,  has  been  described. 

Hysterical  manifestations  during  convalescence  are  not  frequent,  yet 
are  occasionally  seen  both  in  men  and  women. 

Hemiplegia,  due  to  haemorrhage,  thrombosis,  or  merely  temporary 
and  due  to  anaemia  or  spasm  of  the  arteries,  is  very  rare  in  enteric. 

Disseminated  sclerosis  is  found  more  often  after  enteric  fever  than 
after  any  other  infectious  disease. 

Acute  disseminated  myelitis  is  mentioned  by  Leyden  and  others  as 
following  enteric  fever  (21). 

Poliomyelitis.  — Paralysis  of  one  limb  or  portion  of  a  limb,  followed 
by  atrophy,  with  partial  recovery,  has  occasionally  been  noticed.  Some 
of  these  cases  are  more  likely  to  be  forms  of  peripheral  neuritis  (80) ; 
some  are  due  to  an  acute  inflammation  of  the  anterior  cornua,  as  proved 
by  the  post-mortem  examination  (80). 

A  peculiar  complication  occurring  in  enteric  fever  has  been  described 
by  Eisenlohr  (24).  In  three  cases  he  observed  symptoms  of  bulbar 
paralysis,  affecting  the  lips  and  tongue,  interfering  with  articulation, 
and  accompanied  by  weakness  in  the  muscles  of  the  trunk.  One  of  the 
three  cases  ended  fatally,  and  numerous  typhoid  bacilli  were  found  in 
the  brain,  medulla,  cord,  and  chiasma  of  optic  nerves. 

Peripheral  Neuritis.  —  Occasionally  extensive  multiple  neuritis, 
affecting  both  upper  and  lower  extremities,  with  sensory  disturbances 
and  atrophy,  is  seen.  One  such  case  I  saw  in  a  young  girl  (75a),  and 
the  other  in  a  child  three  years  old,  in  whom  contraction  of  both  hands 
and  feet  set  in  after  the  paralysis  had  been  established,  but  it  yielded 
completely  to  treatment.  More  often  the  peripheral  neuritis  is  located 
in  a  plexus  of  nerves,  or  in  the  root  or  trunk  of  one  nerve  only.  The 
affection  usually  sets  in  with  excessive  pain,  followed  by  numbness  and 


830  SYSTEM  OF  MEDICINE 

paresis,  going  on  sometimes  to  complete  paralysis  of  tlie  muscles  supplied 
by  the  affected  nerve  or  nerves,  and  often  followed  by  marked  atrophy. 
I  have  seen  one  case  in  which  the  root  (both  sensory  and  motor)  of  the 
fifth  was  evidently  affected ;  partial  recovery  took  place.  Prof.  Osier 
has  recently  published  some  careful  observations  on  such  cases  (67a). 

Paralysis  of  cranial  nerves  is  very  rare  in  enteric  fever.  Occasion- 
ally paralysis  of  one  or  other  of  the  ocular  muscles  has  been  noticed. 

Of  the  special  sense  organs  hearing  is  commonly  affected  in  enteric 
fever.  In  many  cases  the  deafness  is  due  to  otitis  media,  which  in  the 
course  of  time  may  be  followed  by  the  well-known  cerebral  complicar 
tions — meningitis,  thrombosis  of  cerebral  sinus,  abscess  of  the  brain. 
Sometimes  the  deafness  is  due  to  an  affection  of  the  auditory  nerve,  and 
is  more  permanent. 

Optic  neuritis  is  a  rare  complication.  I  have  seen  one  case  in  which 
amblyopia  and  colour  blindness  occurred  in  one  eye  after  the  fever,  and 
the  optic  disk  was  blurred ;  this  probably  was  a  case  of  retrobulbar 
neuritis.  Ulceration  of  the  cornea  and  suppuration  of  the  orbit  have 
been  described  (Panas). 

Bone  and  Joint  Affections.  —  It  has  been  pointed  out  by  Chantemesse, 
that  in  inoculation  experiments  the  typhoid  bacillus  can  be  traced  to  the 
medulla  of  bone,  and  it  is  therefore  not  astonishing  to  find  that  affections 
of  the  bones  are  no  imcommon  sequelae  of  enteric  fever.  The  most  com- 
mon event  is  the  formation  of  an  abscess  periosteal  or  myelogenic.  The 
tibia  and  femur  are  the  usual  seats  of  these  abscesses,  though  they  may 
occur  in  other  bones,  such  as  the  sternum,  ribs,  etc.  In  the  pus  of  them 
streptococci  or  staphylococci  have  been  found ;  in  some,  however,  only 
the  typhoid  bacillus.  These  abscesses,  ushered  in  by  severe  and  per- 
sistent pains,  redness,  and  swelling  of  the  affected  part,  often  occur 
many  months  after  the  fever ;  and,  in  a  case  recently  recorded  by 
Buschke,  forty-six  years  had  elapsed  since  the  occurrence  of  enteric 
fever,  yet  the  typhoid  bacillus  found  in  the  pus  was  capable  of  further 
growth  and  cultivation.  In  other  cases  the  bone,  instead  of  undergoing 
suppuration,  becomes  hypertrophic  and  deformed — hypertrophic  osteitis. 

In  children  and  young  persons,  after  convalescence  one  occasionally 
notices  an  exaggerated  growth  of  the  bones.  Sometimes  a  circumscribed 
periostitis  is  recorded,  which  comes  on  without  any  great  pain,  and  may 
undergo  complete  absorption  (Hutinel). 

The  joint  affections  associated  with  or  following  enteric  fever  vary 
in  their  nature. 

1.  Pain  and  swelling  of  one  or  more  joints  (the  smaller  joints,  the 
ankle,  wrist,  and  knee)  is  not  a  rare  symptom  in  enteric  fever,  and  may 
come  on  early  in  the  disease.  The  symptoms  generally  subside  during 
convalescence.  As  this  is  seen  in  pure  and  uncomplicated  cases  it  is  prob- 
ably more  or  less  directly  connected  with  the  typhoid  poison  itself  (31). 

2.  The  osteitis  before  described,  when  situated  near  the  joint,  may 
extend  to  the  joint  itself,  and  osteo-arthritis,  with  marked  pain  and 
swelling  of  the  joint,  and  occasionally  even  suppuration,  may  occur. 


ENTERIC  FEVER  831 


3.  Septic  arthritis,  usually  with  other  pysemic  symptoms,  is  seen  in 
the  mixed  infection. 

4.  Occasionally  rheumatic  arthritis,  affecting  several  joints,  may 
complicate  and  follow  enteric  fever,  and  set  up  endocarditis  (94). 

Of  other  complications  we  have  only  yet  to  mention  — 

Suppuration  of  the  Thyroid  Gland.  —  Golgi  found  the  typhoid  bacil- 
lus in  the  pus  (17a). 

The  Nutrition  of  the  Body  in  Enteric  Fever.  — Emaciation  is  most  pro- 
nounced, especially  during  the  latter  part  of  the  attack.  According  to 
Eobin  (75),  a  person  suffering  from  enteric  fever  eliminates  more  solids 
(52  grammes)  than  a  healthy,  well-nourished  person  (50  grammes). 
This,  apart  from  many  other  factors,  would  explain  the  emaciation.  The 
daily  loss  of  weight  is  about  238  grammes.  Klemperer's  observations 
further  show  that  during  the  fever  the  food  albumin  is  not  completely 
used  up  by  the  patient,  who  therefore  gives  up  part  of  his  body  albu- 
min. Ziemec  (102)  found  an  average  daily  loss  of  body  weight  of  0-9 
per  cent  during  the  fever,  a  figure  much  lower  than  Robin's. 

[The  subject  of  tissue  metabolism  in  fever  is  set  forth  in  the  art. 
"Doctrine  of  Fever."] 

Relapse.  —  I  have  already  spoken  of  a  recrudescence  of  the  pyrexia 
during  convalescence  from  various  causes.  From  this  the  true  relapse 
must  be  distinguished,  which  is  indeed  a  fresh  attack  of  enteric  fever, 
and  in  it  appear  many  of  the  noteworthy  symptoms,  such  as  tympa- 
nites, diarrhoea  often  with  slight  haemorrhages,  a  second  series  of  roseo- 
lar  spots,  a  further  enlargement  of  the  spleen,  and  pyrexia  with  marked 
evening  exacerbations.  These  symptoms,  of  course,  are  not  all  con- 
stantly present.  In  the  presence  of  the  eruption  and  the  renewed 
pyrexia,  and  in  the  absence  of  any  local  inflammation,  the  diagnosis  of 
a  true  relapse  must  be  based. 

Authors  differ  somewhat  as  to  the  frequency  of  relapse.  Murchison's 
estimate  is  3  per  cent,  Griesinger  6  per  cent,  whilst  Shattuck  gives  over 
16  per  cent.  Men  appear  more  liable  to  it  than  women.  The  duration 
of  the  relapse  varies  from  nine  to  twenty-one  days ;  thu.s  it  is  shorter, 
and  as  a  rule  the  symptoms  are  less  severe  than  in  the  primary  attack. 
In  Shattuck's  twenty-one  cases  of  relapse  there  was  only  one  death. 

The  relapse  may  occur  early  or  late  during  convalescence ;  in  several 
cases  I  have  seen  it  occur  only  a  few  days  after  defervescence ;  in  most 
cases  it  occurs  within  the  first  fortnight  of  convalescence,  whilst  occa- 
sionally even  a  month  or  more  may  elapse  before  its  occurrence. 

The  first  rehvpse  may  be  followed  by  a  second,  and  sometimes  even 
by  a  third  and  fourth  relapse,  but  as  a  rule  the  subsequent  attacks  are 
shorter  in  duration  and  milder  in  their  symptoms.  The  cause  of  the 
relapse  is  most  likely  a  reabsorption  of  the  poison,  and  probably  glands 
which  escaped  the  typhoid  bacillus  during  the  primary  attack  of  fever 
become  affected ;  or  it  may  be  that  some  of  the  poison  is  retained  in  the 
spleen  or  soine  other  organ,  and  is  subsequently  liberated  and  thrown 
into  the  circulation. 


832  SYSTEM  OF  MEDICINE 

Mixed  hifection.  —  When  describing  the  symptoms  and  complica- 
tions of  enteric  fever  I  have  repeatedly  drawn  .attention  to  the  presence 
of  other  micro-organisms  found  in  the  diseased  tissue,  which  must  be 
looked  upon  as  the  cause  of  these  complications ;  and  we  know  now 
that  in  many  of  these  complications  not  only  in  enteric  fever,  but  in 
other  infectious  diseases,  both  acute  and  chronic  (pneumonia,  diphtheria, 
scarlatina,  tuberculosis,  etc.),  mixed  infection  plays  an  important  part. 
It  is  well  to  distinguish  between  double  infection  and  secondary  infection. 
In  the  first  case  the  symptoms  of  the  two  different  diseases  are  present 
and  can  be  readily  distinguished,  their  association  often  being  only  a 
coincidence,  as,  for  example,  enteric  fever  and  tuberculosis,  or  enteric 
fever  and  typical  diphtheria  due  to  Loffler's  bacillus.  The  chief  double 
infections  which  have  been  noticed  in  enteric  fever  are  with  tuberculo- 
sis—  coming  on  chiefly  after  convalescence  —  scarlet  fever,  diphtheria, 
cholera,  anthrax,  erysipelas,  and  malaria.  In  the  second  case,  the  sec- 
ondary infection,  the  presence  of  one  organism  favours  the  development 
of  the  other.  Thus  it  is  now  well  established  that  the  tubercle  bacillus 
favours  the  growth  and  development  of  the  streptococcus ;  many  of  the 
lesions  and  symptoms  of  phthisis  are  due  to  the  latter  and  not  to  the 
former  micro-organism.  The  same  holds  good  for  enteric  fever,  as 
the  typhoid  bacillus  favours  the  growth  of  other  micro-organisms,  such 
as  the  streptococcus,  the  staphylococcus  pyogenes,  the  bacterium  coli, 
and  the  pneumococcus.  There  are  various  circumstances  which  may 
explain  the  development  of  these  secondary  micro-organisms,  most  of 
which  may  occur  in  the  human  body  or  its  surroundings ;  as  for  example 
the  weakened  state  of  the  system,  the  ulcerated  condition  of  the  intes- 
tines and  other  organs  giving  free  access  to  the  micro-organisms  to  the 
system,  the  presence  of  toxins  in  the  blood,  etc.  The  most  common 
secondary  infection  is  of  septic  nature,  and  due  to  the  various  patho- 
genetic cocci.  It  is  not  always  easy  to  distinguish  the  septic  complica- 
tions from  the  changes  due  to  the  typhoid  bacillus  itself,  especially  as 
it  has  been  shown  that  the  typhoid  bacillus  has  pyogenetic  properties, 
and  may  induce  suppuration  (71,  36,  7).  Bacterioscopic  examination 
of  the  blood  will  enable  us  sometimes  to  detect  the  pathogenetic  cocci 
in  the  blood  of  the  typhoid  patient  (83).  Want  of  attention  to  the 
proper  hygienic  measures  may  easily  lead  to  secondary  infection.  An 
instance  in  point  is  an  observation  by  Korczynski  and  Gluzinski  (48), 
in  a  ward  previously  occupied  by  many  surgical  cases  wherein  a  number 
of  patients  affected  with  enteric  fever  were  afterwards  placed.  Great 
mortality  from  septicaemia,  pyaemia,  phlegmonous  inflammations,  etc., 
ensued,  and  dust  from  the  ward  showed  the  presence  of  staphylococcus 
aureus,  and  the  streptococcus  pyogenes  citreus  and  albus.  After  thor- 
ough disinfection  of  the  ward  these  septic  complications  disappeared  to 
a  great  extent.  Cases  of  measles  and  of  other  acute  infectious  fevers 
in  these  wards  showed  no  such  complications. 

Varieties  of  Enteric  Fever.  — The  diversity  in  the  symptoms  and  course 
of  enteric  fever  has  led  authors  to  distinguish  certain  varieties  of  enteric 


ENTERIC  FEVER  833 


fever.     The  usual  classification,  one  which  recommends  itself  from  a 
clinical  and  practical  point  of  view,  is  the  following :  — 

1.  The  Abortive  Form.  — The  disease  begins,  like  an  ordinary  attack 
of  enteric  fever,  with  high  temperature,  repeated  shivers,  enlargement 
of  the  spleen,  diarrhoea  and  roseola,  or  some  of  these.  Early  in  the 
second  week  the  fever  falls,  and  by  the  end  of  the  week  there  may  be 
complete  defervescence.     Relapses  have  been  noticed. 

2.  The  Mild  Form. — The  symptoms  are  slight  throughout  the 
course  of  the  disease,  which  lasts  from  sixteen  to  twenty-one  days  :  the 
temperature  does  not  reach  103°;  diarrhoea,  if  present,  is  mild ;  the  pros- 
tration not  great.  There  is  no  great  emaciation,  and  convalescence  is 
usually  rapid. 

3.  Ambulatory  Typhoid  (walking  typhoid,  or  latent  typhoid).  —  The 
symptoms  are  here  so  slight  that  the  patient  follows  his  work,  though 
more  or  less  troubled  with  loss  of  appetite,  diarrhoea  and  headache. 
Patients  suffering  from  this  form  have  often  been  known  to  walk  to 
the  out  patients'  room,  where  by  the  condition  of  the  tongue,  the  tremor, 
and  the  temperature,  the  true  nature  of  the  case  is  recognised.  In 
other  cases  violent  delirium  or  profuse  intestinal  haemorrhage  is  the 
first  symptom  which  brings  the  patient  to  the  doctor ;  and  if  death 
occur  soon  after,  as  it  often  does,  extensive  intestinal  ulcerations  are 
found ;  or  sudden  death  may  occur  from  perforation  (92).  I  remember 
one  case  of  a  workman  who,  whilst  repairing  the  roof  of  a  hoixse,  fell  off 
and  was  killed  by  the  fall ;  at  the  post-mortem  examination,  besides 
fracture  of  the  skull,  there  were  found  typical  typhoid  ulcers  in  the 
ileum.  At  the  inquest  the  wife  of  the  deceased  stated  that  her  husband 
had  complained  of  headache,  lassitude,  and  giddiness  for  some  days. 

4.  The  apyrexial  form,  which  runs  its  course  without  any  perceptible 
pyrexia. 

5.  The  grave  form  of  enteric  fever,  characterised  by  high  fever  and 
grave  nervous  symptoms.  According  to  the  more  prominent  symptoms 
we  distinguish  under  this  head—  (a)  The  Bilious  Form  (fievre  bilieuse). 
Frequent  and  persistent  vomiting  of  bilious  matter,  with  severe  and  per- 
sistent headache ;  pulse  quick  and  small ;  the  case  often  ends  fatally 
about  the  end  of  the  second  week  from  asthenia ;  delirium  generally 
absent.  (6)  The  Ataxic  Form.  —  Delirium  with  hallucinations  promi- 
nent, typhoid  symptoms  severe,  and  sometimes  convulsions  occur, 
(c)  The  Adynamic  Form.  — From  the  outset  there  are  great  prostration, 
very  weak  heart's  action,  abundant  diarrhoea,  low  delirium,  profound 
stupor:  if  these  symptoms  are  associated  with  subcutaneous  and  internal 
liaimorrhages  the  case  is  spoken  of  as  the  haemorrhagic  form. 

Most  of  these  severe  forms  are  due  to  a  secondary  infection  of  septic 
naiurf.  Pharyngo-tyi)hoid,  laryngo-typhoid,  pneumo-typhoid,  nephro- 
ty  plioid,  cardio-typhoid,  are  often  instances  of  mixed  infection,  as  already 
mentioned. 

G.  Spleno-typhoid  occupies  a  somewhat  different  position.  It  is 
characterised  clinically  by  a  type  of  fever  which  in  the  excessive  enlarge- 

VOL.    I  3    H 


834  SYSTEM  OF  MEDICINE 

ment  of  the  spleen,  and  in  the  absence  of  intestinal  symptoms,  rather 
resembles  that  of  relapsing  fever  (though  spirilla  are  not  found  in  the 
blood).  The  lesions  in  Peyer's  patches  are  not  well  developed,  only 
congestion  and  swelling  being  noticed  (23).  Moore  i^o)  observed  a  case 
in  which  Peyer's  patches  were  not  even  hypersemic. 

7.  Enteric  fever  in  children  is  not  rare.  Some  of  the  peculiarities 
observed  in  infantile  euteric  fever  we  have  already  noticed.  In  some 
cases  the  infection  runs  the  same  course  as  in  the  adult,  in  others  the  fever 
has  a  remittent  type  (infantile  remittent  fever),  the  evening  temperature 
being  2°  to  3°  higher  than  the  morning  temperature.  Abortive  enteric 
fever  is  also  noticed,  likewise  the  bilious  form.  A  respiratory  or  thoracic 
type  has  been  described  by  some,  the  more  prominent  symptoms  being 
quickened  respiration,  marked  dyspnoea  and  cyanosis,  and  the  presence  of 
fine  rales  over  one  or  both  lungs.  A  meningeal  type  may  be  distinguished 
which  sets  in  with  headache,  vomiting,  and  convulsions,  and  is  followed 
by  delirium,  great  prostration,  and  torpor.  Diarrhoea  and  involuntary 
discharge  of  faeces  is  not  infrequent,  and  the  diagnosis  from  meningitis 
is  often  difficult.  In  these  cases  strabismus,  inequality  of  pupils, 
injection  of  the  conjunctivae,  and  even  the  hydrocephalic  cry  (8),  may 
occur.  Piually,  a  spinal  type,  with  hyperaesthesia  of  the  skin,  contrac- 
tion of  muscles  and  opisthotonus  (26),  is  also  described. 

8.  Enteric  Pever  in  the  Aged.  —  Enteric  fever  is  not  common  in 
persons  after  forty ;  but  in  epidemics  old  people  are  not  infrequently 
affected.  I  have  seen  a  typical  case  of  typhoid  in  a  man  seventy-five 
years  old.^  The  affection  usually  commences  insidiously  with  headache, 
loss  of  appetite,  epistaxis ;  the  fever  is  not  very  high,  and  rarely  reaches 
103° ;  diarrhoea  is  present,  but  not  usually  profuse.  Death  sometimes 
takes  place  before  the  end  of  the  third  week  from  pulmonary  oedema  or 
failure  of  the  heart.     The  mortality  is  high. 

9.  Malario-typhoid.  —  See  articles  on  Malaria  and  on  Climate  and 
Fevers  of  India. 

10.  An  epidemic  atypical  form  of  enteric  fever,  occurring  only  in 
those  who  shortly  before  had  suffered  from  malaria,  is  described  by 
Karlinski  (45).  It  was  observed  in  Bosnia,  and  called  there  dog-typhoid 
{Himde-typlius).  (The  typhoid  bacillus  was  found  in  the  faeces  in  these 
cases.) 

Diagnosis.  —  The  diagnosis  of  enteric  fever  is  often  made  without 
difficulty ;  sometimes  the  diagnosis  can  only  be  made  after  watching  the 
symptoms  for  some  days,  whilst  in  not  a  few  cases  it  is  impossible  to 
arrive  at  a  definite  diagnosis.  It  is  during  the  first  week  of  the  fever 
that  the  difficulty  of  diagnosing  the  disease  is  so  great,  and  here  Wunder- 
lich's  propositions  as  to  the  temperature  will  be  found  a  very  useful 
guide;  also  such  symptoms  as  severe  headache,  sleeplessness,  epistaxis. 
Ehrlich's  diazo  reaction,  though  present  in  most  cases,  is  also  noticed  in 

1  A  well-marked  and  severe  case  occurred  many  years  ago  under  my  care  in  a  vigorous 
old  gentleman  of  eighty-two.  By  the  labours  of  six  nurses,  working  in  pairs  for  eight 
hour  watches,  he  was  brought  to  recovery,  but  only  to  die  during  convalescence  of  a 
diaphragmatic  hernia. — Ed. 


ENTERIC  FEVER  835 


other  febrile  affections,  and  being  often  absent  during  the  first  week, 
is  of  no  great  help  in  doubtful  cases.  Nor  as  yet  can  the  detection  of 
the  typhoid  bacilli  in  the  stools  be  made  of  use  for  clinical  purposes,  as 
their  isolation  and  distinction  from  the  bacterium  coli  take  much  time, 
and  are  processes  too  elaborate  to  be  clinically  useful :  moreover  the 
bacilli  have  not  been  found  in  the  stool  before  the  eighth  or  ninth  day 
of  the  fever.  The  same  applies  to  the  detection  of  the  bacilli  in  the 
urine,  though,  according  to  some  observers,  they  may  be  found  earlier, 
which  seems  to  me  very  doubtful ;  and  in  the  blood,  where  they  have 
only  been  found  very  rarely :  we  cannot  countenance  puncture  of  the 
spleen  for  the  detection  of  the  typhoid  bacilli.  In  distinguishing  enteric 
fever  from  other  affections  we  must  note  the  temperature  curves,  the 
intestinal  symptoms,  the  characteristic  rash,  the  enlarged  spleen,  and 
other  less  prominent  symptoms.  Thus,  in  typhus  fever  we  have  the 
typhoid  state,  and  we  may  have  diarrhoea,  but  the  fever  is  less  grad- 
ual in  onset;  it  remains  high  during  the  whole  time  of  the  fever, 
and  on  the  fourteenth  day  there  is  usually  a  crisis  and  a  rapid  fall  to 
the  normal.^  The  rash  in  typhus  appears  earlier,  generally  about  the 
fourth  da}^  does  not  occur  in  successive  crops,  and  persists  to  the  end 
of  the  fever ;  the  rash  consists  of  spots  of  irregular  form,  red  or  dirty 
pink,  which  become  reddish  brown  and  then  do  not  disappear  on  press- 
ure, they  often  become  hsemorrhagic,  and  they  are  more  numerous  and 
more  widely  distributed ;  besides  the  spots  there  is  marked  mottling  of 
the  skin  of  the  abdomen.  Violent  delirium  is  much  rarer  in  typhus 
than  in  enteric  fever. 

In  tubercular  meningitis  the  temperature  is  rarely  so  high  as  in  enteric 
fever  with  marked  cerebral  symptoms ;  the  pulse  if  soft  is  no  longer 
dicrotic,  and  may  even  be  hard;  persistent  vomiting  during  the  first 
few  days  occurs  more  frequently,  and  the  abdomen  is  generally  retracted. 
Optic  neuritis,  whilst  extremely  rare  in  enteric  fever,  is  not  uncommon 
in  meningitis ;  the  same  may  be  said  of  the  inequality  of  pupils,  and  of 
squint.  Tubercle  of  the  choroid  would  be,  of  course,  a  pathognomonic 
sign,  but  it  is  not  often  present  in  the  latter  disease. 

In  acute  general  miliary  tuberculosis  we  may  have  the  history  of  pre- 
vious cough  or  pleurisy  ;  the  temperature  is  not  so  high,  the  pulse  is  not 
dicrotic,  the  abdomen  is  retracted,  roseola  is  rare,  the  examination  of 
the  stools  may  sometimes  show  the  presence  of  tubercle  bacilli,  and 
emaciation  is  noticed  early  in  the  disease ;  yet  in  some  cases  the  diag- 
nosis is  impossible.  A  roseolar  rash  may  occur,  though  very  rarely,  in 
miliary  tuberculosis;  I  have  seen  it  in  three  cases  —  two  at  the  Fever 
Hospital,  and  one  under  the  care  of  my  colleague,  Dr.  Steell,  at  the 
Manchester  Infirmary.  Diarrhoea  and  even  intestinal  haemorrhage  may 
be  noticed,  with  tympanites  and  gurgling  in  the  right  iliac  fossa,  while 
the  temperature  curve  may  be  very  much  like  that  of  enteric  fever  (79). 

^  It  is  jrcnerally  stated  that  in  typhus  the  fever  terminates  abruptly  in  a  crisis.  Ac- 
(•<)Ti\\n^  to  Dr.  Steell's  observations  (83a)  this  is  not  correct ;  the  defervescence  is  gradual, 
lasfinj^  two  days,  and  the  fall  of  the  pulse  during  the  period  of  defervescence  is  also 
gradual. 


836  SYSTEM   OF  MEDICINE 

The  much  quicker  pulse  and  the  absence  of  dicrotism  appear  to  me  to 
be  very  significant  distinguishing  features  in  acute  miliary  tuberculo- 
sis, and  also  the  aspect  which  is  usually  alert  and  even  excited;  not 
oppressed,  not  apathetic,  save  towards  the  end ;  rarely  even  indifferent. 

Tahercidar  peritomtis  may  simulate  enteric  fever.  I  recall  two  cases 
admitted  into  the  Monsall  Hospital  as  enteric  fever,  in  which  for  several 
weeks  the  symptoms  much  resembled  it.  In  one  of  the  two  cases  large 
tumour  masses  in  the  abdomen  could  be  detected  about  the  fourth  week 
of  illness,  and  in  the  other  case,  after  some  weeks  of  pyrexia,  fluid  was 
discovered  in  the  abdomen ;  in  both  cases  the  pulse  was  over  130  for 
many  days. 

The  gastro-intestinal  form  of  epidemic  influenza  may  closely  simulate 
enteric  fever.  We  may  have  a  roseolar  rash  (though  this  is  very  rare, 
and  when  it  does  occur  is  more  widely  distributed,  and  does  not  appear 
in  successive  crops),  tympanites,  gurgling  (which,  however,  is  not  con- 
fined to  the  right  iliac  fossa),  a  markedly  enlarged  spleen,  and  profuse 
diarrhoea.  The  sudden  onset  of  the  fever,  which  often  in  less  than 
twenty-four  hours  reaches  103°  and  104°,  and  the  subsidence  of  the 
fever  symptoms  before  the  end  of  the  second  week,  will  help  us  to  dis- 
tinguish iiifluenza  from  enteric  fever,  so  will  also  the  condition  of  the 
tongue  and  pulse.  In  some  cases  of  influenza  the  pyrexia  persists  for 
several  weeks,  but  diarrhoea  and  the  other  symptoms  have  then  subsided 
(57).  If  there  be  cough  with  expectoration,  the  examination  of  the 
sputum  for  influenza  bacilli,  which  can  be  easily  recognised  without  any 
cultivatioii,  will  assist  us  materially  to  a  correct  diagnosis.  I  must,  how- 
ever, here  observe  that  enteric  fever  and  influenza  may  occur  together. 
I  have  seen  two  undoubted  cases  of  enteric  fever  immediately  following 
an  attack  of  epidemic  influenza :  in  one  the  diagnosis  was  verified  by  a 
post-mortem  examination,  and  in  the  second  there  was  a  distinct  relapse 
after  the  enteric  fever.  Both  cases  occurred  in  adults ;  several  mem- 
bers of  the  family  were  affected  with  typical  influenza  at  the  time,  and 
in  both  cases  a  subsidence  of  the  influenza  symptoms  had  taken  place, 
when  the  temperature  again  rose,  and  gradually  all  the  prominent 
symptoms  of  enteric  fever  were  manifested. 

We  have  already  spoken  of  pneumonia  complicating  typJioid,  and  of 
typhoid  pneumonia.  There  is,  however,  a  form  of  pneumonia  —  the  cere- 
bral pneumonia —  where  the  symptoms  for  a  few  days  very  much  resem- 
ble those  of  enteric  fever.  There  may  be  no  rigor,  no  pleuritic  pain,  the 
onset  of  the  fever  may  not  be  sudden,  and  on  physical  examination  of 
the  chest  no  signs  of  pneumonia  may  be  noticed  for  several  days,  that  is 
to  say,  until  the  pneumonic  process  has  reached  the  periphery  of  the  lung. 

PycEmic  and  septicoimic  affections,  such  as  ulcerative  endocarditis,  osteo- 
myelitis, idiopathic  pyo-sepiiccem/a,  and  piterperaZ  septicmmia,  may  produce 
a  train  of  symptoms  very  much  like  those  of  enteric  fever,  including  a 
roseolar  rash,  tumefaction  of  the  spleen,  and  diarrhoeal  tympanites.  Thus 
three  members  of  one  family  had  lived  in  a  cellar  dwelling,  which  had 
been  under  water  at  a  time  of  an  extensive  flood,  and  being  attacked  with 


ENTERIC  FEVER  857 


febrile  symptoms,  they  were  sent  to  the  Monsall  Fever  Hospital.  Their 
symptoms  closely  resembled  those  of  enteric  fever,  and  one  of  them 
presented  on  the  third  day  of  admission  marked  roseolar  spots,  and  had 
slight  intestinal  haemorrhage  on  the  fifth  day  ;  the  temperature  showed 
marked  evening  exacerbations  ;  the  patient  died  from  exhaustion  on  the 
fourteenth  day  after  admission  (about  the  seventeenth  day  of  the  fever), 
and  on  post-mortem  examination  the  intestines  appeared  healthy.  I  could 
quote  several  other  similar  cases.  Puerperal  septicaemia  may  sometimes  be 
indistinguishable  from  enteric  fever.  Thus  in  a  case  reported  by  Leu  (59), 
a  roseolar  rash,  tympanites,  enlarged  spleen,  intestinal  haemorrhage,  and 
a  pyrexial  curve  like  that  of  enteric  fever  were  noted.  In  most  cases  of 
puerperal  septicsemia,  however,  we  notice,  apart  from  any  local  symptoms, 
a  high  temperature  early  in  the  disease.  There  is  from  the  first  a,nd 
often  throughout  the  course  of  the  disease  vomiting  and  profuse  diarrhoea ; 
the  pulse  from  the  first  is  quick,  and  not  dicrotic ;  the  spleen  is  found 
slightly  enlarged  from  the  first,  and  shows  no  further  increase  as  the 
disease  progresses ;  epistaxis  and  deafness  are  absent.  The  puerperal 
septicsemia  of  ten  ends  fatally  after  a  few  days  —  from  four  to  ten  days  —  or 
if  recovery  take  place,  the  fever  symptoms  subside  at  an  earlier  date  than 
is  the  case  in  enteric  fever.  In  doubtful  cases  bacteriological  examination 
of  the  blood  will  not  help  us  much,  as  there  may  be  a  mixed  infection  of 
enteric  fever  and  septicaemia.  Some  of  the  most  difficult  cases  are  those 
in  which  during  or  after  some  pelvic  inflammation  or  mild  septic  poi- 
soning enteric  fever  gradually  supervenes  as  an  independent  event. 

Acute  g astro-intestinal  catarrh  may,  if  the  fever  be  high,  and  remain 
so  for  a  few  days,  as  not  infrequently  happens  in  the  young  and  in  chil- 
dren, give  rise  to  symptoms  like  a  mild  or  abortive  attack  of  enteric  fever. 
The  difficulties  of  diagnosis  become  especially  great  at  the  time  of  an 
epidemic  of  enteric  fever,  when  many  mild  and  abortive  cases  are  about. 

The  malarial  affections  which  occur  in  this  country  can  scarcely  be 
mistaken  for  enteric  fever ;  in  the  remittent  type  of  the  severe  malarial 
affections  as  they  occur  in  tropical  climates  the  presence  of  the  Plasmo- 
dium in  the  blood  would  form  a  pathognomonic  sign. 

Other  affections  with  which  enteric  fever  may  occasionally  be  con- 
founded are  —  acute  rheumatic  arthritis  (especially  during  the  first  week, 
when  severe  pains  in  the  joints  may  be  present),  mania,  perityphlitis, 
hmmorrJiagic  colitis,  pelvic  cellulitis,  epidemic  cerebrospinal  meningitis, 
extravasation  of  urine,  acute  trichiniasis. 

In  discussing  diagnosis,  we  may  remark  that  sometimes  patients 
present  themselves  for  treatment  with  symptoms  of  sequelae  of  enteric 
fever,  in  whom  the  enteric  fever  had  not  been  diagnosed.  The  case  of 
intestinal  obstruction  already  quoted  is  an  instance  in  point,  and  other 
cases,  especially  some  with  prominent  nervous  symptoms,  could  be  cited. 

Pathological  Anatomy.  —  We  have  to  distinguish  between  the  lesions 
which  are  characteristic  of  enteric  fever,  those  which  are  common  to 
most  acute  febrile  infections,  and  those  which  are  the  result  of  secondary 
infection  or  complication. 


SYSTEM  OF  MEDICINE 


The  characteristic  changes  are  seen  in  the  intestines,  mesenteric 
glands,  and  spleen. 

Intestines.  —  The  lower  part  of  the  ileum  is  the  portion  affected,  and 
here  the  parts  close  to  the  ileo-caecal  valve  are  more  markedly  affected 
than  those  higher  up.  In  some  cases  the  large  bowel  may  show  a  few  dis- 
eased patches,  and  occasionally  the  jejunum  and  even  the  duodenum  may 
be  the  seat  of  the  characteristic  lesions.  The  affection  is  to  a  great  extent 
confined  to  the  follicular  apparatus  —  the  solitary  follicles  and  Peyer's 
patches  —  and  consists  at  first  in  a  hyperaemia,  followed  by  an  infiltration 
of  the  glands  with  cell  elements ;  the  infiltrated  patches  then  undergo 
necrosis,  the  typhoid  slough  forms,  and  becomes  detached,  and  an  ulcer- 
ated surface  is  left  behind  which  undergoes  cicatrisation.  Considering 
these  several  stages  more  in  detail,  we  have  first,  and  for  a  few  days 
only,  marked  hyperaemia  of  the  affected  part,  the  mucous  surface  appears 
swollen  and  red,  and  is  covered  by  an  abundant  secretion  of  mucus. 
As  cell  infiltration  takes  place  the  hypersemia  disappears,  the  blood- 
vessels becoming  compressed ;  the  mucous  surface  is  now  paler,  and  the 
follicles  and  Peyer's  patches  stand  out  prominently.  This  is  the  stage  of 
infiltration,  which  reaches  its  height  from  the  8th  to  the  12th  day.  Micro- 
scopic examination  with  the  usual  staining  agents  (eosin  and  hsema- 
toxylin)  shows  the  follicle  filled  with  cells  of  the  type  of  leucocytes, 
many  having  one  large,  well-stained  nucleus ;  in  others  the  nucleus  is 
badly  stained  and  pale,  and  this  infiltration  extends  slightly  into  the 
neighbourhood  of  the  follicles ;  the  walls  of  the  blood-vessels  show  infil- 
tration, and  are  compressed ;  the  lymphatic  vessels  are  dilated  and  filled 
with  cells,  and  we  see  in  them  large  ovoid  cells  with  large  nuclei  —  the 
proliferating  endothelial  cells.  In  a  section  stained  with  aniline  dyes 
for  the  detection  of  micro-organisms,  large  numbers  of  typhoid  bacilli 
are  seen,  most  numerously  in  the  centre  of  the  follicle  where  the  cell 
nuclei  appear  less  stained ;  we  notice  them  also  collected  in  large  num- 
bers in  the  lymphatic  vessels  of  the  follicle,  and  can  trace  a  few  into 
the  submucous  tissue.  When  this  stage  has  reached  its  height  (10th-12th 
day)  we  may  have  in  mild  cases  a  gradual  resolution ;  the  cells  which 
infiltrate  the  follicular  apparatus  undergo  necrosis  or  fatty  degeneration, 
and  become  absorbed.  This  process  may  be  unaccompanied  by  ulcera- 
tion, or  by  a  few  superficial  erosions  only  with  slight  heemorrhage.  In 
most  cases,  however,  as  the  swelling  of  the  gland  is  considerable,  the 
necrosis  of  the  cells  (which  is  a  true  coagulation  necrosis)  leads  to  the 
formation  of  smaller  or  larger  sloughs,  which  are  of  yellowish  or  grayish 
colour,  soft,  and  raised  at  the  edges  ;  these  when  microscopically  examined 
are  found  to  consist  of  granule  cells,  detritus,  fibrin,  red  blood  corpuscles 
and  sundry  micro-organisms.  The  slough  gradually  becomes  detached 
and  an  ulcer  is  left  (third  week  of  fever).  The  ulcer  is  either  round 
(solitary  follicle  or  partial  necrosis  of  Peyer's  patch)  or  oval  (Peyer's 
patch),  with  its  long  axis  corresponding  to  the  long  axis  of  the  intestines ; 
the  floor  is  usually  smooth,  and  consists  of  the  exposed  muscular  coat ; 
sometimes  the  floor  is  irregular  and  shreddy,  but  it  is  not  hardened  or 


ENTERIC  FEVER  839 


much  infiltrated ;  the  edges  are  not  indurated,  they  are  often  undermined, 
and  float  when  the  ulcer  is  held  under  water.  The  depth  of  the  ulcer 
varies  according  to  the  extent  of  the  necrosis.  The  serous  surface  of 
the  intestine  shows  no  changes. 

Microscopic  examination  of  a  section  of  the  affected  part  shows  that 
the  tissue  of  the  intestinal  wall  adjoining  the  follicles  and  floor  of  the 
ulcer  is  filled  with  mononuclear  cells  and  blood  corpuscles ;  it  presents 
all  the  appearance  of  embryonic  tissue. 

The  number  of  ulcers  varies  considerably.  I  have  twice  seen  a 
solitary  ulcer,  situated  near  the  caecum  ;  in  ordinary  cases  they  are  more 
numerous  near  the  ilio-csecal  valve,  and  farther  from  this  site  they 
become  smaller,  and  often  more  shallow. 

In  a  few  cases  the  lesions  of  enteric  fever  have  been  found,  with  the 
exception  of  intestinal  ulcers ;  the  Pey  er's  patches  in  these  cases  presented 
swelling  and  congestion  only.  Death  in  the  cases  reported  had  occurred 
at  a  date  (after  the  21st  day)  when  the  ulceration  ought  to  have  been 
well  marked  (69).  We  may  assume  that  in  these  cases  little  phagocytic 
action  is  opposed  to  the  typhoid  bacilli  in  the  walls  of  the  intestines, 
and  that  they  pass  through  to  the  mesenteric  glands. 

Cicatrisation  of  the  ulcer  occurs  in  the  last  stage  ;  small  granulations 
form,  which  gradually  become  changed  into  firm  fibrous  tissue.  From 
the  neighbouring  part  of  the  mucous  surface  an  epithelial  covering 
extends,  and  the  glands  may  to  some  extent  become  regenerated.  The 
cicatrix  scarcely  ever  tends  to  narrowing  of  the  lumen  of  the  gut;  it  is 
smooth,  depressed,  and  pigmented,  and  may  be  often  recognised  years 
after  the  occurrence  of  the  enteric  fever. 

Mesenteric  Glands.  —  Here  we  observe  a  process  very  similar  to  that 
seen  in  the  follicles.  At  first  the  glands  are  slightly  enlarged  by  hyper- 
semia,  especially  in  their  peripheric  part ;  then  they  swell  considerably, 
and  become  paler  and  softer  (cell  infiltration).  The  infiltrated  cells  then 
undergo  fatty  degeneration  and  become  absorbed,  and  the  gland  gradually 
diminishes  and  becomes  firmer.  Occasionally  the  gland  may  undergo 
suppuration,  which  is  probably  due  to  a  septic  infection,  though  the 
typhoid  bacillus  may  cause  suppuration;  the  pus  may  burst  into  the 
peritoneal  cavity,  causing  peritonitis,  or  it  may  become  inspissated,  and 
eventually  form  a  calcareous  mass.  A  man,  who  two  years  before  had 
passed  through  a  severe  attack  of  enteric  fever,  came  under  my  care  for 
intestinal  obstruction ;  the  symptoms  pointed  to  an  obstruction  of  the 
small  intestine,  and  an  operation  was  performed :  the  cause  of  obstruction 
was  then  found  to  be  a  large  mesenteric  gland  which  had  become  adherent 
to  a  part  of  the  small  intestine,  and  had  dragged  in  a  portion  of  the  wall 
of  it,  causing  marked  diminution  of  the  lumen. 

The  spleen  shows  similar  changes.  It  gradually  increases  in  volume, 
and  by  the  end  of  the  third  week  may  be  three  to  four  times  its  normal 
size  and  weight ;  the  swelling  is  less  marked  in  old  people.  During  the 
first  week  there  is  hypersemia.  The  capsule  becomes  stretched,  and  on 
section  the  spleen  has  a  cherry-red  colour,  and  the  stroma  is  indistinct ; 


840  SYSTEM  OF  MEDICINE 

gradually  the  pulp  becomes  softer,  bulges  forward,  and  the  Malpighian 
bodies  appear  distinct  and  larger  (third  week) ;  with  the  fourth  week,  or 
sometimes  later,  diminution  begins,  the  pulp  appears  pale  or  brownish, 
the  consistence  of  the  spleen  becomes  increased,  and  later  still  the  stroma 
becomes  more  fibrous.  Histologically  we  find  at  the  height  of  the  disease 
an  infiltration  of  leucocytes,  some  of  them  degenerated,  large  endothelial 
cells  with  one  or  more  nuclei,  and  large  cells  containing  several  red  blood 
corpuscles.  The  typhoid  bacilli  are  found  disseminated  through  the 
spleen,  and  are  often  found  in  clumps. 

The  tonsils  and  the  glands  in  the  pharynx  are  found  enlarged  and 
infiltrated,  but  as  this  affection  is  seen  in  other  acute  infective  fevers,  it 
cannot  be  looked  upon  as  a  lesion  specific  to  enteric  fever. 

The  medulla  of  hone  resembles  in  its  structure  the  pulp  of  the  spleen, 
and  as  in  certain  maladies  (Hodgkin's  disease,  leucocythaemia)  the  glands, 
spleen,  and  medulla  of  bone  are  often  alike  implicated,  some  observers 
have  laid  stress  in  enteric  fever  on  changes  in  the  medulla  of  bone  com- 
parable with  those  of  the  spleen.  These  changes,  however,  have  been 
found  in  other  affections  accompanied  by  profound  disorders  of  the  blood, 
and  have  nothing  specific  in  character.  Yet  a  close  connection  between 
the  typhoid  bacillus  and  bone  is  suggested  by  the  frequent  occurrence  of 
osteitis,  osteoperiostitis,  or  abscess  of  bone,  Avhich  so  often  follow  in  the 
wake  of  the  disease,  and  in  them  the  typhoid  bacillus  has  been  found 
(see  section  on  Symptomatology). 

I  will  now  briefly  touch  upon  the  lesions  found  in  the  other  organs 
in  enteric  fever,  omitting  those  affections,  the  nature  and  appearance  of 
which  is  sufficiently  evident  during  life,  and  a  description  of  which  will 
be  found  under  Symptomatology. 

Digestive  Tract.  —  The  stomach  is  often  the  seat  of  catarrh.  Cornil 
(18)  describes  cell  infiltration  of  the  adenoid  tissue,  and  compares  it  to 
the  intestinal  lesion.  Handford  (37)  noticed  similar  changes  and  haemor- 
rhages. The  ccBcum  and  colon  may  occasionally  show  enlargement  of  the 
solitary  glands  and  there  may  be  ulceration  also  of  the  appendix ;  the  rest 
of  the  large  intestine  is  often  the  seat  of  catarrh,  and  occasionally  ulcers 
are  noticed,  which  may  go  on  to  perforation,  which  is  less  serious  than  per- 
foration of  small  intestines ;  perforation  of  the  rectum  has  been  found 
with  formation  of  recto-vaginal  fistula.  I  have  once  seen  marked  heemor- 
rhagic  infiltration  of  the  greater  part  of  the  large  intestines.  The  livej-  is 
not  found  enlarged,  it  is  pale  in  colour  and  the  gall-bladder  is  moderately 
filled  with  light  coloured  bile.  Histologically  we  find  more  or  less  marked 
granular  degeneration  of  the  liver  cells,  and  small  necrotic  areas;  the 
capillaries  are  sometimes  found  dilated,  and  when  death  has  taken  place 
at  a  late  period  of  the  fever  we  find  slight  perilobular  cell  infiltration  in  the 
portal  canals.  Chantemesse  describes  small  foci  of  cell  infiltration  in  the 
central  part  of  the  lobule  with  degeneration  of  the  adjacent  liver  cells.  Ty- 
phoid bacilli  are  often  seen  in  large  numbers  filling  up  the  capillaries  (56). 

Acute  yellow  atrophy  of  the  liver  and  abscess  of  the  liver  may  be 
cited  as  very  rare  complications.     The  gall-bladder  and  large  bile-ducts 


ENTERIC  FEVER  841 


may  be  the  seat  of  catarrh.  We  may  have,  as  rare  complications,  sup- 
puration, ulceration,  and  perforation  of  the  gall-bladder;  more  commonly 
the  catarrh  of  the  gall-bladder  leads  to  the  formation  of  gall-stone. 

The  spleen  may  be  the  seat  of  infarcts  which  may  form  pysemic 
abscesses ;  in  persons  who  have  died  after  many  weeks  from  exhaustion 
owing  to  long-continued  suppuration  (bed-sores,  empyema),  lardaceous 
degeneration  of  the  spleen  and  other  organs  may  be  found. 

Lungs.  —  Besides  the  affections  mentioned  under  symptoms,  we  notice 
at  times  haemorrhagic  infarcts  in  the  lungs  and  occasionally  gangrene 
or  pyaemic  abscesses. 

Heart.  —  The  heart  is  flabby,  pale  in  colour,  and  soft  in  consistency, 
sometimes  almost  friable.  Microscopic  examination  reveals  a  variety  of 
changes ;  in  some  cases  no  noteworthy  alteration  in  the  myocardium  is 
found,  in  others  there  are  changes  in  the  muscular  fibres,  interstitial 
tissue,  and  blood-vessels.  The  muscular  fibres  may  show  fatty  degenera- 
tion and  occasional  waxy  degeneration ;  in  some  cases  of  sudden  death 
segmentation  of  the  muscular  elements  (myocardite-segmentaire  of  Renaut) 
has  been  noted ;  in  cases  in  which  the  fever  has  run  a  more  protracted 
course,  small  pigment  granules  in  the  neighbourhood  of  the  muscle  nuclei 
have  been  observed ;  hyaline  (Zenker's)  degeneration  is  rare ;  inter- 
muscular cell  infiltration  is  occasionally  seen,  and  the  small  arteries  of 
the  m3''ocardium  may  be  the  seat  of  endarteritis  (77).  Chantemesse  and 
Widal  have  found  typhoid  bacilli  in  the  heart-muscle.  The  endocardium 
and  pericardmm  are  not  often  found  affected,  though  occasionally  there 
may  be  both  the  vegetative  and  ulcerative  form  of  endocarditis. 

The  Kidneys.  — The  changes  in  the  kidney  are  manifold,  and  are  not 
always  in  proportion  to  the  renal  symptoms  exhibited  during  the  disease. 
In  some  cases  in  which  during  life  there  was  persistent  albuminuria  with 
casts,  no  noteworthy  changes  have  been  found ;  but  in  most  cases,  even 
with  but  slight  albuminuria,  we  observe  clovidy  swelling  of  the  epithelium 
of  the  convoluted  tubes ;  in  cases  in  which  during  life  there  have  been 
signs  of  haemorrhagic  nephritis,  or  in  which  from  the  first  there  have 
been  grave  renal  symptoms,  the  changes  are  marked.  The  kidneys  are 
enlarged,  especially  the  cortical  part;  the  epithelium  of  the  convoluted 
tubes  is  granular.  Renaut  describes  a  distension  of  the  glomerular 
cavities  and  adjacent  renal  tubes  Avith  an  albuminous  material.  Peri- 
vascular cell  infiltration  may  also  be  noticed.  In  cases  with  septic 
complications  there  are  sometimes  small  cell  accumulations  round  the 
blood-vessels  in  various  parts  of  the  kidney.  These  have  been  specially 
noticed  by  Wagner,  and  have  been  compared  to  multiple  lymphomata : 
they  represent,  however,  only  microscopic  abscesses,  and  may  eventually 
lead  to  small  visible  abscesses.  They  are  found  more  often  in  scarlet 
fever  and  diphtheria  than  in  enteric  fever.  The  typhoid  bacillus  and 
Vjacill.  coli  commun.  have  both  been  found  in  sections  of  the  kidney. 

Muscles.  —  The  changes  observed  here  have  been  noticed  in  other 
febrile  affections,  though  perhaps  more  frequently  found  in  enteric  fever. 
Some  of  the  muscles  (recti  abdominis,  adductors  of  the  thigh,  pectorales, 


842  SYSTEM  OF  MEDICINE 

diaphragm)  appear  pale  and  waxy  to  the  naked  eye,  and  microscopically 
examined  show  Zenker's  hyaline  degeneration.  A  muscle  so  affected 
may  rupture  and  give  rise  to  hsemorrhagic  extravasation.  Other 
muscles  show  fatty  degeneration,  especially  when  fever  has  continued 
for  weeks.  Another  change  consists  in  a  proliferation  of  the  muscle 
nuclei.  According  to  Metschnikoff,  this  appearance  is  due  to  an  infiltra- 
tion with  leucocytes  (phagocytes)  rather  than  to  a  nuclear  proliferation. 

Nervous  System.  —  Most  of  the  nervous  symptoms  during  the  fever 
are  due  to  the  toxic  products  of  the  typhoid  bacillus,  which  give  rise  to 
no  anatomical  changes ;  yet  certain  alterations  have  been  found,  such  as 
oedema  of  the  membranes  and  of  the  brain  itself  and  distension  of  the 
ventricles,  pigmentations  of  the  ganglion  cells,  infiltration  of  the  perivas- 
cular spaces  with  leucocytes,  and  of  the  spaces  round  ganglion  cells,  fatty 
degenerated  nerve  fibres  and  haemorrhages  (meningeal  and  cortical). 
Meningitis  rarely  complicates  enteric  fever.  The  pathological  anatomy 
of  the  nervous  affections  occurring  during  convalescence  (peripheral 
neuritis,  sclerosis,  etc.)  need  not  be  described  here. 

Pathological  Physiology.  —  Much  on  this  subject  is  still  very  obscure. 
The  bacilli,  after  they  have  reached  the  intestines,  multiply,  penetrate 
into  the  mucous  and  submucous  coats,  invade  the  lymphatic  tissue, 
and  pass  thence  through  the  lymph  channels  into  the  mesenteric  glands. 
Some  of  the  bacilli  reach  the  blood  and  pass  to  internal  organs,  princi- 
pally the  spleen.  The  bacilli  produce  various  poisons,  at  present  hardly 
known;  some  of  these  have  a  pyrogenetic  action,  and  thus  produce 
the  fever.  As  a  result  of  their  irritant  action  and  that  of  their  products 
we  get  the  intensely  inflammatory  signs  in  the  intestines  leading  to 
necrosis. 

The  fever  during  the  first  eight  to  ten  days  is  most  likely  due  to  the 
direct  action  of  the  bacilli  and  of  their  toxins.  During  the  second  and 
third  weeks,  when  the  intestines  are  ulcerated,  another  factor  concerned 
is  probably  the  absorption  of  some  septic  material  into  the  blood, 
co-operating  with  the  specific  poison ;  the  various  complications  which 
so  often  accompany  enteric  fever  probably  also  add  their  quota.  The 
diarrhoea  is  partly  due  to  the  irritation  produced  by  the  ulcers,  but 
chiefly  to  catarrh  of  the  large  intestine  with  increased  peristalsis.  As 
it  has  been  distinctly  proved  that  typhoid  bacilli  may  by  themselves  give 
rise  to  suppuration,  we  have  an  explanation  of  the  occurrence  of  abscesses 
during  or  more  especially  after  the  attack.  Lastly,  as  has  already  been 
pointed  out,  both  when  considering  the  etiology  and  the  symptomatology 
of  enteric  fever,  some  of  the  symptoms,  and  especially  many  of  the 
complications,  are  to  be  traced  to  other  micro-organisms,  which  find  a 
favourable  soil  for  growth  and  development  in  the  tissues  and  organs 
of  the  patient  whose  resistance  has  been  much  reduced  by  the  fever. 

As  yet  the  numerous  experimental  investigations  with  injections  of 
typhoid  bacilli,  of  bacterium  coli,  of  serum  from  immunised  animals,  etc., 
have  not  helped  us  much  in  clearing  up  the  pathology  of  the  disease, 
nor  has  the  chemical  examination  of  affected  organs  led  to  a  clearer 


ENTERIC  FEVER 


understanding.  Fenwick  (25)  extracted  from  the  spleen  of  typhoid 
cases  three  varieties  of  chemical  substances :  albuminoses,  alkaloids  and 
fatty  bodies  ;  the  injection  of  the  albuminoses  into  lower  animals  caused 
a  rise  of  temperature  for  thirty  hours,  with  anorexia  and  emaciation,  but 
no  further  changes  of  importance  were  noticed,  whilst  the  injection  of 
the  alkaloids  and  fatty  extracts  was  unattended  by  any  results. 

Prognosis.  —  Enteric  fever,  even  in  its  mildest  form,  must  be  looked 
upon  and  treated  as  a  serious  disease ;  for  even  in  mild  cases  death  may 
occur  from  perforation,  or  from  haemorrhage,  and  sudden  death  without 
any  premonitory  symptoms,  and  for  which  no  adequate  cause  can  be 
found  on  autopsy,  is  occasionally  seen.  Perforation  may  occur  during 
convalescence.  As  a  relapse  may  occasionally  be  fatal,  and  as  serious 
complications  may  occur  during  convalescence,  the  patient  cannot  be 
considered  out  of  danger  till  convalescence  is  complete.  We  have  fur- 
ther to  bear  in  mind  that  however  mild  the  fever  may  appear  during  the 
first  and  second  weeks,  grave  symptoms  are  none  the  less  likely  to  ap- 
pear before  the  third  week ;  no  case  therefore,  however  slight  the  symp- 
toms at  first,  should  be  lightly  treated.  Some  general  propositions, 
however,  may  be  stated  as  regards  prognosis.  As  regards  age,  we  may 
say  that  the  older  the  subject  the  more  unfavourable  the  prognosis :  as 
regards  sex  authors  differ  somewhat;  according  to  many  the  affection  is 
more  serious  in  women  than  in  men.  The  prognosis  is  less  favourable 
in  stout  than  in  lean  people,  and  very  unfavourable  in  drunkards,  in 
persons  who  have  undergone  great  privation  and  fatigue  (soldiers  in 
war),  in  persons  with  weak  or  dilated  hearts  or  who  are  affected  with 
valvular  affections  of  the  heart,  or  who  have  incipient  phthisis  or  dia- 
betes ;  the  prognosis  is  also  grave  in  pregnant  and  puerperal  women. 
In  persons  of  marked  neurotic  disposition,  acquired  or  inherited,  the 
nervous  symptoms  and  sequelae  are  to  be  feared ;  and  in  those  affected 
with  renal  disease  aggravation  of  this  disease  and  uraemic  symptoms 
are  apt  to  occur.  Septic  complications  are  to  be  feared  in  those  who 
suffer  from  surgical  diseases,  especially  suppurating  wounds;  and  in 
those  who  live  in  unhealthy  or  insanitary  districts.  It  is  also  a  well- 
known  fact  that  in  hot  weather  the  disease  is  often  more  serious  than 
in  cold  weather.  During  the  decline  of  epidemics  of  enteric  fever,  as 
in  other  infectious  diseases,  the  cases  become  less  and  less  serious. 
Certain  families  show  a  particular  disposition  to  enteric  fever,  several 
members  of  the  same  family  may  be  attacked  at  the  same  time,  and 
other  members  readily  contract  the  disease  (see  Pfeiffer,  Wagner). 
Recently  with  Dr.  Wm.  Sellers,  junior,  of  Radcliffe,  I  saw  two  cases  in 
the  same  family:  in  this  family  no  less  than  five  members  had  been 
attacked  by  it  at  various  times ;  one  contracted  it  by  assisting  in  the 
laying  out  of  the  body  of  a  relation  who  had  died  of  enteric,  and  an- 
other had  had  it  twice. 

Apart  from  these  general  considerations,  we  are  guided  in  our 
prognosis  — 

1.    By  the  pulse :  a  slow,  regular  pulse  indicates  a  favourable  course; 


SYSTEM  OF  MEDICINE 


an  irregular  and  intermittent  pulse,  even  if  not  high,  is  a  grave  omen,  as 
it  may  denote  myocarditis ;  a  very  qnick  and  small  pulse,  except  in 
young  children,  is  an  equally  unfavourable  sign,  and  if  the  pulse  reach 
140  or  more  in  an  adult,  the  issue  is  almost  always  unfavourable ;  a 
short  and  weak  first  sound,  at  the  apex  of  the  heart,  or  disappearance 
of  the  first  sound,  is  a  grave  symptom;  a  soft  systolic  bruit,  limited  in 
extent  and  not  due  to  previous  endocarditis,  is  of  no  special  significance. 

2.  By  the  temperature :  in  young,  strong  subjects  a  high  tempera- 
ture, say  104-5°-105°,  if  it  only  last  for  a  few  hours  and  rapidly  fall  to 
a  lower  temperature,  and  if  the  pulse  be  not  very  quick,  is  of  no  serious 
importance :  if,  however,  the  temperature  remain  high  for  some  time, 
and  especially  if  the  fever  be  accompanied  by  nervous  symptoms,  and 
not  quickly  reduced  by  antipyretics,  it  is  to  be  looked  upon  as  very 
serious.  Hyperpyrexia  is  a  very  unfavourable  symptom,  especially  if 
after  the  application  of  cold  the  temperature  does  not  fall  much  and 
rises  very  quickly  afterwards ;  sudden  fall  of  temperature,  with  the 
pulse  remaining  high,  often  denotes  haemorrhage  or  collapse. 

3.  By  the  nervous  symptoms  :  low,  muttering  delirium,  subsultus 
tendinum,  convulsions  (in  adults),  and  incontinence  of  fasces  and  urine 
are  of  very  grave  omen. 

4.  By  the  intestinal  symptoms :  diarrhoea  only  becomes  serious 
when  it  persists  and  is  very  profuse.  Of  the  gravity  of  haemorrhage 
and  perforation  we  have  already  spoken. 

Such  complications  as  extensive  pneumonia,  pulmonary  oedema, 
oedema  of  the  glottis,  haemorrhagic  nephritis,  and  symptoms  of  septic 
infection,  are  of  serious  import. 

Special  attention  has  been  drawn  to  sudden  death  in  enteric  fever ; 
it  occurs  in  about  4  per  cent  of  the  fatal  cases,  and  generally  about  the 
end  of  the  third  week.  Excluding  sudden  or  rapid  death  from  perfora- 
tion, in  about  two-thirds  of  the  cases  changes  have  been  found  post- 
mortem, such  as  embolism  or  thrombosis  of  the  pulmonary  artery, 
myocarditis,  and  degenerative  changes  in  the  myocardium,  sufficient  to 
account  for  the  sudden  death ;  in  about  one-third  no  such  changes  could 
be  found.  Some  think  that  death  is  due  to  syncope  caused  by  reflex 
influence  from  intestinal  lesions,  others  (Laveran)  attribute  the  death 
to  cerebral  anaemia.  The  premonitory  symptoms  are  sudden  dyspnoea, 
irregularity  of  the  pulse,  and  syncopal  attacks  (20). 

Mortality  from  Enteric  Fever.  — Numerous  statistics  exist  on  this  sub- 
ject (see  Table  II.,  Appendix).  I  will  allude  here  only  to  a  few  of  the 
more  important  points.  The  mortality  per  population  has  markedly 
decreased  in  England,  but  the  mortality  of  the  number  of  persons  at- 
tacked with  typhoid,  or  (to  apply  a  term  used  by  continental  observers) 
the  mortality  compared  to  the  morbidity,  is  still  for  England  as  high 
as  it  was  in  Murchison's  time,  namely,  about  17  per  cent.  From  1848- 
1870  it  was  17-26  per  cent,  according  to  the  return  of  the  Registrar- 
General,  and  also  according  to  the  report  of  some  of  the  larger  fever 
hospitals    (see  table   for   Monsall    Hospital    return.   Appendix).     In 


ENTERIC  FEVER  S45 


the  Cork  Fever  Hospital  the  mortality  (1871-1890)  was  8-6  per  cent ; 
the  mortality  in  the  Glasgow  Fever  Hospital  was  17-29  per  cent.  The 
statistics  of  some  of  the  larger  continental  hospitals  when  compared  with 
those  of  English  hospitals,  show  in  many,  like  those  of  Berlin  and  Paris, 
a  mortality  slightly  less  ;  thus  in  Paris  for  1882-88  it  was  14-1  per  cent, 
though  since  then  it  has  risen  to  20-6  per  cent ;  in  Berlin  it  was  14 -o  per 
cent ;  in  Leipzig  (for  1880-1893),  12-7  per  cent,  whilst  other  places  (such 
as  Hamburg)  show  a  much  smaller  mortality.  To  establish  anything 
like  a  mean  mortality  in  enteric  fever  is  most  difficult ;  it  varies  from 
year  to  year,  and  it  varies  with  the  age  and  sex  of  the  patient.  Con- 
trary to  Murchison's  views,  most  observers  (Griesinger,  Gesenius)  are 
agreed  that  amongst  very  young  children  the  mortality  is  high  ;  in  per- 
sons from  ten  to  thirty  years  of  age  it  is  much  less,  but  it  increases 
again  in  persons  over  thirty.  The  mortality  is  higher  in  women  than 
in  men  ;  thus,  according  to  Hayem,  the  mortality  in  Paris  for  1888-1893 
was  of  men  (over  fifteen  years  of  age)  19  per  cent ;  of  women  (over  fif- 
teen years)  22-5  per  cent.  In  pregnant  women  (91)  the  mortality  was 
17  per  cent,  abortion  occurring  in  'o^  per  cent ;  on  the  introduction  of 
the  cold  bath  treatment  it  fell  to  6  per  cent,  with  ho  per  cent  abortions ; 
in  puerperal  women  the  mortality  is  nearly  50  per  cent.  The  mortality 
amongst  soldiers,  as  given  in  the  reports  of  the  various  military  hos- 
pitals, is  better  fitted  for  statistical  purposes,  inasmuch  as  the  reports 
deal  with  persons  in  the  prime  of  life  and  living  under  the  same  condi- 
tions. The  mean  mortality  (from  1875-1891)  in  the  French  army,  as 
given  by  Brouardel,  was  12-2  per  cent,  and  during  these  seventeen  years 
it  only  varied  between  11  per  cent  and  14  per  cent. 

It  is  of  great  importance  to  know  how  far  the  various  methods  of 
treatment  affect  the  mortality.  To  arrive  at  a  satisfactory  conclusion 
we  must  not  consider  results  obtained  from  a  limited  number  of  cases  in 
one  locality  or  observations  made  during  one  epidemic.  The  evidence 
appears  now  to  be  conclusive  that  the  hydropathic  treatment  carried  out 
strictly  after  Brand's  method  has  considerably  lessened  the  mortality. 
Thus  in  the  Prussian  army  the  mortality  fell  from  25  per  cent  to  8  per 
cent,  and  in  the  various  hospitals,  both  in  Germany,  France,  and  America, 
where  this  system  was  rigidly  carried  out,  equally  satisfactory  results 
were  obtained  (93).     Thus  — 

Per  cent 

Drasche  (Vienna)  found  a  reduction  from  .  16-2  to  9-3 

Tripicr  and  Eouveret  (Lyon)  found  a  reduction  from  25     to  7-5 

•    Osier  (Baltimore)  ,,  „  ,,  21-8  to  7-4 

Thompson  (New  York)  ,,  ,,  ,,  19     to  7- 

And  lastly,  Vogl  (Munich  garrison)  gives  the  following  statistics :  — 

I'cr  cent 
For  1841-18f!0      ........  21 

,,     1800-1875,  treatment,  partly  expectant,  partly  by  cold  bath        ,  15-2 

,,     1875-1881-2,  treatment  by  bath  and  combined      .  .  .  6 '6 


SYSTEM  OF  MEDICINE 


It  must,  however,  be  noted  tliat  the  cold  bath  treatment  in  some  of 
the  larger  German  hospitals  has  not  reduced  the  mortality  to  so  low  a 
level  as  in  the  list  given  above. 

The  antiseptic  treatment,  so  much  recommended  of  late  by  some 
clinicians  in  England,  has  not  as  yet  produced  any  marked  diminution 
in  the  mortality  of  typhoid ;  but  I  do  not  know  how  far  it  is  adopted 
in  the  larger  fever  hospitals.  At  the  Monsall  Fever  Hospital  at  Man- 
chester, where  the  mean  mortality  is  about  17  per  cent,  the  mortality 
fell  during  one  year,  when  this  treatment  was  extensively  used,  to  13 
per  cent ;  and  some  physicians,  like  Dr.  Caton  of  Liverpool,  dealing  with 
a  smaller  number  of  cases,  have  recorded  even  a  much  lower  mortality. 

Treatment.  —  We  have  as  yet  no  specific  treatment  of  enteric  fever. 
We  do  not  know  of  any  drug  which  destroys  the  typhoid  bacillus,  or 
checks  its  growth  in  the  intestinal  glands  and  other  organs  ;  nor  of  any 
agent  to  counteract  or  neutralise  the  action  of  the  toxins  of  the  bacillus 
circulating  in  the  blood.  (The  treatment  recommended  by  Simmonds 
is  mentioned  further  on.)  In  our  treatment  we  must  therefore  try  to  put 
the  organism  into  a  state  in  which  it  can.  successfully  withstand  the 
action  of  the  poisonous  products,  and  maintain  it  there ;  we  must  also 
try  to  prevent,  if  possible,  the  ingress  of  septic  organisms  into  the  sys- 
tem, and  of  toxic  bodies  which  result  from  abnormal  fermentation  proc- 
esses in  the  intestines. 

In  speaking  of  the  treatment  of  enteric  fever  it  is  well  to  consider, 
first,  the  management  of  the  patient  as  regards  hygienic  conditions,  diet, 
etc.,  and  then  to  review  special  treatment  by  drugs,  baths,  etc. 

Hygienic  Measures  and  Management  of  the  Patient. — The  patient 
should  be  put  to  bed  as  soon  as  the  symptoms  show  themselves.  The 
bedroom  should  be  large,  airy,  and  well  ventilated ;  it  should  be  in  a  quiet 
part  of  the  house ;  it  should  not  contain  too  much  furniture,  and  should 
have  no  carpets  or  bed-hangings.  It  is  well  to  have  two  beds  in  the  room, 
so  that  the  patient  may  be  changed  from  one  to  the  other  ;  especially  is 
this  useful  when  the  patient  is  treated  with  the  cold  pack.  The  patient 
should  rest  on  a  spring  mattress,  and  a  mackintosh  be  placed  beneath 
the  sheet ;  he  should  only  be  lightly  covered,  and  the  temperature  of 
the  room  be  kept  between  60°  and  65°.  In  hot  weather  the  tempera- 
ture of  the  room  may  be  artificially  reduced.  The  patient  should  not 
be  allowed  to  get  up,  and  should  be  made  to  use  bed-pans ;  he  should  be 
as  little  disturbed  as  possible,  and  not  examined  oftener  than  necessary, 
the  right  iliac  region  in  particular  should  be  rarely  and  gently  handled  ; 
to  prevent  hypostatic  congestion  his  position  should  be  changed.  The 
trunk  and  limbs  should  be  sponged  with  vinegar  and  water  (at  85°-90° 
F.)  night  and  morning;  the  mucous  membrane  of  the  mouth  kept 
clean,  and  gargled  with  boracic  acid,  or  with  the  following  mouth- 
wash (Acid  boracic  3j.,  Potass,  chlorate  3j.,  Glycerini  §j.,  Aquam  ad  §vj.), 
or  the  parts  painted  with  boroglyceride ;  for  the  teeth  the  same  wash 
may  be  used.  Special  care  should  be  taken  to  prevent  the  formation 
of  bed-sores  by  washing  the  nates  and  adjacent  parts  with  weak  spirit  or 


ENTERIC  FEVER  847 


spirit  of  camphor.  As  soon  as  erythema  appears  water  or  air  cushions 
should  be  used,  aud  the  parts  dusted  over  with  boracic  acid  or  salicylic 
acid  and  prepared  chalk.  The  patient  should  not  be  left  alone,  and  if 
there  be  any  active  and  violent  delirium  he  should  be  treated  with, 
consideration  and  yet  with  firmness ;  he  should  never  be  strapped 
or  otherwise  fastened  down,  put  into  jackets,  or  otherwise  restrained. 
Under  urgent  circumstances,  and  for  a  short  time,  the  sheet  may  be 
tightly  drawn  over  him  and  fastened  on  both  sides ;  but  the  proper 
means  is  to  add  to  the  number  of  the  trained  nurses.  The  window 
should  be  stopped  so  as  to  open  no  more  than  six  inches,  or  a  heavy 
table  may  be  put  in  front  of  it. 

Diet.  —  The  diet  should  be  nourishing,  yet  easily  assimilable  and  non- 
irritating,  and  the  food  given  often;  the  secretions  of  saliva,  gastric 
juice,  pancreatic  juice,  and  bile  being  diminished,  and  the  intestines 
ulcerated,  we  have  to  be  very  careful  in  the  selection  of  the  diet.  Milk 
is  an  excellent  food  in  enteric  fever ;  it  is  as  a  rule  well  borne,  and  should  . 
be  given  throughout  the  whole  course  of  the  illness.  Two  to  three  pints 
in  the  twenty-four  hours  is  a  sufficient  quantity  ;  patients  will  often  take 
more,  but  then  the  milk  may  be  seen  partly  digested  in  the  stool.  The 
stools  should  be  inspected,  and  the  qtiantity  of  milk  reduced  if  many 
curds  are  found.  It  is  well  to  give  it  diluted  with  lime  Avater  or  soda 
water,  or  other  aerated  water,  and  administered  about  every  two  hours. 
Or  it  may  be  given  in  weak  tea,  or  in  the  form  of  custard,  or  whey 
or  junket  beaten  up  with  egg.  Some  people  cannot  take  milk,  then 
peptouised  milk,  Benger's  food,  or  arrowroot  may  be  given  instead. 

Besides  milk  the  patient  may  take  broth,  such  as  chicken  or  mutton 
broth,  beef -tea,  chicken  jelly,  and  some  of  the  other  jellies,  artificially 
prepared  extracts,  or  cold  meat  or  chicken  juice,  made  by  macerating 
finely  chopped  lean  meat  or  chicken  in  water ;  some  hydrochloric  acid 
and  a  little  salt  being  added,  and  the  whole  strained  through  a  cloth. 
If  there  be  much  diarrhoea  beef-tea  or  even  mutton  broth  had  better 
be  avoided.  Emit  is  inadvisable  especially  if  there  be  diarrhoea;  but 
occasionally  grapes,  with  skins  and  seeds  removed,  are  much  enjoyed 
and  help  to  clean  the  tongue.  As  a  beverage  give  pure  water  (which  has 
been  especially  recommended  in  very  large  quantities  by  recent  writers) 
or  barley  water,  or  toast  and  water,  or  water  containing  the  white  of 
raw  Q%%  strained  through  a  cloth ;  weak  tea  to  which  milk  is  added, 
or  iced  coffee  may  be  given,  especially  when  the  stomach  is  irritable, 
and  the  pulse  flagging;  aerated  waters  also  may  be  allowed,  except  in 
those  cases  in  which  there  are  much  flatulency  and  tympanites. 

Alcoholic  stimulants  need  not  be  given  unless  there  are  special  indica- 
tions for  it :  such  as  failure  of  the  heart,  pulmonary  oedema  or  congestion, 
insomnia,  low  muttering  delirium,  threatening  collapse,  or  very  high 
temperature.  In  tipplers  stimulants  are  often  necessary  from  the  first, 
and  should  be  given  to  avert  some  of  the  graver  symptoms  which  so 
often  threaten  them.  When  the  cold  bath  is  given  or  the  ice  pack, 
alcohol  may  be  required  before  and  after  especially  if  the  patient  be 


SYSTEM  OF  MEDICINE 


very  weak  or  feel  exhausted  or  faint.  Alcohol  is  also  needed  when 
certain  complications  arise,  such  as  perforation  or  heemorrhage,  which 
lead  to  collapse.  The  best  form  of  stimulant  is  brandy  or  whisky ; 
the  quantity  depends  on  the  age  of  the  patient  and  the  gravity  of  the 
symptoms ;  three  to  four  ounces  in  twenty -four  hours  usually  suffice  for 
adults.  When  the  pulse  becomes  small  and  thready  much  larger  doses, 
even  ten  to  twelve  ounces  or  more,  may  be  necessary.  Alcohol  should 
be  given  soon  after  some  food  is  taken ;  or  it  may  be  taken  in  the  milk 
every  two  or  three  hours ;  in  critical  cases  every  hour.  Its  effects  should 
be  watched  and  the  large  doses  diminished  as  soon  as  the  desired  effect  is 
produced ;  of  this  the  pulse  is  the  best  index,  which  should  become 
stronger  and  slower.  In  some  cases  in  which  brandy  is  disliked  we  may 
give  champagne  or  good  claret.  Alcohol  should  be  withheld  if  signs  of 
haemorrhage  from  bowel  or  kidney  appear,  or  if  the  urinary  secretion 
become  very  much  diminished. 

Medicinal  Treatment.  —  In  mild  cases,  when  the  temperature  does 
not  exceed  102-5°,  no  medicine  maybe  needed;  some  physicians  give 
small  doses  of  hydrochloric  acid  and  quinine,  and  if  the  patient  come 
under  treatment  before  the  9th  day,  several  doses  of  calomel  (gr.  ij.  to 
gr.  V.)  over  two  or  three  days.  This  administration  of  calomel,  recom- 
mended by  Wunderlich,  Liebermeister  and  others,  appears  to  prevent  a 
further  rise  of  the  fever,  and  to  diminish  the  diari-hcea  during  the  sub- 
sequent period;  I  have  tried  it  also  with  good  effect  in  the  Monsall 
Fever  Hospital.  In  the  severer  cases  many  physicians  still  follow  an 
expectant  treatment,  and  only  treat  such  grave  symptoms  as  pyrexia, 
profuse  diarrhoea,  etc.,  as  they  arise ;  others  follow  a  particular  line  of 
treatment,  which  in  its  conception  is  either  antipyretic  or  antiseptic,  or  a 
combination  of  both. 

Antipyretic  Treatment. — We  have  various  hi  cans  of  lowering  febrile 
temperature,  and  I  would  distinguish  particularly  between  the  antipy- 
retic treatment  by  means  of  the  cold  bath  or  allied  methods,  and  that  by 
means  of  antipyretic  drugs. 

A  certain  amount  of  pyrexia  is  an  essential  element  in  fever  and  is 
looked  upon  by  many  persons  as  beneficial ;  it  probably  does  interfere 
somewhat  with  the  further  growth,  development,  and  action  of  the 
typhoid  bacillus  and  its  products,  and  it  is  said  to  increase  the  resistance 
of  the  organism.  On  the  other  hand,  we  know  that  a  high  temperature 
in  itself  is  directly  injurious  to  many  organs,  and  occasionally  the 
cause  of  severe  nervous  disturbances,  though  many  of  the  grave  nervous 
symptoms  may  occur  with  moderate  temperature.  Most  observers  are 
agreed  that  a  high  febrile  temperature  requires  active  interference. 
Now  the  method  of  reducing  the  temperature  is  by  no  means  a  matter  of 
indifference.  Abstraction  of  heat  without  much  diminishing  the  pro- 
duction of  heat,  which  to  a  large  extent  is  caused  by  the  oxidation  of 
the  tissues  and  by  increased  tissue  metabolism,  is  the  safest  and  best  way 
of  reducing  the  temperature  ;  and  the  application  of  cold,  especially  in 
the  form  of  the  cold  bath,  best  fulfils  the  requirements.     There  can  be 


ENTERIC  FEVER  849 


little  doubt  that  whenever  this  treatment  can  be  applied  it  is  far 
preferable  to  antipyretic  treatment  by  drugs  ;  and  a  comparison  of  the 
mortality  statistics  of  the  cases  in  which  the  cold  bath  treatment  is  carried 
out,  with  those  of  cases  in  which  antipyretic  drugs  are  administered, 
clearly  shows  the  superiority  of  the  former  method  of  antipyretic  treat- 
ment (12  to  16  per  cent  compared  to  6  to  10  per  cent).  Some  of  the  best 
English  clinicians,  like  Sir  Wm.  Jenner  and  others,  are  not  in  favour 
of  the  cold  bath  treatment.  Yet  a  glance  at  the  tables  published  by  the 
Registrar-General,  and  by  the  several  Hospital  Boards  in  England, 
must  satisfy  every  one  that,  whilst  the  mortality  is  much  diminished, 
the  mortality  from  enteric  fever  per  case  rate  in  England,  in  spite  of 
better  hygienic  conditions  and  management,  is  still  very  considerable. 

The  cold  hath  treatment,  first  recommended  by  Currie  in  1787,  is  now 
extensively  used,  especially  on  the  Continent.  Its  reintroduction  is  due 
to  Dr.  Brand  of  Stettin  (1861),  who  showed  how  the  mortality  of  enteric 
fever  was  lessened  by  its  adoption ;  and  his  method  was  soon  followed 
in  a  more  or  less  modified  form  by  other  observers.  In  England  Dr. 
Cayley  has  most  strongly  advocated  the  use  of  the  cold  bath  in  enteric 
fever  (12).  Brand  recommends  it  to  be  used  whenever  the  temperature 
is  over  102°  (measured  in  the  rectum),  and  this  treatment  he  adopts 
from  the  very  beginning. 

Before  the  patient  is  put  into  the  bath  the  face  and  chest  may  be 
sponged  with  cold  water,  and  if  the  patient  be  weak  and  exhausted  he 
receives  some  stimulant.  The  temperature  of  the  bath  varies  from  70" 
to  %5°  F.,  the  bath  is  placed  close  to  the  bed,  and  the  patient  is  lifted 
into  it  and  so  immersed  that  the  water  covers  the  chest ;  the  back  of 
the  patient  is  supported  by  a  water  cushion,  and  a  sheet  or  napkin  is 
folded  round  the  loins.  The  head  and  forehead  are  now  covered  by  a 
cloth  wrung  out  in  cold  water,  and  whilst  the  patient  is  in  the  bath  cold 
water  (of  lower  temperature  than  that  of  the  bath)  is  applied  to  the  head 
every  three  to  four  minutes,  whilst  the  limbs  and  thorax  are  rubbed 
during  the  whole  time  of  the  immersion.  While  in  the  bath  the  patient 
has  some  cold  water  to  drink.  The  duration  of  the  bath  is  from  ten 
to  fifteen  minutes  as  a  rule ;  the  patient  is  then  lifted  out  and  dried 
gently,  except  over  the  abdomen,  put  into  bed  lightly  covered,  and  hot 
bottles  are  placed  at  the  feet.  A  second  dose  of  some  stimulant,  such 
as  whisky  and  hot  water,  is  then  given  to, him.  During  the  bath  the 
state  of  the  patient  must  be  carefully  watched  ;  with  the  fall  of  the 
l)ody  temperature  he  begins  to  shiver ;  but  if  the  temperature  before 
the  bath  has  been  very  high,  he  may  still  be  left  for  some  minutes  longer 
whilst  the  limbs  and  thorax  are  more  vigorously  rubbed.  If  the  pulse 
be  very  weak,  and  the  patient  become  cyanotic,  he  shoiild  be  removed 
from  the  bath  at  once.  After  the  bath  the  patient  may  take  some  food, 
and  he  generally  then  falls  into  a  quiet  slumber;  if  not,  Brand  recom- 
mends the  ap])]ication  of  compresses  wrung  out  in  cold  water  to  the 
chest  and  a})(lomen.  Half  an  hour  after  the  removal  from  the  bath  the 
temperature  is  taken ;   it  is  usually  found  to  have  fallen  1°  to  3°  F., 

voj..  I  3  I 


850  SYSTEM.  OF  MEDICINE 

and  if  in  two  or  three  hours  the  temperature  again  exceeds  102-2°  the 
bath  is  renewed.  Brand  has  given  as  many  as  eight  baths  in  the  twenty- 
four  hours,  but  usually  four  to  six  sufilce.  The  good  effects  of  the  cold 
bath  are  readily  seen :  the  pulse  becomes  slower  and  the  tension  of  the 
artery  is  increased,  the  number  of  respirations  diminish,  the  tongue 
becomes  moist,  and  the  appetite  improves ;  the  nervous  system  is 
especially  relieved,  the  delirium  disappears  for  a  time,  the  patient 
apjDcars  much  calmer,  and  the  sleep  becomes  more  natural.  The  ad- 
vantages claimed  for  the  cold  water  treatment  are :  that  the  fever  runs 
a  less  protracted  course,  that  grave  nervous  symptoms  are  less  apt  to 
occur,  that  the  heart  and  pulse  remain  strong,  that  the  tongue  remains 
moist  and  the  appetite  good,  and  that  the  diarrhoea,  if  not  lessened,  is 
certainly  not  increased :  statistics  show  that  the  mortality  is  less.  The 
cold  bath  is  contra-indicated  when  the  pulse  is  irregular  and  intermittent, 
and  when  we  suspect  myocarditis  or  pericarditis ;  also  in  intestinal 
haemorrhage  occurring  during  the  later  stage,  in  peritonitis,  and  in  old 
people.  On  the  other  hand  the  puerperal  state^  pregnancy,  broncho- 
pneumonia, pneumonia,  intestinal  haemorrhages  during  the  first  week, 
and  albuminuria,  are  no  contra-indications  (Chantemesse).  Relapses 
appear,  however,  to  occur  more  frequently  with  the  cold  bath  treatment. 

Brand's  system  of  treatment  is  still  carried  out  by  a  good  many 
medical  men,  especially  on  the  Continent.  Many  physicians,  however,  do 
not  bathe  the  patient  unless  the  temperature  reach  103°  or  103'5° :  many 
also  advise  the  use  of  water  of  80°  F.,  the  temperature  of  which  is  gradu- 
ally lowered  to  70°  or  65° ;  this  plan  appears  to  have  many  advantages, 
but  it  does  not  give  quite  as  good  results  as  the  stricter  method  of  Brand. 

For  the  five  years  ending  loth  May  1895,  systematic  hydrotherapy 
—  the  method  of  Brand  with  certain  minor  modifications  —  has  been  used 
in  the  Johns  Hopkins  Hospital  at  Baltimore.  Each  patient  receives  a  tub- 
bath  of  twenty  minutes  at  70°  every  third  hour,  if  the  rectal  temperature 
be  at  or  above  102°  W.  Prof.  Osier  (67a)  says:  ''Two  advantages  are 
claimed  for  hydrotherapy  in  typhoid  fever  —  a  mitigation  of  the  general 
symptoms  of  the  disease  and  a  reduction  in  the  mortality.  Our  experi- 
ence during  the  past  five  years  bears  out  these  claims."  Osier  adds  that 
the  beneficial  action  is  "  not  so  much  special  and  antipyretic  as  general 
tonic  and  roborant.  The  typhoid  picture  is  not  so  frequently  seen." 
About  6  to  8  per  cent  more  lives  are  saved.  While  continuing  its  use 
the  author  says  that  he  prays  for  a  method  which,  "while  equally  life 
saving,  may  be,  to  put  it  mildly,  less  disagreeable." 

In  certain  cases  it  is  well  to  place  the  patient  in  a  warm  bath  and 
to  lower  the  temperature  gradually  by  the  addition  of  pieces  of  ice ;  these 
are  cases  of  threatening  syncope,  or  cases  in  which  the  breathing  is  very 
much  oppressed  from  emphysema  or  laryngeal  complications,  or  in  which 
there  is  profuse  sweating. 

As  the  cold  bath  treatment  is  difficult  to  carry  out  in  private  practice, 
other  modifications  of  applying  cold  to  the  body  have  been  recommended ; 
such  as  the  wet  pack,  the  ice  pack,  sponging  the  body  with  iced  water,  or 


ENTERIC  FEVER  851 


with  cold  water  and  vinegar,  placing  a  cradle  over  the  patient  in  which 
buckets  containing  pieces  of  ice  are  suspended  (Fenwick),  or  Leiter's 
tubes,  with  iced  water  running  through  them,  which  are  placed  over 
various  regions  of  the  body,  head,  chest  or  abdomen.  None  of  these  pro- 
cedures, except  perhaps  the  ice  pack,  reduce  the  temperature  so  effectively 
as  the  cold  bath. 

Many  physicians  combine  the  cold  water  treatment  with  medicinal 
treatment.  Jurgensen  recommends  the  cold  bath  when  the  temperature 
reaches  104°,  and  gives  quinine.  Liebermeister  gives  calomel  when  the 
patient  is  seen  early ;  he  recommends  a  bath  of  70°  F.  when  the  tem- 
perature in  the  axilla  is  over  102-2°  F.,  and  moreover  large,  doses  of 
quinine  (20  to  40  grains  in  the  evening).  Bouchard  combines  antiseptic 
treatment  with  the  baths,  but  the  initial  temperature  of  the  bath  is  only 
about  5°  F.  lower  than  the  temperature  of  the  patient  and  is  gradually 
reduced  to  85°. 

Partly  as  antipyretic,  but  more  as  hydropathic  treatment,  must  be 
mentioned  the  prolonged  immersion  in  a  tank  bath,  recommended  by  Dr. 
James  Barr  of  Liverpool  (5). 

The  temperature  of  the  bath,  which  varies  from  90°  F.  to  98°  F.,  is 
regulated  according  to  the  temperature  of  the  fever  patient,  that  is,  the 
higher  his  temperature  the  lower  the  temperature  of  the  bath  ;  the  patient 
is  kept  in  the  water  for  days  (six  to  thirty-one  days),  and  passes  all  his 
discharges  into  the  bath.  Dr.  Barr  claims  all  the  good  effects  produced  by 
the  cold  bath  for  his  immersion  treatment,  which,  on  the  other  hand, 
avoids  the  objections  usually  urged  against  the  cold  bath :  out  of  forty 
cases  treated  by  him  in  this  way  only  one  died. 

In  England,  and  to  some  extent  also  on  the  Continent,  the  cold  water 
treatment  is  principally  confined  to  cases  of  hyperpyrexia,  and  for 
ordinary  cases  of  enteric  fever  one  or  other  of  the  antipyretic  drugs  is 
given  when  the  temperature  reaches  103°  or  103-5°.  Quinine  is  still  much 
used ;  it  should  be  given  in  one  or  two  large  doses  daily,  and  only  at 
those  times  of  the  day  when  there  is  a  natural  fall  in  the  temperature, 
that  is,  evening  and  forenoon:  the  dose  for  an  adult  should  be  from 
15-30  grains,  for  a  child  3-5  grains.  Antifebrin  (4-8  grain  doses) 
and  phenacetin  (10-15  grains)  are  now  much  preferred  to  antipyrin 
(^10-20  grains),  as  the  latter  may  cause  the  temperature  to  fall  too  rapidly, 
and  induce  symptoms  of  collapse  and  irregularity  of  the  pulse.  Salicy- 
late of  sodium  (15-30  grains)  was  formerly  given  largely  in  enteric 
fever.  At  the  Monsall  Fever  Hospital  some  years  ago  the  late  Dr. 
Tomkins,  then  resident  medical  officer,  tried  salicylate  of  sodium  in  a 
very  large  number  of  cases  ;  but  the  depressing  effects,  the  unpleasant 
accidents  (such  as  delirium,  vomiting,  dyspnoea,  etc.),  and  the  tendency  to 
hfftmorrhage  from  the  intestines  which  it  prodviced,  made  us  abandon  its 
use.  Tlie  antipyretics  —  antipyrin,  antifebrin,  and  phenacetin  —  are  given 
when  the  temperature  is  over  103°  F.,  and  repeated  after  some  hours 
when  the  temperature  has  again  risen.  A  combination  of  y)henacetin  with 
2-5  grains  of  quinine  is  now  very  mucli  used.    Apart  from  the  therapeutic 


852  SYSTEM  OF  MEDICINE 

effect,  it  mast  be  noted  that  a  rapid  fall  of  temperature  after  the  ad- 
ministration of  a:iy  of  these  antipyretics  is  as  a  rule  a  good  prognostic 
sign.  Quite  recently  two  new  antipyretics,  malakin  (44)  and  lactophe- 
nin  (90)  have  been  described,  and  the  action  of  lactophenin  in  typhoid 
is  much  praised  by  v.  Jaksch.  Among  other  drugs  which  were  formerly 
preferred,  but  which  are  now  rarely  applied  as  antipyretics,  are  digitalis 
and  veratria.  Kairin  and  thallin  have  marked  antipyretic  properties, 
and  thallin  is  still  occasionally  used  (78). 

Antiseptic  Treatment.  —  Of  the  various  antiseptic  remedies  calomel  wsis 
the  first  to  be  used,  and  is  still  largely  used  by  some  physicians.  It  was 
not  given  in  the  first  instance  on  account  of  its  antiseptic  properties,  but 
because  under  its  use  the  duration  of  the  fever  seemed  to  be  lessened,  and 
its  course  to  be  milder.  Of  its  antiseptic  virtue  there  can  be  no  doubt,  and 
experimental  investigations  have  shown  that  it  readily  kills  bacteria,  that 
it  prevents  butyric  acid  fermentation,  —  a  fermentation  brought  about  by 
micro-organisms,  —  that  it  checks  the  formation  of  products  of  decomposi- 
tion usually  found  in  the  digestive  tract  (indol,  skatol),  and  that  it  does 
not  interfere  with  the  action  of  the  unorganised  ferments  of  the  saliva, 
gastric  and  pancreatic  juices  (Wassiljeff). 

Percliloride  of  Mercury  (-^-  to  1  drachm  of  the  solution  of  perchloride 
of  mercury,  with  1  or  2  grains  of  quinine,  given  every  four  hours  for 
several  days)  has  been  highly  recommended  by  Sir  W.  Broadbent; 
especially  when  the  motions  are  very  offensive  and  accompanied  by  much 
gas,  the  abdomen  much  distended,  and  the  fever  high.  Calomel  or 
perchloride  of  mercury  are  only  to  be  given  for  a  few  days;  but 
within  the  last  few  years  more  thorough  antiseptic  treatment  has  been 
advised,  and  numerous  drugs  have  been  recommended,  not  so  much  with 
the  object  of  checking  the  action  of  the  typhoid  bacilli  which  have 
already  passed  the  intestines  and  reached  internal  organs,  as  with  that  of 
acting  on  any  toxins  as  yet  unabsorbed,  and  particularly  of  checking 
fermentation  and  the  action  of  the  numerous  micro-organisms  found  in 
the  alimentary  canal,  the  growth  and  development  of  which  are  favoured 
by  the  presence  of  the  typhoid  bacillus,  and  the  products  of  which  may 
be  absorbed  through  the  ulcerated  surface  of  the  intestines. 

One  effect  of  the  antiseptic  treatment  which  is  often  apparent  is  that 
the  dejections  become  less  offensive,  sometimes  quite  odourless ;  bacterio- 
logical examination  of  the  faeces,  however,  shows  that  they  still  contain 
a  very  large  amount  of  living  micro-organisms.  Diarrhoea  is  often 
diminished,  the  temperature  reduced,  and  some  of  the  graver  nervous 
symptoms  are  said  to  be  prevented.  Wliilst  some  speak  very  highly 
of  the  effects  of  the  antiseptic  treatment,  and  record  a  very  low  mortality, 
others  have  seen  but  little  benefit  from  the  treatment.  My  own  experi- 
ence from  a  number  of  cases  in  which  the  various  antiseptics  have 
been  tried  makes  me  think  well  of  this  treatment,  though  it  is  certainly 
inferior  to  the  cold  water  treatment. 

Of  the  various  antiseptics  which  have  been  recommended  we  may 
mention — 


ENTERIC  FEVER  853 


/3  Naphthol,  is  given  either  alone  in  powders  or  capsules  (5-10  grains 
every  four  liours),  or  mixed  with  salicylate  of  bismuth.  150  grains  of 
fi  naphthol  are  mixed  with  75  grains  of  salicylate  of  bismuth  and 
divided  into  thirty  powders.  From  three  to  twelve  of  these  are  given  in 
the  twenty-four  hours.  Teissier  recommends  besides,  that  four  enemata 
with  cold  water  be  given  daily  to  aid  diuresis,  and  one  enema  containing 
15  grains  of  quinine  and  an  infusion  of  valerian  (33).  In  cases  in  which 
constipation  exists,  salicylate  of  magnesium  (50-100  grains  daily)  has 
been  recommended. 

Salicylate  of  quinine  I  have  often  given  (10-15  grains)  with  good  effect. 

Salol  (40-60  grains  in  twenty-four  hours)  has  come  much  into  use 
of  late.  It  is  usually  well  borne,  produces  in  these  doses  no  toxic 
effects,  deodorises  the  stool,  and  often  relieves  flatulence  and  tympanites. 

Betol,  or  salicylate  of  naphthol,  na,phthalin,  and  benzoate  of  /?  naph- 
thol, or  benzo-naphthol,  have  been  highly  spoken  of  by  French  observers. 
Hydronaphthol  was  recommended  by  Clarke;  magnesium  benzoate  by 
Klebs ;  dermatol  (17)  by  other  observers. 

Carbolic  Acid.  — 2-^3  grains  in  keratin  pills,  or  in  the  following  mixt- 
ure (14),  Acid  carbolic  liquefact.  (Calvert)  riixij.,  Tr.  iodi.  (B.  P.)  ^xvj., 
Tr.  aurant.  3iss.,  Syrup  simpl.  jiij.,  Aquas  §  viij. ;  5  j.  may  be  given  every 
four  hours  for  the  first  fourteen  days,  or  till  the  urgent  symptoms  yield, 
and  then  three  times  a  day  (Moore),  or  creasote  may  be  used,  in  pills  or 
capsules,  1  to  2  minims ;  or  paracreasotic  acid  (51). 

Turpentine  acts  both  as  an  antiseptic  and  as  a  stimulant,  it  checks 
tympanites,  and  is  especially  to  be  recommended  in  haemorrhage.  It 
must  be  given  cautiously  if  nephritis  be  present.  A  dose  of  5-15  minims 
given  in  capsules,  or  emulsified  with  yolk  of  eggs,  I  have  often  found 
well  borne,  or  a  mixture  of  the  same  with  spirit  of  nitrous  ether  and 
spirit  of  chloroform  (Moore). 

Chlorine  is  highly  recommended  by  Burney  Yeo.  Into  a  twelve- 
ounce  bottle  put  30  grains  of  powdered  potassium  chlorate,  and  pour  on  it 
40  minims  of  strong  hydrochloric  acid.  Chlorine  gas  is  at  once  liberated. 
Fit  a  cork  into  the  mouth  of  the  bottle,  and  keep  it  clos'ed  till  it  has 
become  filled  with  the  greenish  yellow  gas.  Then  pour  water  into  the 
bottle,  little  by  little,  closing  the  bottle,  and  well  shaking  at  each  addi- 
tion, until  the  bottle  is  filled.  To  12  oz.  of  this  solution  24-36  grains  of 
quinine  are  added,  and  1  oz.  of  syrup  of  orange-peel.  Dose,  1  oz.  every 
two,  three,  or  four  hours,  according  to  the  severity  of  the  case. 

Camphor  is  recommended  by  Janeway ;  Thymol  has  been  also  used 
(89). 

Chloroform  may  be  given  internally,  1  part  of  chloroform  in  150  of 
water  (84,  98).     Chloroform  rapidly  destroys  typhoid  bacilli. 

Quinine  must  also  be  grouped  with  the  antiseptic  remedies. 

I>esides  the  antiseptic  treatment  of  enteric  fever  we  have  yet  to 
mention  the  administration  of  potassium  iodide,  which  was  very  much  in 
vogue  on  the  Continent,  as  a  remedy  throughout  the  fever  period,  and  is 
spoken  of  very  highly ;  also  the  administration  of  large  quantities  of  water 


854  SYSTEM  OF  MEDICINE 

by  the  mouth.  (74),  or  in  the  form  of  enemata :  Cantario  recommended 
large  enemata  of  cold  water  and  gallic  acid  (5  to  100  of  water). 

The  antitoxin  treatment,  successfully  applied  in  diphtheria  and 
tetanus,  finds  as  yet  no  place  in  the  treatment  of  enteric  fever.  E. 
Frankel  (28)  in  more  than  fifty  patients  suffering  from  enteric  fever 
used  subcutaneous  injections  of  sterilised,  attenuated  cultures  of  typhoid 
bacilli,  grown  on  beef -tea  made  from  thymus  gland;  the  injections 
which  produced  a  distinct  reaction  were  repeated  several  times.  Frankel 
states  that  the  treatment  shortened  the  duration  of  the  fever,  and  altered 
the  continued  into  a  remittant  form.  This  treatment  can  scarcely  be 
looked  upon  as  a  specific  treatment,  for  Kumpf  obtained  results 
similar  to  Frankel's  by  using  the  products  of  other  bacteria,  such  as 
the  bac  pyocyaneus.  Local  haemorrhagic  infiltration  round  the  typhoid 
ulcers,  the  probable  result  of  this  treatment,  has  been  noted  by  Kraus 
and  Baswell. 

Treatment  of  Special  Symptoms  and  Complications.  — I  can  only  refer 
here  to  a  few  of  the  more  important. 

Hyperpyrexia.  —  All  authors  are  agreed  that  there  is  but  one  plan  of 
treatment  for  this  event,  namely,  the  cold  bath.  Where  this  is  inappli- 
cable, the  ice-pack  or  cloths  wrung  out  in  iced  water  are  to  be  applied  to 
the  limbs  and  trunk  of  the  body,  the  cloths  to  be  repeatedly  changed 
till  the  temperature  of  the  body  is  sufficiently  reduced.  At  the  same 
time  large  doses  of  quinine,  30-40  grains,  may  be  given.  This  plan  I 
found  successful  in  two  cases  in  which  the  temperature  had  reached 
106-5°  and  107°  respectively. 

For  the  adynamic  form  of  fever  subcutaneous  injections  of  ether, 
caffein  (subcutaneously  or  by  the  mouth,  1-3  grains),  musk,  or  camphor 
may  be  used. 

In  the  petechial  form  large  doses  of  quinine,  perchloride  of  iron,  lime 
juice  are  prescribed. 

Constipation.  —  Constipation  lasting  only  a  few  days,  and  not  accom- 
panied by  much  tympanites  and  flatulency,  need  not  be  treated  medici- 
nally ;  an  adinixture  of  beef-tea  and  milk  diet  may  be  tried.  If  the  con- 
stipation be  more  obstinate  glycerine  enemata  or  cold  water  enemata 
may  be  given;  should  these  produce  little  effect,  and  the  constipation 
have  gone  on  for  five  days  or  more,  small  doses  5f  castor  oil  (one  to  two 
teaspoonfuls  in  milk)  may  be  given,  and  repeated  after  some  hours  if 
necessary. 

Profuse  Diarrhoea.  —  This  may  have  to  be  treated  if  the  alvine  dis- 
charges amount  to  more  than  eight  in  the  twenty-four  hours,  and  if  the 
patient  is  thereby  rendered  weak  and  exhausted.  A  starch  enema,  to 
which  20-30  drops  of  laudanum  are  added,  often  suffices  to  keep  the 
diarrhoea  within  bounds ;  it  causes  diminished  peristalsis  in  the  large 
intestines,  and  often  the  diarrhoea  is  due  more  to  a  catarrh  of  the  large 
bowel  than  to  the  ulcerated  state  of  the  small  intestines.  Nitrate  of 
bismuth,  salicylate  of  bismuth,  and  mistura  cretse  are  equally  efficacious; 
but  if  they  fail  one  need  not  hesitate  to  give  opium,  either  alone  or  in 


ENTERIC  EEVER  855 

combination  with  acid  (sulphuric  acid  preferred),  or  with  acetate  of  lead 
or  sulphate  of  copper.  There  is  no  objection  to  giving  the  opium  with 
the  lead  or  copper  salt  in  the  form  of  a  pill ;  but  it  is  better,  perhaps, 
to  give  it  in  liuid  form,  so  as  to  avoid  mechanical  irritation  of  the 
ulcerated  surface  in  case  the  pill  should  not  dissolve  before  it  reach  the 
affected  part.  As  I  have  said,  antiseptics,  such  as  /?  naphthol,  often 
subdue  the  diarrhoea  quickly. 

Persistent  Vomiting.  —  Food  should  be  given  in  small  quantities  and 
often.  Milk  and  lime  water  or  Benger's  food  may  be  tried,  or  some  of 
the  prepared  foods,  or  cold  meat  juice  with  acid.  Bismuth  in  powder 
(10  grains)  with  cocaine  hydroehlor.  (gr.  i),  given  three  to  four  times 
daily,  I  have  often  found  very  efficacious.  A  sinapism  to  the  epigastrium 
may  also  be  applied.     Ingluvin  in  5  grain  doses  has  been  recommended. 

Pain  in  the  abdomen  may  be  relieved  either  by  cold  or  hot  applica- 
tions to  the  abdomen.  The  latter,  either  as  fomentations  or  poultices, 
are  highly  spoken  of  by  some  English  observers. 

Tynvpanites.  —  Often  a  troublesome  symptom.  Enemata  with  tur- 
pentine or  tincture  of  valerian  often  give  decided  relief.  Turpentine 
may  be  given  internally  in  capsules  of  10  minims.  If  there  be  much 
flatulence,  carbolic  acid,  or  creasote  or  sulphocarbolate  of  soda  (15  grains) 
may  be  tried.  The  application  of  ice  to  the  surface  of  the  abdomen  is 
higlily  recommended  by  Cayley.  If  the  tympanites  do  not  yield  to  any 
of  these  drugs,  the  introduction  of  a  long  tube  may  give  passage  to 
much  flatus;  but  this  operation  has  to  be  repeated,  as  its  effects  are 
often  very  temporary. 

Hcemorrhage  from  the  Bowels.  —  We  have  already  spoken  of  the 
gravity  of  intestinal  haemorrhage  when  it  occurs  after  the  first  week,  and 
when  it  is  profuse.  The  patient  must  be  kept  quiet  in  the  recumbent 
posture,  and  a  small  dose  of  morphia  (i  grain)  should  be  injected  at  once. 
Ice  should  be  applied  to  the  abdomen  (the  ice  may  be  placed  between 
flannel,  or  small  pieces  of  ice  may  be  placed  in  a  kind  of  square  dish 
made  out  of  a  piece  of  mackintosh).  The  patient  should  suck  small 
yjieces  of  ice,  and  all  his  food  should  be  iced.  Milk  should  be  stopped, 
or  given  with  carbonate  of  soda,  or  in  the  form  of  alum  whey,  that  is, 
mixed  with  finely  powdered  alum  and  the  curds  separated  from  the 
serum  (21a).  Ergot  was  formerly  in  general  favour,  but  has  fewer  ad- 
vocates now;  it  is  best  given  as  a  subcutaneous  injection  of  ergotin  —  1 
to  3  grains.  Of  much  more  service  are  large  doses  of  acetate  of  lead, 
given  every  two  to  three  hours,  or  gallic  acid  and  opium.  Turpentine  in 
10  minim  capsules  (1  drachm  given  two  to  three  times  a  day)  has  given  me 
by  far  the  best  results.  It  is  also  contained  in  the  mixture  recommended 
by  Murchison.  (Acidi  tannici  gr.  x.,  Tinct.  opii  "ix..  Spirit,  terebinthini 
%-x.v.,  Mucilag.  3ij.,  Tinct.  chloroform,  co.  "Ixv.,  Aquam  menth.  pip.  ad  §  j.; 
this  dose  to  be  taken  every  two  hours.)  Ice-water  injections  have  also 
been  tried  with  success.     Opium  enemata  are  to  be  recommended. 

The  pi'ofonnd  anmmia  which  accompanies  or  follows  ])i'ofuse  haemor- 
rhage is  best  treated  by  subcutaneous  injections  of  ether,  and  if  the 


856  SYSTEM  OF  MEDICINE 

pulse  become  very  frequent  and  small  a  large  quantity  of  normal  salt 
solution  is  to  be  injected  into  the  subcutaneous  tissue.  The  salt  solution 
is  contained  in  a  tin  or  glass  vessel  held  or  suspended  at  some  height 
from  the  patient,  and  connected  by  means  of  an  indiarubber  tube  with  a 
line  aspirating  needle ;  this  is  inserted  into  the  skin  below  the  scapula, 
where  the  subcutaneous  tissue  is  loose.  As  the  salt  water  flows  into  the 
tissue  under  a  high  pressure,  a  large  quantity,  half  a  pint  or  more,  can 
thus  be  easily  injected.  The  operation  can  be  repeated  on  the  other 
side  after  a  little  time.  A  very  marked  improvement  follows  the 
injection,  though  too  often  it  is  but  temporary. 

In  peritonitis,  whether  dne  to  extension  of  inflammation  or  to  per- 
foration, large  doses  of  opivim  are  given  and  poultices  applied  locally ; 
if  accompanied  with  symptoms  of  collapse  alcoholic  stimulants  should 
be  given  freely,  ether  injected,  and  heat  applied  to  feet  and  legs. 

As  perforation  is  almost  always  fatal,  and  the  medicinal  treatment  of 
little  value,  surgical  interference  (that  is,  laparotomy,  washing  out  of  the 
peritoneal  cavity,  suturing  the  intestines,  or  the  establishment  of  an  arti- 
ficial anus)  has  been  suggested.  Van  Hook  (43)  records  one  recovery 
out  of  four  cases  in  which  he  operated.  When  he  wrote  nineteen 
laparotomies  with  four  recoveries  were  recorded.  It  is  very  difficult  to 
give  the  indications  which  render  an  operation  likely  to  be  successful. 
Those  cases  in  which  there  is  no  great  collapse,  or  in  which  the  collapse 
and  the  more  acute  symptoms  have  passed  off,  but  all  the  signs 
of  peritonitis  with  exudation  exist,  appear  the  most  favourable  for 
operative  interference. 

Some  of  the  various  symptoms  may  require  special  treatment: 

Persistent  Insomnia.  —  Sulphonal,  or  trional  in  15-25  grain  doses 
rarely  has  much  effect.  Cliloral  and  bromide  act  better,  but  should  not 
be  given  if  heart's  action  is  weak;  small  doses  of  morphia  may  often 
be  given  with  advantage,  and  without  producing  any  ill  effects ;  or 
paraldehyde. 

In  Delirium.  —  Ice  to  the  head,  a  sinapism  to  the  back  of  the  head, 
and  morphia  with  quinine ;  if  of  low  muttering  character,  stimulants 
may  be  given. 

Delirium  tremens  is  best  treated  by  large  doses  of  paraldehyde,  and 
occasionally  morphia  may  be  necessary. 

Weakness  of  the  heart's  action,  indicated  by  the  pulse,  and  due  to 
change  in  the  myocardium  or  to  general  prostration,  is  best  treated 
by  digitalis,  ether,  citrate  of  caffein,  and  by  subcutaneous  injections 
of  strychnia  (J^  of  a  grain).  Digitalis  may  also  be  given  with  ad- 
vantage in  the  form  of  digitalin  subcutaneously,  or  in  granules,  but  its 
effects  on  the  pulse  must  be  watched.  Ziemmsen  recommends  subcu- 
taneous injections  of  camphor  dissolved  in  olive  oil  (camphor  1  gramme, 
olive  oil  5  grammes). 

In  acute  dilatation  of  the  heart,  if  it  occur  in  plethoric  subjects,  and 
especially  if  associated  with  pulmonary  complications,  cyanosis,  and 
marked  distension  of  the  veins,  venesection  may  be  resorted  to. 


ENTERIC  FEVER  857 


Bed-Sores.  —  These  can  be  prevented  by  jn-oper  attention  to  the 
patient,  as  I  have  already  said.  The  nurses  should  be  able  to  lift  the 
patient  easily,  he  must  not  remain  a  moment  wet  or  soiled,  the  buttocks 
must  be  washed  (if  danger  threaten)  once  or  twice  a  day  with  warm 
soap  and  water,  and  the  skin  disinfected  with  boracic  acid  and  lanoline 
or  other  means.  If  the  skin  become  rough,  reddened,  or  show  slight 
abrasions,  the  part  may  be  washed  with  boracic  acid  solution  or  weak 
perchloride  of  mercury  solution,  and  some  ointment,  such  as  zinc  or 
boracic  acid  ointment,  or  iodoform  powder,  may  be  applied  to  the 
abraded  part.  If  a  slough  have  formed  antiseptic  and  stimulating 
dressings,  such  as  carbolic  acid  (1  in  40),  or  compound  tincture  of 
benzoin,  or  balsam  of  Peru  are  required.  Over  the  lint,  which  ought 
to  fit  exactly  into  the  ulcer,  a  piece  of  gutta-percha  tissue  is  applied, 
and  outside  this  again  some  folds  of  lint,  and  the  whole  fixed  by  a 
strip  of  diachylon  plaster.  When  the  slough  is  large  it  is  best  to 
dust  it  over  with  iodoform,  or  iodol,  or  aristol;  this  is  covered  by 
gutta-percha  tissue,  and  over  this  lint  dipped  in  an  antiseptic  or 
stimulating  lotion  is  placed.  The  best  preventive  against  bed-sores 
is  to  warn  the  head  nurse  that  she  will  be  superseded  if  they  occur. 
[See  article  on  '*  Nursing."] 

It  would  be  beyond  the  scope  of  this  article  to  speak  of  the  treat- 
ment of  the  many  complications  and  sequelae  of  enteric  fever,  such  as 
pneumonia,  pleurisy,  nephritis,  etc.,  as  these  subjects  will  be  dealt  with 
in  the  several  articles  on  these  affections. 

Treatment  during  Convalescence.  —  Considering  the  nature  of  the 
lesion  in  enteric  fever,  and  that  the  healing  process  can  be  but  slow,  the 
patient's  progress  during  convalescence  should  be  most  carefully  watched, 
and  strict  injunctions  given  as  to  rest,  diet,  and  general  management. 

The  temperature  should  still  be  taken  for  a  fortnight,  so  as  to  judge 
of  the  progress  of  the  case  or  foretell  an  impending  relapse.  The  patient 
should  keep  to  his  bed  for  some  days  after  the  subsidence  of  the  fever 
and  till  he  feels  sufficiently  strong  to  get  up;  if  there  have  been  any 
heart  symptoms  he  should  keep  to  the  recumbent  posture  even  longer. 
Usually  we  may  allow  the  patient  to  sit  up  for  a  short  time  about  a 
week  after  convalescence  has  begun. 

"With  the  beginning  of  convalescence  the  stimulant  should  be  at  once 
reduced,  and  in  young  subjects  may  soon  be  stopped  altogethei'.  The 
diet  for  eight  to  ten  days  should  still  be  chiefly  of  milk ;  soft  boiled  eggs 
may  be  allowed,  and  soups,  milk  puddings,  and  custards :  if  the  diar- 
rhoea continue  during  convalescence,  even  a  longer  period  —  about  a  fort- 
night—  must  elapse  before  the  patient  is  allowed  solid  food;  and  then 
he  should  only  jje  allowed  to  eat  at  first  fish  (whiting,  sole),  then  such 
light  food  as  chicken,  pigeon,  sweet-bread,  tripe,  before  reaching  beef 
and  mutton.  .Stale  bread  or  biscuits,  and  a  small  amount  of  vegetables 
frice,  maslicd  potato),  and  stewed  fruit  may  be  allowed  with  the  solid 
food.  Drugs  are  rarely  necessary  during  convalescence.  If  diarrhoea 
persist,  Ijismuth,  opium  and  lead  may  be  given ;  if  on  the  other  hand 


SYSTEM   OF  MEDICINE 


constipation  occur,  cold  -neater  taken  in  the  morning  fasting,  or  a  cold 
infusion  of  senna-pods,  or  stewed  fruit,  will  often  overcome  it :  if  these 
be  insufficient,  mild  laxatives  (Hunyadi  Janos,  Carlsbad  salts,  etc.) 
should  be  administered.  When  the  patient's  recovery  is  very  slow, 
and  he  suffers  much  from  anaemia  and  weakness,  the  mineral  acids, 
with  quinine  or  nux  vomica,  may  be  given,  followed  by  mild  iron  prepa- 
rations. Change  of  air  materially  helps  to  complete  the  convalescence, 
bat  the  patient  should  not  leave  his  home  for  a  month  after  the  subsid- ' 
ence  of  the  fever  lest  a  relapse  occur. 

P rophylaxis  of  Enteric  Fever. — Knowing  the  cause  of  enteric  fever, 
the  vehicles  which  convey  it,  and  the  factors  which  aid  in  its  develop- 
ment, much  can  be  done,  and  a  good  deal  has  been  done  (1)  to  check 
outbreaks  of  enteric  fever,  and  (2)  to  prevent  the  spread  of  the  disease. 

With  the  first  of  these  two  propositions  sanitary  science  has  occu- 
pied itself  for  many  years  and  with  very  good  results ;  many  of  the 
epidemics  have  been  traced  to  a  contaminated  water  or  milk  supply. 
Defective  drainage  and  impure  water  may  play  an  important  part  in 
the  production  of  enteric  fever,  but,  as  explained  in  the  chapter  on 
Etiology,  they  chiefly  act  by  preparing,  as  it  were,  a  favourable  soil  for 
the  growth  and  development  of  the  specific  bacillus,  and  by  rendering 
the  body  less  resistant  to  its  action.  When  enteric  fever  breaks  out,  it 
is  advisable  to  boil  drinking  Avater  and  milk,  and  to  skin  fruit  before 
eating  it.  As  in  many  places  on  the  Continent  the  sanitary  arrange- 
ments as  to  drainage  and  water-supply  are  still  far  from  satisfactory ; 
and  as  travellers  and  new  residents  are  more  apt  to  be  attacked  with 
enteric  fever  in  places  where  enteric  fever  is  endemic,  than  the  inhabi- 
tants of  the  district,  who  appear  to  acquire  immunity  from  it,  it  is  well 
that  travellers  to  continental  towns  should  abstain  from  drinking  water 
and  unboiled  milk,  and  when  eating  raw  fruit  should  remove  the  skin  of 
the  fruit. 

To  prevent  the  spread  of  the  disease,  when  it  occurs  in  an  endemic 
form,  from  the  patient  to  those  who  come  in  contact  with  him,  is  no  diffi- 
cult matter  if  proper  care  be  taken ;  for  it  is  well  established  that  the  faecal 
discharges  and  perhaps  the  urine  are  the  only  excretions  which  contain 
the  active  agent.  Sputum,  if  there  be  any,  should  also  be  disinfected. 
The  following  measures  should  be  adopted  :  the  dejections  (both  urine  and 
faeces)  are  to  be  received  into  a  bed-pan  containing  a  strong  disinfectant 
(1-20  carbolic  acid),  and  a  sufficiently  large  quantity  of  the  disinfectant 
is  to  be  added  to  the  discharge  and  well  mixed  with  it.  The  nates  must 
be  well  cleaned  with  paper,  or  with  linen  moistened  with  dilute  carbolic 
acid;  this  refuse  is  burnt  or  added  to  the  contents  of  the  bed-pa-n.  The 
bed-linen,  blanket,  and  body  linen  of  the  patient  should  be  changed  at 
once  when  soiled ;  they  should  be  placed  in  a  sheet  soaked  in  carbolic 
acid  (1  in  40),  and  afterwards  kept  for  some  hours  in  carbolic  acid  solu- 
tion of  the  same  strength :  before  they  are  sent  to  the  laundry  they  should 
be  well  boiled.  The  feeding  utensils  are  to  be  cleaned  in  dilute  carbolic 
acid,  and  afterwards  with  boiling  water.    The  nurse  after  attending  to 


ENTERIC  FEVER  859 


the  alvine  discharges  or  changing  the  linen,  and  always  before  she  takes 
her  meals,  should  wash  her  hands  in  corrosive  sublimate  solution  (1  to 
1000).  Every  precaution  should  be  taken  after  the  death  of  a  patient 
as  regards  the  bed-clothing,  sheets,  etc.  Mattresses,  pillows  and  clothes 
should  be  sent  to  a  disinfecting  oven,  v\^hen  this  is  feasible. 

Instead  of  carbolic  acid  as  a  disinfectant  some  use  strong  commercial 
hydrochloric  acid  or  corrosive  sublimate.  Chloride  of  lime  is  an  excellent 
disinfectant  which  quickly  destroys  typhoid  bacilli,  and  it  may  be  used  to 
disinfect  the  fseces. 

If  there  be  any  expectoration  the  sputa  are  to  be  dealt  with  in  like 
manner. 

Julius  Dreschfeld. 


[Appendix, 


86o 


SYSTEM   OF  MEDICINE 


APPENDIX 

Table  I.  —  Annual  Mortality  per  Million  Persons  living  from  Fever. 


Eng-land. 

London. 

Period. 

Typhus. 

Enteric. 

Ill-defined. 

Typhus. 

Enteric. 

Ill-defined. 

V 

V. 

^ 

1S38 

122S 

1839 

1010 

1840 

10S9 

1841 

932 

1842 

1004 

620 

1813 

1075 

1844 

849 

1845 

641 

1846 

873 

1847 

isoi 

1474 

18iS 

1266 

1647 

1849 

1044 

1125 

1850 

865 

875 

1851 

997 

1000 

1852 

1022 

901 

1853 

1008 

1064 

1854 

1015 

1125 

1855 

875 

966 

1856 

847 

1045 

185T 

988 

833 

1858 

918 

716 

1859 

806 

675 

1860 

652 

531 

1861 

767 

656 

1862 

919 

284 

1863 

874 

988 

1864 

960 

1278 

1865 

1089 

1074 

1S66 

986 

884 

1867 

778 

708 

1868 

895 

786 

1869 

193 

390 

239 

225 

337 

194 

1870 

147 

3S8 

233 

147 

303 

177 

1871 

121 

871 

186 

lis 

267 

133 

1872 

80 

377 

145 

52 

242 

97 

1873 

70 

376 

132 

82 

269 

96 

1874 

74 

374 

130 

91 

256 

98 

1875 

62 

371 

108 

37 

235 

78 

1876 

48 

309 

81 

45 

217 

57 

1877 

45 

279 

78 

44 

251 

54 

1878 

86 

306 

71 

41 

283 

54 

1879 

21 

231 

58 

19 

229 

43 

1880 

21 

261 

58 

20 

186 

35 

18S1 

21 

212 

44 

24 

254 

35 

1SS2 

36 

229 

39 

14 

252 

24 

1883 

33 

228 

36 

14 

247 

26 

1884 

12 

236 

28 

8 

284 

20 

18S5 

12 

175 

24 

7 

150 

20 

1886 

9 

184 

22 

3 

154 

18 

1887 

8 

185 

18 

5 

151 

11 

1888 

6 

172 

15 

2 

169 

9 

1889 

5 

176 

15 

4 

130 

10 

1890 

5 

179 

13 

2 

146 

9 

1891 

5 

168 

11 

3 

132 

10 

1892 

3 

137 

8 

8 

102 

5 

ENTERIC  FEVER 


861 


Table  II.  —  Death-rate  from  Enteric  Fever  per  1,000,000. 


Year. 

England. 

London. 

Manchester.! 

1871 

371 

267 

450 

1872 

377 

242 

400 

1873 

376 

269 

460 

1874 

374 

256 

390 

1875 

371 

235 

440 

1876 

309 

217 

420 

1877 

279 

251 

290 

1878 

306 

283 

310 

1879 

231 

229 

180 

1880 

261 

186 

260 

1881 

212 

254 

170 

1882 

229 

252 

260 

1883 

228 

247 

200 

1884 

236 

234 

190 

1885 

175 

150 

170 

1886 

184 

154 

290 

1887 

185 

151 

310 

1888 

172 

169 

3.30 

1889 

176 

130 

310 

1890 

179 

146 

270 

1891 

168 

132 

370 

1892 

137 

102 

240 

1893 

161 

250 

1  The  rates  for  the  years  previous  to  1891  are  for  the  Township  of  Manchester,  and 
the  Unions  of  Chorlton  and  Prestwich,  which  have  been  taken  to  approximately  repre- 
sent "Manchester." 


862 


SYSTEM  OF  MEDICINE 


Table  III.  —  Enteric  Fever  :    Monsall  Fever  Hospital, 
2Qth  August  1884  to  25th  August  1894. 


Males. 

Females. 

Males  and  Females. 

Age. 

Admitted. 

Died. 

Per 

cent. 

Admitted. 

Died. 

Per 

cent. 

Admitted. 

Died. 

Per 
cent. 

Under 
5  years. 

89 

2 

5-18 

31 

5 

16-13 

70 

7 

10-00 

5  years 

and 
under  10. 

151 
moribund      1 

152 

S 

1 

_9 

5-29 
5-92 

1.51 

9 

5-96 

302 
moribund      1 

303 

17 

18 

5-62 
5-94 

10  years 
and 

under  15. 

200 
moribund      4 

21)4 

15 

4 

19 

7 -.50 
9-31 

183 
moribund       1 

184 

17 
1 

18 

9-29 
9-78 

383 
moribund      5 

388 

32 
5 

87 

8-85 
9-53 

15  years 

and 
under  20. 

2T4 
moribund      4 

278 

88 
4 

42 

13-S6 
15-10 

150 
moribund      1 

151 

20 

1 

30 

19 -.33 
19-86 

424 
moribund      5 

429 

07 
72 

15-80 
10-78 

20  ye.",rs 

and 
under  25. 

224 
moribund      5 

22i» 

41 
5 

46 

18-30 
20-08 

128 
moribund      1 

129 

19 

1 
20 

14-84 
15-.50 

8.52 
moribund      6 

358 

CO 
(i 

61; 

17-()4 
18-43 

25  years 

and 
under  30. 

144 
moribund      1 

145 

40 

1 

41 

27-77 
28-27 

98 
moribund      5 

103 

18 
5 

23 

18 -.36 
22-33 

242 
moribund      6 

248 

58 
6 

64 

23-96 

25-80 

.30  years 

and 
under  40. 

118 

moribund      6 

124 

34 

6 

40 

28-81 
.32-25 

77 
moribund      2 

79 

IS 

2 

20 

23-87 
25-31 

195 
moribund      8 

203 

52 

8 

60 

26-66 
29-55 

40  years 

and 
under  50. 

39 
moribund      3 

42 

13 
3 

10 

33-83 
.38-09 

40 
moribund      3 

43 

14 
3 

17 

85-00 
.39-53 

79 
moribund      6 

27 
C 

33 

84-17 
38-82 

50  years 

and 
under  60. 

3 

1 

33-33 

11 

8 

27-27 

14 

4 

28-57 

Over  CO. 

1 

2 

1.32 
18 

145 

3 

All  Ages. 

1193 
moribund      24 

12n 

192 
24 

216 

1607 
17-74 

871 
moribund     18 

884 

15-15 
16-40 

2064 
moribund    37 

2101 

324 

87 
361 

15-60 
17-18 

ENTERIC  FEVER  863 


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864  SYSTEM  OF  MEDICINE 


1887. —75a.  Ross  and  Bury.  Peripheral  Neuritis.— 16.  Rumpf.  Deutsch.  med.  Wochen. 
18i)3,  No.  41.  —  77.  Romberg.  —  Arch.  f.  klin.  Med.  1891,  vol.  xlviii.  p.  3(i9.  —  78.  Schmid. 
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xvii.  1892,  p.  272.— 80.  Shore.  Barth.  Hosp.  Rsp.  vol.  xxiii.  — 81.  Silvestrini. 
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Practitioner,  1890,  pp.  347,  401.  — 84.  Stepp.  Miinch.  med.  Wochen.  18.;0,  No.  45.— 
85.  Stern.  Deutsch.  med.  Wochen.  1892. —  85a.  Strfolansky  aud  Stroganoff. 
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Some  of  the  references  not  incliided  in  the  ahove  Bibliography  will  be  found  in 
the  larger  treatises  on  enteric  fever,  which  the  author  has  consulted  in  the  composition 
of  this  article.  Besides  the  treatises  of  Murchison  and  Moore  these  are:  —  Zuelzer's 
article  "  Typhus  "  in  Eulenberg's  Real  Encyclopedic  der  gesammler  Heilkunde,  Lieber- 
meister  (article  "Typhoid  Fever"  in  Ziemssen's  System  of  Medicine),  Chantemesse 
(article  "  Fievre  typhoide,"  in  vol.  i.  of  Traite  de  m^declne,  edited  by  Cliarcot, 
Bouchard,  aud  Brissaud,  1891),  and  Brouardel  and  Thoinot  {La  fievre  typhoide. 
Paris,  1895). 

J.  D. 


CHOLEEA   ASIATIC  A 

Nomenclature.  —  The  Hippocratic  term  cholera  was  originally  employed 
to  indicate  bilious  diarrhoea.  It  has  come,  in  course  of  time,  to  be  ap- 
plied to  any  violent  intestinal  flux;  such  adjectives  as  simplex,  biliosa, 
nostras,  infantilis,  serosa,  spastica,  perniciosa,  epidemica,  etc.,  being  used 
to  distinguish  varieties.  The  qualifying  adjective  commonly  added  to 
the  word  cholera,  in  order  to  denote  the  disease  which  is  the  subject'  of 
this  article,  is  f  ojmded  on  the  circumstance  that  in  some  parts  of  Asia  — 
or,  more  strictly,  of  India  —  it  is  perennially  present ;  and  that,  when  it 
makes  its  appearance  in  other  countries  and  continents,  it  can  always  be 
traced  back  to  its  Asiatic  birthplace  and  home.  It  is  by  this  geographi- 
cal title  that  serous,  spasmodic,  pernicious,  epidemic  cholera  is  known 
in  all  the  languages  of  Europe.  In  India  it  is  usually  denominated 
by  the  vernacular  term  haiza  (Hindostanee) ;  other  Eastern  names  are 
Enenim  Vanclee  (Tamil),  Ookal  Julab  (Deccan),  Vantee  (Telegoo),  Duba 
(Arabic),  Ho-louan  (Chinese),  Visuchika  (Sanscrit). 

Definition.  —  Cholera  Asiatica  may  be  defined  as  "a  specific  and 
communicable  disease,  probably  due  to  a  specific  organism,  prevailing 
endemically  in  some  parts  of  India,  and  from  time  to  time  diffused 
epidemically  throughout  the  world ;  it  is  characterised  by  violent  vomit- 


CHOLERA   A  STATIC  A  865 

ing,  purging,  cramps,  collapse,  and  suppression  of  urine,  followed  by 
febrile  reaction ;  case  mortality  about  50  per  cent." 

History  and  Geography.  —  The  authentic  history  of  Asiatic  cholera 
dates  from  the  year  1817,  when  it  broke  out  violently  in  Lower  Bengal, 
and  became  the  subject  of  close  and  exact  observation.  There  is  every 
reason  to  believe  that  previous  to  that  date  the  disease  prevailed  in 
India,  and  spread  at  intervals  throughout  Asia  as  it  does  now ;  but  it  is 
very  doubtful  whether  it  overstepped  Asiatic  limits.  Certain  passages 
in  Sanscrit,  Chinese,  Arabic,  and  Greek  medical  literature  have  been 
supposed  to  refer  to  it;  but  the  descriptions  of  all  writers  before 
our  own  century  are  vague,  and  vary  as  the  colliquative,  spasmodic, 
febrile,  or  prostrating  features  of  the  malady  chiefly  arrested  attention. 
Cullen,  for  example,  placed  the  disease  among  spasmodic  neuroses,  and 
it  cannot  excite  surprise  that  physicians  less  learned  and  accurate  than 
he  should  have  seized  upon  partial  aspects  of  it  to  name,  class,  and 
describe  it,  thus  creating  difficulties  of  identification.  It  seems  cer- 
tain, however,  that  Portuguese,  Dutch  and  English  physicians  found 
the  disease  prevailing  in  India  and  its  dependencies  in  the  fifteenth, 
sixteenth,  seventeenth,  and  eighteenth  centuries  ;  and  when  the  outbreak 
of  1817  occurred  it  was  recognised  as  a  severe  manifestation  of  a  familiar 
scourge.  Since  1817  Asiatic  cholera  has  been  watched  with  keen 
interest  wherever  it  has  prevailed;  and  the  facts  relating  to  its  prevalence 
in  India  and  elsewhere  have  been  recorded  with  great  minuteness  and 
care.  Voluminous  as  these  records  are,  the  story  of  cholera  is  a  very 
simple  a.nd  singidarly  interesting  one.  It  presents  the  pictures  of  a 
deadly  disease  prevailing  perennially  in  certain  parts  of  India,  which 
have  been  recognised  as  its  home  or  field  of  endemic  lodgment,  where 
it  waxes  and  wanes,  but  never  altogether  disappears ;  and  of  a  dread 
epidemic  taking  its  departure  from  its  endemic  habitat,  after  a  re- 
crudescence of  more  than  usual  severity,  and  diffusing  itself  along  the 
ordinary  routes  of  commerce  and  pilgrimage  throughout  the  inhabited 
world.  The  history  of  cholera  is  thus  a  tale  of  repeated  invasions,  pre- 
senting a  remarkable  similarity.  It  is  not  easy  to  define  with  exactitude 
the  endemic  centre  from  which  these  invasions  have  proceeded :  some 
authorities  assert  that  there  are  several  such  centres  in  India;  the 
principal  one  is  undoubtedly  the  delta  of  the  Ganges  and  the  vast 
creek  and  river-netted  alluvial  plain  which  lies  south  of  its  confluence 
with  the  Brahmaputra.  How  far  the  endemic  area  extends  up  the 
Gangetic  and  Assam  valleys  it  is  difficult  to  say  ;  or  whether  other 
deltaic  regions  in  India,  as  of  the  Godaveri  and  Kaveri  rivers,  are  also 
endemic  areas.  It  is  important  to  note  that,  even  in  its  endemic 
haunts,  cholera  presents  most  of  the  features  which  characterise  its 
epidemic  f acies.  It  rises  and  falls,  and  travels ;  and  if  we  carefully 
study  particular  tracts  of  country,  we  shall  find  that  the  disease  pre- 
sents a  succession  of  outbreaks  and  an  aspect  of  grouping  very  similar 
to  what  is  observed  in  Europe  v/hen  the  disease  visits  a  susceptible 
place  and  people  in  a  favouraV)le  season. 

VOL.    I  3  k 


866  SYSTEM  OF  MEDICINE 


It  is  observable  that  every  departure  of  cholera  beyond  Indian  limits 
has  been  preceded  by  an  outbreak  in  India  of  marked  and  unusual 
violence.  Its  westward  diffusions  have  naturally  attracted  most  atten- 
tion;  but  eastern  diffusions  have  also  occurred  —  to  the  Straits  Settle- 
ments, Siam,  China  and  Japan  —  which  have  not  been  so  carefully 
investigated.  The  western  invasions  have  taken  place  by  three  routes, 
namely,  (1)  through  Afghanistan,  Persia  and  Central  Asia,  to  Eastern 
Eussia,  along  trade  routes  crossing  or  bordering  the  Caspian  Sea,  and 
thence  into  tiie  interior  of  Russia  along  the  Volga ;  (2)  by  the  Persian 
Gulf  to  Turkish  Arabia  and  Persia;  thence  to  Turkey  in  Asia,  and 
along  or  across  the  Black  Sea  to  Constantinople  and  the  Danube ;  and 
(3)  by  the  Indian  Ocean  and  lied  Sea  to  Aden  and  Mecca,  thence  to 
Egypt  and  the  countries  bordering  the  Mediterranean.  The  disease 
prefers  a  land  route  to  a  sea  route,  and  has  sometimes  travelled  west- 
wards by  more  than  one  route. 

Seven  distinct  invasions  of  Europe  have  taken  place  in  the  present 
century.  The  outbreak  of  1817  reached,  but  did  not  enter  Europe.  It 
covered  India  in  1818 ;  found  its  way  to  Mauritius  and  Burmah  in 
1819,  reached  Arabia,  Siam,  Malacca,  and  China  in  1820,  prevailed  in 
Persia  and  Asiatic  Turkey  in  1821,  and  got  as  far  as  Tiflis  and  Astra- 
khan in  1823.     There  its  westward  march  ended. 

The  first  European  invasion  covers  a  period  of  thirteen  years  — 
1826-39.  During  the  first  three  years  India  was  extensively  overrun 
by  it;  in  1829  the  disease  was- carried  by  the  Central  Asian  route  through 
Kabul,  Herat,  Bokhara,  Khiva,  and  Orenburgh,  as  far  as  Nijni-Nov- 
gorod ;  in  1830  it  travelled  through  Persia  and  by  Resht,  Tabriz,  Tiflis, 
and  Astrakhan  to  Southern  Russia,  eventually  reaching  Moscow.  Russia 
and  Poland  were  then  occupied,  and  in  1831  Northern  and  Central 
Europe ;  in  1832  it  invaded  the  United  Kingdom  and  America,  and  in 
1833  France,  Spain,  and  Portugal ;  in  1834  Italy  and  North  Africa 
suffered,  and  the  disease  lingered  in  Europe  till  1839. 

The  second  European  invasion  commenced  in  1840  and  ended  in 
1851  —  eleven  years.  Cholera  Avas  carried  to  China  by  our  troops,  and 
after  raging  severely  in  that  empire,  was  conveyed  by  trade  routes 
into  Burmah,  Yarkand  Turkestan,  and  other  pai'ts  of  the  Central 
Asian  plateau.  It  broke  out  in  Persia  in  1845,  in  Arabia  and  Turkish 
Arabia  in  1846,  it  reached  Eastern  Russia  in  1847,  and  in  1848  it  spread 
through  Europe,  visiting  the  United  Kingdom,  and  reaching  America 
via  New  Orleans  from  Havre.     This  epidemic  subsided  in  1851. 

The  third  European  invasion  covered  nine  years  — 1848-57.  It  is 
thought  by  some  authorities  to  have  been  a  recrudescence  of  the  cholera 
of  1840-51.  During  1848-50  the  disease  ravaged  India  extensively  ;  in 
1851-52  it  spread  through  Turkish  Arabia  and  Persia,  and  reached 
Russia;  in  1853  Asiatic  Turkey  and  Northern  Europe  suffered;  in 
1854-55  the  rest  of  Europe,  Great  Britain,  and  America  were  invaded. 
This  outbreak,  which  died  out  in  1856-57,  was  the  cholora  from  which 
the  army  of  the  Crimea  suffered ;  and  it  was  during  this  epidemic  that 


CHOLERA    ASIA  TIC  A  867 


certain  celebrated  observations  were  made  upon  the  agency  of  water  in 
cholera  diffusion. 

The  fourth  European  invasion  of  1863-67  took  place  through  Arabia 
and  Egypt  as  well  as  by  way  of  Persia,  the  Black  Sea,  and  the  Caspian. 
The  disease  occupied  Europe  in  1865,  and  in  1866  it  prevailed  in 
Britain  and  America. 

The  fifth  European  invasion  commenced  in  India  in  1867  —  the  year 
of  the  celebrated  Hurdwar  outbreak  —  and  lasted  till  1873.  Europe  was 
reached  by  the  Persian  and  Turkish-Arabian  route,  and  during  the  years 
1870-73  the  disease  raged  in  Europe  and  also  in  America,  which  was 
reached  through  New  Orleans  from  Jamaica. 

The  sixth  European  invasion,  dating  from  1879,  took  place  via 
Mecca  (1882)  and  Egypt  (1883).  The  countries  bordering  the  Medi- 
terranean suffered  first  and  most,  and  the  disease  lingered  in  these  till 
1887.  Indeed  an  outbreak  in  Paris  in  1892  is  considered  to  have  been 
a  survival  of  this  epidemic.  It  was  in  Egypt,  in  1883,  that  Koch 
discovered  the  bacillus  which  has  formed  so  prominent  a  feature  of 
cholera  research  in  recent  years. 

The  seventh  European  invasion  of  1891-95  is  remarkable  for  the 
unprecedented  rapidity  with  which  the  disease  travelled  westward  and 
overspread  Europe.  Beginning  in  Bengal  in  1891,  it  raged  in  Upper 
India  in  1892,  and  in  the  same  year  ravaged  Kashmir  and  Kabul, 
travelling  rapidly  through  Persia  and  Central  Asia,  and  spreading  over 
Northern  and  Central  Europe.  There  was  a  violent  outbreak  at 
Hamburg,  which  has  so  frequently  endured  severe  visitations.  Cases 
occurred  in  English  seaport  towns,  but  the  epidemic  did  not  penetrate 
inland.  In  1893  sharp  outbreaks  occurred  at  Hull,  Grimsby  and  Yar- 
mouth, and  in  many  adjoining  inland  localities ;  but  this  country  as  a 
whole  escaped. 

From  this  cursory  sketch  it  is  evident  that  human  intercourse  and 
agency  are  the  cardinal  factors  in  cholera  propagation :  and  the  main 
question  which  has  agitated  the  public  mind,  and  engaged  the  attention 
of  conferences  and  commissioners  during  these  years,  is  whether  the 
progress *of  cholera  can  be  stayed  by  stopping  communication  between 
infected  and  non-infected  places  by  means  of  a  system  of  quarantine. 
This  question  resolves  itself  into  two  subsidiary  ..questions,  namely, 
whether  quarantine  be  feasible  and  effective  ;  and,  if  so,  whether  the 
disturbance  of  social  life  and  interruption  of  commerce  which  it  implies 
be  justifiable.  Unfortunately  these  questions  have  been  chiefly  debated 
on  theoretical  grounds,  and  have  mainly  turned  on  whether  the  disease 
be  personally  communicable  or  the  reverse.  Sufficient  experience  has 
now  been  gained  to  render  a  solution  of  the  question  possible  on  the  surer 
basis  of  natural  experiment.  As  regards  inland  quarantine,  the  experi- 
ence gained  by  numerous  trials  in  India  and  Europe  has  resulted  in  almost 
uniform  failure;  and  when  the  difficulties  of  imposing  a  rigid  quaran- 
tine and  the  chances  of  evasion  are  considered,  together  with  the  possibil- 
ity that  dissemination  may  be  effected  by  other  agencies  than  human  — 


868  SYSTEM  OF  MEDICINE 

by  animals,  birds,  and  insects,  or  by  wind  and  water  —  it  is  not  strange  that 
the  disease  has  so  often  overstepped  the  most  rigid  cordons.  Maritime 
quarantine  presents  easier  postulates,  and  has  been  attended  with  more 
success  ;  but  ships,  unless  crowded  with  emigrants,  pilgrims,  or  soldiers 
under  unsanitary  conditions,  are  not  such  good  porters  of  cholera  as 
caravans,  armies,  hordes  of  pilgrims,  and  unsavoury  travellers  by  road 
and  rail.  The  policy  of  detaining  masses  of  men  in  unwholesome 
lazarettos,  subject  to  infection  by  new  arrivals,  has  certainly  proved 
disastrous;  and  a  system  of  accurate  and  early  information,  careful 
inspection,  isolation  of  the  sick  and  suspected,  and  sanitation  general 
and  special,  has  been  productive  of  greater  benefit  than  any  wholesale 
attempt  to  hinder  the  movements  of  men  and  merchandise. 

There  are  certain  parts  of  the  earth's  surface,  more  or  less  insulated, 
which  have  not  been  visited  by  cholera.  The  most  remarkable  are  the 
Andaman  Islands  in  the  Bay  of  Bengal,  Keunion,  Australia,  New 
Zealand,  and  other  islands  of  the  Pacific,  the  Cape  of  Good  Hope  and 
West  Coast  of  Africa,  St.  Helena,  Ascension,  the  Azores,  Bermudas, 
West  Coast  of  South  America,  Orkney  and  Shetland  Islands,  Iceland  and 
the  Faroe  Islands.  This  list  is,  moreover,  by  no  means  exhaustive. 
There  are  certain  localities  in  all  countries  which  have  seldom  or  never 
been  visited,  while  epidemics  have  prevailed  around ;  and  in  any  out- 
break even  in  India,  the  places  and  persons  attacked  are  always  a 
minority  of  the  whole.  Even  in  Calcutta,  the  head  centre  and  perpetual 
home  of  cholera,  there  is  a  quarter  of  the  city  which  possesses  as  com- 
plete an  immunity  from  the  disease  as  Iceland.  No  better  illustration 
than  this  could  be  given  of  the  power  of  sanitation  to  extirpate  cholera. 

Cholera  literature  is  immensely  voluminous,  and  from  time  to  time 
many  theories  have  been  advanced  to  explain  the  nature,  origin  and  dif- 
fusion of  the  disease.  These  speculations,  putting  aside  the  purely 
mythical,  have  concerned  themselves  with  every  possible  influence  — 
cosmic,  sidereal,  telluric,  climatic,  septic,  ochlotic,  etc.  —  to  account  for 
cholera  visitations.  A  study  of  statistical  aggregates  and  too  exclusive 
an  attention  to  "broad"  views  have  begotten  vague  and  fatalistic  gen- 
eralisations, as  of  mysterious  forces  and  pandemic  waves,  which  have  of 
late  years  become  discredited.  General  causes  do  not  produce  except- 
ional, limited,  erraj^c,  and  contingent  results ;  and  a  closer  study  of 
cholera  on  a  more  rational  basis  has  made  it  clear  that  so  specific  a  mal- 
ady must  have  a  specific  cause.  The  microbic  agents  investigated  by 
Koch  and  others  have  now  for  eleven  years  been  subject  to  criticism, 
experiment,  and  research,  and  year  by  year  his  theory  has  gained  sup- 
port from  clinical,  pathological,  bacteriological,  and  epidemiological  stud- 
ies. The  theory  which  ofEers  a  key  to  the  bewildering  mass  of  cholera 
literature  which  the  present  century  has  produced,  is  that  which  finds 
the  causation  of  cholera  in  a  disregard  of  the  laws  of  health,  and  in  the 
presence  of  an  organic  (microbic)  poison,  capable  of  conveyance  under 
favouring  circumstances  by  man  himself. 

K.  M. 


CHOLERA   ASTATIC  A  869 


Etiology  and  Epidemiology.  —  Seeing,  then,  that  cholera  is  due  to  a 

living  contagium  —  Koch's  cholera  bacillus  —  which,  growing  in  the 
intestines  of  the  patient,  causes  death  partly  by  the  effect  of  the  toxins 
produced  by  it  and  partly  by  the  profuse  purging  which  it  sets  up,  the 
further  etiology  of  the  disease  resolves  itself  into  two  factors :  first,  the 
means  by  which  the  microbe  gains  access  to  the  body ;  second,  the  con- 
ditions which  render  the  body  susceptible  to  the  microbe.  Of  the  first 
of  these  we  know  much,  of  the  second  little. 

Mode,  of  Access.  —  It  is  certain  that  cholera  is  not  contagious  in  the 
ordinary  sense  of  the  word.  Cholera  cannot  be  caught  by  contact,  and 
although  nurses  and  those  who  attend  to  the  sick  are  often  affected  in 
larger  proportion  than  others,  this  is  readily  explained  by  the  fact,  that 
unless  constant  care  is  exercised  in  regard  to  cleanliness  of  hands  and 
utensils  they  are  much  more  exposed  than  are  others  to  the  known  and 
recognised  mode  of  infection,  which  is  by  the  mouth.  All  evidence  goes 
to  show  that  the  infection  of  cholera  to  take  effect  must  be  swallowed. 

Now,  as  in  all  zymotic  diseases,  the  materies  morbi  —  the  contagium 
vivum  —  greatly  increases  within  the  body  of  the  patient  during  the 
progress  of  his  malady.  During  the  disease  a  minute  amount  of  infec- 
tious material  grows  into  an  amount  capable  of  giving  the  infection  to 
thousands ;  and,  in  the  case  of  cholera,  this  infectious  material  finds  its- 
exit  from  the  patient's  body  in  the  discharges  caused  by  the  disease. 

The  study  of  the  etiology  of  cholera,  then,  is  to  a  large  extent  a 
study  of  the  steps  by  which  matter  which  has  left  one  patient  so  gains 
access  to  some  article  of  food  as  to  be  swallowed  by  some  one  else. 

It  is  conceivable  that  in  the  presence  of  a  great  abundance  of  the  in- 
fection it  might  be  inhaled  in  the  form  of  dust.  Of  this,  however,  there 
is  no  evidence,  nor  is  it  probable  unless  it  be  in  the  case  of  those  who 
have  slept  in  cholera-soiled  bedding ;  the  cholera  bacillus  is  so  readily 
killed  by  desiccation  that  such  a  mode  of  transference  is  in  the  highest 
degree  unlikely.  It  is  with  food  a,nd  drink  that  it  commonly  gains 
access  to  the  human  body. 

Well-authenticated  instances  are  related  in  which  flies  have  appeared 
to  carry  the  infection  from  cholera  dejecta  to  milk  and  various  articles 
of  diet ;  and  M.  Haffkine  has  detected  cholera  bacilli  in  specimens  of 
sterilised  milk,  exposed  in  new  vessels,  to  which  flies  were  permitted 
free  access  during  an  outbreak  of  cholera  (1). 

The  use  of  cholera-infected  water  for  washing  cooking  utensils  and 
articles  used  in  the  preparation  of  food  is  another  mode  of  local  distri- 
bution ;  especially  in  regard  to  the  spread  of  the  disease  by  milk. 

In  the  case  of  nurses  and  those  who  attend  to  the  sick,  or  have  charge 
of  the  dead,  the  cholera  poison  may,  as  a  result  of  want  of  strict  cleanli- 
ness, be  transferred  to  the  mouth  by  the  fingers,  either  directly  or  by 
means  of  the  food  they  touch. 

l>rit  the  great,  the  persistent,  and  the  almost  universal  mode  by  which 
the  cholera  germ  gains  access  to  the  body  is  in  the  drinking  water. 
This  is  now  so  well  recognised  that  it  is  unnecessary  to  go  again  over 


870  SYSTEM   OF  MEDICINE 

the  evidence  by  whicli  the  fact  has  been  proved  to  demonstration.  It 
may,  however,  be  well  to  refer  to  a  few  of  the  classical  examples  of  this 
mode  of  cholera  distribution.^ 

A  full  account  of  the  case  of  the  Broad  Street  pump,  which  was  in- 
vestigated by  Dr.  Snow,  is  to  be  found  in  the  Report  of  the  Committee 
for  Scietitijic  Inquiries  into  the  Cholera  of  1854.  The  relation  between 
the  incidence  of  cholera  and  the  sonrce  of  the  Avater-supply  to  different 
parts  of  London  is  described  in  the  Report  of  the  Royal  Commission  on 
Water-Supply,  1869.  The  outbreak  of  cholera  in  the  East  End  of  Lon- 
don in  1866,  which  was  traced  to  the  supply  of  specifically  contaminated 
water,  is  described  by  Mr.  Netten  Radcliffe  in  the  Report  of  the  Medical 
Officer  to  the  Local  Government  Board,  1866  ;  and  the  great  outbreak  of 
cholera  in  Hamburg  is  described  Avith  full  statistical  detail  in  the  Report 
of  the  Medical  Officer  to  the  Local  Government  Board,  1892-93. 

There  is  a  good  deal  of  evidence  to  show  that  water  does  not  act 
as  a  mere  diluent  and  distributor  of  the  cholera  poison,  but  that  under 
certain  conditions  the  cholera  bacilli  grow  and  for  a  short  time  increase 
in  virulence  during  their  sojourn  in  this  medium.  In  the  presence,  how- 
ever, of  sunlight  and  ordinary  water-bacteria  they  are  either  rapidly 
destroyed  or  soon  cease  to  multiply.  The  persistence  of  cholera  in  a 
district  is  indicative  of  more  than  a  single  pollution  of  the  water-supply, 
and  generally  points  to  a  persistence  of  some  insanitary  conditions  which 
favour  repeated  infection. 

It  is  not  always  the  case,  hoAvever,  that  the  infection  is  conveyed 
directly  from  man  to  man  by  means  of  water.  Where  Ave  find  sudden  out- 
bursts of  disease  affecting  large  numbers  of  people  draAving  their  Avater- 
supply  from  a  common  source,  some  direct  and  Avholesale  fouling  of  the 
supply  is  generally  the  cause  of  the  mischief.  But  much  more  commonly, 
especially  near  its  endemic  home  in  India,  cholera  does  not  occur  in  great 
outbursts ;  small  local  epidemics  arise,  die  doAvn,  and  then  recur.  The 
cholera  bacillus,  in  fact,  grows  in  the  foul  soil,  is  now  and  again 
washed  into  the  Avells,  and  so  sets  up  disease  in  those  that  draAv  their 
water  from  them.  The  key,  then,  to  this  side  of  the  etiology  of  cholera 
is  to  be  found  in  the  habits  of  the  people,  and  the  degree  of  care  or 
want  of  care  they  exercise  in  the  protection  of  their  water-supplies. 

The  natural  home  of  cholera  is  a  land  of  foul  water.  In  Lower 
Bengal,  AA'^here  cases  are  reported  every  month  in  every  year,  an  inquiry 
into  the  habits  of  the  people,  and  the  condition  of  the  tanks  from  Avhich 
they  largely  draw  their  water-supply,  is  sufficient  to  shoAV  how  constant 
are  the  opportunities  both  for  food  and  Avater,  especially  the  latter,  to 
be  exposed  to  faecal  contamination. 

In  many  of  the  toAvns  of  Southern  Europe,  also,  Avhich  have  most 
markedly  suffered  from  the  ravages  of  cholera  (among  these  Naples  and 
Marseilles  may  be  specially  mentioned),  it  has  been  demonstrated  that 

1  In  how  wide  a  sense  the  term  "  drinking  water  "  may  properly  be  applied  is  indi- 
cated by  the  alleged  dissemination  of  the  cholera  poison  by  means  of  oysters  which  had 
been  exposed  to  the  af&uence  of  sewage. 


CHOLERA    ASIA  TIC  A  871 


while  the  water-supplies  had  been  contaminated,  the  habits  of  the  people 
had  intensified  the  evils  resulting  from  this  cause.  On  the  other  hand, 
our  own  practical  immunity  during  the  epidemics  which  have  broken  out 
in  Europe  since  greater  attention  has  been  given  in  England  to  the  secur- 
ing of  pure  water,  compared  with  our  great  mortality  from  cholera  in 
earlier  epidemics,  together  with  the  great  lessening  of  the  cholera  mor- 
tality in  those  towns  in  India  which  have  obtained  pure  water  while 
epidemics  have  continued  as  of  old  in  surrounding  districts,  both  tend 
to  show  that  when  the  habit  of  drinking  water  which  has  been  exposed 
to  chances  of  feecal  defilement  is  once  broken  cholera  fails  to  take  root. 

Individual  Susceptibility. —  We  do  not,  however,  completely  explain 
the  etiology  of  cholera  by  the  statement  that  it  depends  on  the  ingestion 
of  cholera-infected  water ;  another  condition  is  also  necessary,  namely, 
the  susceptibility  of  the  individual. 

Considerable  differences  exist  in  the  habits  of  the  various  members 
of  every  community ;  thus  it  often  happens  that  even  where  the  habits 
of  the  majority  are  foul,  a  fcAv  are  protected  froui  receiving  the  infec- 
tion by  the  greater  cleanliness  and  propriety  of  their  lives.  Yet 
many  fail  to  sicken,  although  they  are  known  to  have  swallowed  the 
very  infective  matter  which  at  the  same  time  is  producing  cholera  in 
others.  We  have  proof  of  this  in  every  wide-spread  water  epidemic ; 
the  number  of  those  who  swallow  the  poison  must  in  these  cases  vastly 
exceed  the  number  of  those  who  are  attacked  by  the  disease.  Mac- 
namara  gives  an  instance  in  which  a  vessel  of  drinking  water  was  acci- 
dentally polluted  with  fresh  cholera  excreta,  and  after  being  exposed  to 
the  sun  all  day  the  water  was  partaken  of  by  nineteen  persons  ;  of  these 
five  only  subsequently  suffered  from  cholera. 

It  seems  clear  that  the  inhabitants  of  the  areas  in  which  cholera  is 
frequently  present,  notwithstanding  habits  which  expose  them  continu- 
ally to  chances  of  infection,  are  much  less  frequently  attacked  than  hew 
arrivals  in  the  districts,  much  less,  for  instance,  than  Europeans,  although 
when  attacked  they  succumb  more  readily.  How  far  this  immunity  is 
racial,  or  how  far  it  is  the  result  of  a  frequently  repeated  small  infec- 
tion, creating  and  maintaining  an  artificial  immunity  (as  is  presumed  by 
some  to  occur  in  the  case  of  yellow  fever),  is  a  question  which  cannot  at 
present  be  decided.  There  is,  however,  much  in  the  progress  and  rapid 
recession  of  cholera  epidemics  to  favour  the  opinion,  that  exposure  to  the 
influence,  if  it  does  not  produce  the  disease,  does  induce  some  temporary 
immunity. 

On  the  other  hand  there  is  a  good  deal  of  clinical  evidence  —  of  a 
nature,  however,  that  can  hardly  be  brought  to  the  test  of  statistics 
—  to  show  that  any  disturbance  of  the  balance  of  the  digestive  organs, 
especially  the  dyspepsia  common  among  drinkers,  and  the  looseness  of 
the  bowels  often  brought  on  by  eating  over-ripe  or  decomposing  fruit, 
distinctly  tends  to  leave  the  patient  open  to  the  cholera  infection  — that 
in  fact  an  active  gastric  digestion  and  ahcalthy  intestinal  mucous  surface 
form  a  considerable  bar  to  attacks  of  cholera. 


872  SYSTEM  OF  MEDICINE 

The  predisposing  influence  of  poverty  and  bad  food  partly  consists, 
no  doubt,  in  such  disturbances  of  the  digestive  organs ;  while  the  thirst 
and  consequent  ingestion  of  large  quantities  of  water  common  among 
the  labouring  people  may  cause  indigestion,  and  do  expose  them  to  in- 
creased risks  of  cholera  when  the  water  is  infected. 

So  far  we  have  considered  the  etiology  of  cholera  as  it  affects  the 
individual.  We  have  shown  that  although  the  condition  of  the  patient 
has  an  influence  on  the  effect  of  the  attack,  the  immediate  factor  in  the 
production  of  cholera  is  the  swallowing  of  an  infection  which  has  come, 
directly  or  indirectly,  from  the  dejecta  passed  by  another  patient  suffer- 
ing from  the  saoie  disease  ;  thus  we  have  demonstrated  that  cholera 
may  properly  be  called  a  filth  disease  :  not  that  filth,  miless  infected 
with  cholera,  can  cause  the  disease,  but  that,  without  the  filthy  habits 
which  bring  about  the  consumption  of  food  or  drink  befouled  by  man's 
dejecta,  cholera  cannot  be  transmitted. 

Epidemic  Prevalence.  —  This  view,  however,  of  the  etiology  of  cholera 
by  no  means  explains  the  occurrence  of  epidemics,  nor  the  tendency  of 
these  epidemics  at  varying  periods  to  spread  beyond  the  normal  confines 
of  the  disease,  to  extend  into  areas  which  for  long  series  of  years 
had  been  entirely  free  from  it,  to  advance  stage  by  stage,  and  thus  to 
march  around  the  globe  ;  theii  to  retire,  and  for  an  uncertain  period 
either  to  lie  latent  or  to  be  confined  within  the  endemic  area. 

To  understand  this  peculiarity  of  cholera,  it  is  necessary  to  bear  in 
mind  the  various  factors  which  aid  in  the  dissemination  of  the  disease, 
and  to  recognise  that  it  is  the  coincidence  of  many  factors  which  sets 
cholera  on  the  march. 

Within  certain  areas  in  India  cholera  is  endemic,  especially  in  the 
country  of  the  Lower  Ganges.  There  '•  the  air,  the  water,  and  the  soil 
are  never  cold,  the  ground  is  often  damp,  and  when  it  is  dry  the  tanks 
are  foul,  so  that  there  is  always  a  fit  breeding-place  for  the  contagion, 
and  the  habits  of  the  people  in  every  way  facilitate  its  entry  into  their 
systems  "(2). 

The  habits  of  the  people  and  the  condition  of  the  water-supply  in 
many  Indian  villages  are  such  that,  if  one  did  not  bear  in  mind  that 
a  necessary  factor  in  the  etiology  of  cholera  is  the  susceptibility  of  the 
individual,  one  might  expect  the  Avhole  mass  of  the  inhabitants  to  perish 
rapidly  of  that  disease.  If,  however,  we  examine  more  carefully  the 
incidence  of  cholera  within  the  endemic  area,  it  becomes  obvious  that, 
although  in  every  district  deaths  from  it  may  be  reported  every  year  and 
every  month  in  every  year,  still  the  incidence  of  this  mortality  is  by  no 
means  evenly  distributed ;  even  within  the  endemic  area  cholera  wanders 
about,  one  village  after  another  being  attacked  and  then  left  at  peace  for 
a  time.  It  seems  as  if  there  were  the  same  tendency  for  these  outbursts 
to  die  down  within  the  area  as  there  is  outside  it ;  but  that  in  consequence 
of  the  great  facilities  for  reimportation,  and  of  the  condition  of  the  soil, 
which  makes  it  possible  for  the  germ  to  maintain  its  vitality  and  carry 
on  the  saprophytic  phase  of  its  existence  for  a  considerable  time,  the 


CHOLERA   ASIATIC  A  873 


disease  frequently  crops  up  again  —  Avhenever,  in  fact,  there  is  a  suffi- 
ciency of  susceptible  people  for  it  to  prey  upon,  and  whenever  accident 
introduces  it  afresh  into  the  drinking  water. 

It  is  important  to  bear  in  mind  the  somewhat  curious  fact,  that  the 
highest  mortality  from  cholera  does  not  occur  in  the  parts  in  which  the 
disease  is  permanently  endemic ;  this  points  strongly  to  the  probability 
that  dwellers  within  the  endemic  area  attain  some  degree  of  immunity 
from  the  infection. 

Tlie  Spread  of  Epidemic  Cholera.  —  One  of  the  most  striking  peculiari- 
ties of  epidemic  cholera,  when  it  oversteps  the  bounds  of  its  endemic 
area,  is  its  tendency  to  advance  along  fairly  definite  tracks ;  to  go  from 
town  to  town,  from  country  to  country ;  to  attack  each  fresh  district 
with  enormous  virulence  at  first ;  then,  in  a  short  time,  to  become 
much  modified  in  intensity,  subsiding  altogether  in  about  three  months 
to  return  again  the  next  year,  and  perhaps  the  year  after ;  then  again 
to  die  out  entirely  till  it  is  introduced  afresh,  passing  on  meanwhile  to 
some  other  place  where  the  same  course  is  repeated.  The  study  of  the 
epidemiology  of  cholera  thus  involves  that  of  the  modes  by  which  the 
disease  is  carried  from  place  to  place,  the  influences  which  favour  its  dis- 
semination, those  which  favour  or  retard  its  taking  root  in  fresh  locali- 
ties, together  with  those  curious  periodic  variations  of  intensity  which,  for 
the  sake  of  a  phrase,  are  sometimes  attributed  to  "epidemic  influence." 

There  can  no  longer  be  any  doubt  that  cholera  is  disseminated  by 
human  intercourse.  The  march  of  cholera  coincides  with  the  march  of 
man,  and  it  is  carried  from  place  to  place  either  by  infected  man  or  by 
cholera-tainted  clothing.  There  seems  no  practical  limit  to  the  distance 
to  which  it  would  be  possible  to  transmit  the  infection  in  a  bundle  of 
imperfectly  dried  rags  soiled  by  cholera  excreta ;  man,  however,  can  but 
carry  the  disease  so  far  as  he  is  able  to  travel  between  receiving  the 
infection  and  being  laid  low. 

What  Ave  find,  then,  on  comparing  the  march  of  the  earlier  epidemics 
of  cholera  with  those  that  have  occurred  in  more  recent  years,  is  that 
whereas  when  travel  was  slow  the  disease  swept  steadily  forwards, 
occupying  the  land  as  it  advanced ;  in  later  times  it  has  bounded  forward 
with  long  strides,  occupying  outposts  far  ahead  of  infected  areas  by 
means  of  railway  and  steamboat  communication,  and  then,  from  these 
outlying  foci  of  infection,  has  spread  in  both  directions,  coalescing  per- 
haps at  a  much  later  date  with  the  main  body  of  the  epidemic  which 
has  slowly  advanced  across  country  from  the  earlier  centres. 

Certain  as  it  is,  however,  that  man  is  the  porter  by  whom  cholera  is 
introduced  to  any  place,  it  must  not  be  forgotten  that  its  development 
in  that  place  depends  on  insanitary  circumstances,  the  chief  condition 
necessary  being  the  liability  of  the  drinking  water  to  be  contaminated 
by  infected  excreta.  Hence  it  has  happened  again  and  again  that 
cholera  has  proved  the  touchstone  to  the  sanitary  deficiencies  of  towns 
and  districts,  leaving  unharmed  those  witli  pure  water,  and  ravaging 
those  whose  water-supply  was  ojjen  to  defilement. 


874  SYSTEM   OF  MEDICINE 

It  will  thus  be  readily  nnderstood  why  cholera  is  so  apt  to  be  spread 
iu  epidemic  form  by  wars  and  pilgrimages.  Cholera  may  and  often 
does  travel  along  the  tracks  of  ordinary  trade  ;  but  it  never  advances  far 
unless  along  its  path  there  be  places  where  the  sanitary  conditions  enable 
the  disease  to  take  root  and  start  upon  its  course  afresh.  When,  how- 
ever, as  in  the  case  of  wars  or  pilgrimages,  great  bodies  of  men  are 
camped  out  without  any  proper  means  of  dealing  with  their  excreta,  or 
any  assurance  that  their  water-supply  remains  untainted ;  and  especially 
when,  as  is  the  case  in  the  great  religious  pilgrimages  which  are  recruited 
from  within  the  endemic  home  of  cholera,  the  men  who  form  these 
camps  carry  with  them  those  habits  and  customs  which,  within  that 
area  tend  to  make  cholera  permanently  endemic,  then  we  find  every  con- 
dition fulfilled  for  the  epidemic  propagation  of  the  disease. 

Accepting  the  view  that  when  cholera  is  introduced  into  new  dis- 
tricts it  is  carried  thither  by  cholera-infected  rags,  cholera-infected  food, 
or  cholera-infected  man,  it  becomes  a  matter  of  great  importance  to 
determine  whether  the  last  (namely,  cholera-infected  man)  can  carry 
with  him  the  germs,  deposit  them  in  fresh  places,  infect  water-supplies, 
and  set  up  epidemics,  without  himself  suffering  from  cholera  and  be- 
traying its  symptoms.  Till  a  few  years  ago  this  question  would  have 
been  unhesitatingly  answered  in  the  negative;  and  in  fact  it  is  in  the 
belief  that  a  man  cannot  carry  cholera  unless  he  himself  suffers  from  if; 
that  the  modern  substitute  for  quarantine  is  founded,  namely,  the  sys- 
tem of  medical  inspection  and  detention  of  invalids.  Modern  travel  is 
condiicted  on  so  vast  a  scale,  and  the  numbers  moving  from  place  to 
place  are  so  enormous,  that  efficient  quarantine  is  obviously  impossible. 
It  has  been  hoped,  however,  that  if  those  actually  ailing  be  sorted  out 
the  rest  may  safely  be  allowed  to  pass.  Hence  the  modern  system. 
The  more  recent  investigations  of  Koch  and  others  tend,  however,  to 
throw  some  doubt  upon  the  efficiency  of  such  measures ;  and  although 
they  have  appeared  successful  in  preventing  the  disease  from  taking  root 
in  England,  it  is  quite  possible  that  the  greater  attention  which  of  late 
years  has  been  given  to  the  purity  of  the  water-supply  of  our  towns  may 
have  had  a  much  larger  share  than  our  port  sanitary  inspection  in  giv- 
ing us  the  exemption  we  have  enjoyed.  Koch  has  shown  (3),  audit  has 
been  shown  repeatedly  at  the  observation  stations  which  were  established 
in  Germany  at  the  time  of  the  epidemics  in  Hamburg  in  1892  and  1893, 
that  among  those  who  had  been  exposed  to  the  possibility  of  cholera 
infection,  and  who  yet  remained  apparently  healthy,  there  were  indi- 
viduals "whose  faeces  although  hardly  diarrhoeic  —  nay,  quite  normal  — 
yet,  nevertheless,  contained  cholera-bacteria.  "  It  is  now  certain  that 
among  a  number  of  persons  who  have  been  exposed  to  cholera  infection 
the  resultant  cases  may  show  the  whole  scale  from  the  severest  and 
rapidly  fatal  cases  down  to  the  mildest  imaginable,  demonstrable  only 
by  bacteriological  investigation." 

The  determination  of  this  point  goes  far  to  explain  outbreaks  of 
cholera  in  which  the  first  apparent  sufferers  could  be  shown  not  to  have 


CHOLERA    ASIATIC  A  875 


entered  any  infected  district.  The  very  first  case  has,  in  fact,  not  been 
recognised,  maybe  the  patient  has  not  known  that  lie  was  ill;  his  dejecta 
have  nevertheless  obtained  access  to  the  water-supply,  and  thus  given  rise 
to  the  outbreak.  It  seems  only  in  this  way  possible  to  explain  some  of  the 
isolated  sporadic  cases  which  have  occurred  in  England,  cases  in  which, 
notwithstanding  the  entire  want  of  evidence  of  any  connection  -with, 
any  known  focus  of  the  disease,  the  typical  micro-organisms  have  been 
discovered. 

Conditions  determining  Character  of  Outbreak.  —  When  the  cholera 
germs  have  once  been  introduced  into  a  district  their  fate  will  depend 
on  various  conditions.  If  they  chance  to  gain  access  to  a  public  water- 
supply  they  will,  as  has  been  shown  again  and  again,  set  up  a  sudden 
and  wide-spread  epidemic  among  the  consumers  of  the  water  —  an 
epidemic  which  breaks  out  simultaneously  in  different  parts  of  the  dis- 
trict, rages  violently  for  a  time,  and  if  the  infected  water  be  cut  off, 
stops  almost  as  suddenly  as  it  had  begun. 

If,  however,  the  germs  do  not  gain  access  to  a  general  Avater-supply, 
but  are  deposited  in  the  neighbourhood  of  the  dwellings  of  the  people, 
they  will  only  set  up  small  and  localised  outbreaks  ;  in  one  part  after 
another  of  a  town,  in  one  town  after  another,  cholera  will  arise  and 
soon  die  out,  only  to  crop  up  again  in  neighbouring  places,  or  even  in 
the  same  place  again ;  and  thus  an  epidemic,  never  perhaps  severe,  may 
continue  so  long  as  to  cause  serious  loss  of  life.  The  continuance  of  an 
outbreak  of  this  latter  sort  depends  upon  local  conditions;  and  it  is 
obvious  that,  although  a  general  water-epidemic  has  a  sudden  rise  and  a 
sudden  fall,  one  occurring  in  a  district  which  favours  the  development  of 
foci  of  cholera,  although  it  may  rise  as  suddenly,  will  not  terminate  so 
quickly :  it  will  rather  set  up  a  multitude  of  centres  from  which  it  will 
continue  to  spread  as  in  the  second  mode,  the  mode  in  which  it  mostly 
shows  itself  in  countries  in  which  it  is  endemic  during  non-epidemic 
times  —  countries  in  most  parts  of  which  no  such  thing  as  a  public 
water-supply,  in  the  modern  sense  of  the  term,  exists.  It  becomes  then 
very  important  to  inquire  into  the  causes  other  than  the  infection  of 
public  water-supplies  which  favour  the  development  of  epidemic  cholera; 
for  it  is  certain  that  "  in  many  districts  of  greater  or  less  extent,  the 
cholera  has  never  reached  any  considerable  or  strictly  epidemic  devel- 
opment notwithstanding  repeated  importations  of  the  poison  "  (4). 

Conditions  favouring  the  Development  of  Cholera  Epidemics.  — Hirsch 
says,  "  As  there  are  certain  local  peculiarities  which  furnish  the  con- 
ditions for  the  endemic  disease,  so  also  there  are  certain  factors  re- 
siding in  the  circumstances  of  place  or  season,  which  are  necessary  to 
give  potency  to  the  cholera  poison  beyond  its  native  habitat;"  and  he 
quotes  Hergt  as  saying,  "The  rise  of  the  cholera  epidemic  at  any  one- 
place  implies,  besides  importation  of  the  contagium,  certain  local  con- 
ditions of  atmosphere  and  of  soil  as  well.  These  conditions  must  be 
a])le  at  a  given  place  to  generate  themselves  and  to  disappear  again." 
The   latter  is  an  important   qualification,  for  it  appears  certain  that 


876  SYSTEM  OF  MEDICINE 

among  the  causes  necessary  for  the  development  of  cholera  in  an  epi- 
demic form,  except  when  widely  distributed  by  water,  are  some  which 
are  purely  temporary,  as  for  example  those  which  are  connected  with 
season ;  and  that  a  locality,  which  at  one  time  may  be  capable  of  devel- 
oping cholera  in  a  most  virulent  form,  may  at  other  times  be,  compara- 
tively speaking,  protected  from  its  attacks.  Putting  then  on  one  side 
infection  of  public  water-supply,  which  is  capable  of  creating  an  epi- 
demic in  any  place  and  in  any  season,  we  have  to  consider  the  factors 
in  the  production  of  an  epidemic  not  arising  from  that  cause. 

According  to  Dr.  Davidson  (6)  they  may  be  classed  as — ^^Local  con- 
ditions :  Seasonal  influences :  Predisposing  conditions :  Facilities  of  in- 
tercourse :  Race  proclivities  :  Epidemic  influences. 

Of  these  the  ^'  predisposing  conditions  "  and  the  "  racial  proclivities  " 
have  already  been  dealt  with ;  and  after  what  has  been  said  regarding 
the  mode  of  dissemination  of  cholera,  the  importance  of  facilities  for 
intercourse  is  obvious.  "Epidemic  influence,"  again,  and  the  curious 
tendency  of  cholera,  like  other  infectious  diseases,  to  rise  into  epidemic 
'  importance  at  moderately  regular  intervals  of  time,  must  be  regarded 
as  due  to  the  coincidence  of  several  causes,  each  emphasising  the  impor- 
tance of  the  other.  It  remains  then  to  consider  the  conditions  of  place 
and  of  season  which  influence  the  occurrence  of  epidemic  cholera. 

(a)  Altitude.  —  Elevated  districts  often  remain  exempt  from  cholera ; 
on  the  other  hand  valleys  and  low-lying  areas  are  much  more  apt  to 
suffer :  in  towns  situated  on  a  slope,  or  occupying  different  elevations, 
it  is  Usually  found  that  within  the  same  town  the  higher  districts  are 
least  affected.  On  the  other  hand,  cholera  has  occurred  at  very  consid- 
erable altitudes,  and  even  sufficiently  often  in  the  higher  parts  of  towns 
to  make  it  clear  that  the  cause  of  the  apparent  variation  of  cholera  with 
altitude  must  be  sought  elsewhere,  probably  in  its  relation  to  tempera- 
ture, water-supply,  and  movement  of  ground  water. 

(h)  Relation  to  Rivers.  —  It  has  constantly  been  observed  that  not 
only  does  cholera  follow  rivers,  which  it  should  be  noted  are  also  com- 
monly lines  of  traffic  and  centres  for  the  aggregation  of  large  popula- 
tions,—  two  main  factors  in  the  dissemination  of  the  disease, —  but 
that  it  attacks  places  on  the  banks  of  rivers  and  even  of  small  streams 
with  special  severity.  This  again  probably  has  relation  to  conditions 
of  soil  and  density  of  population,  as  well  as  to  the  double  function  of 
rivers  as  drains  and  sources  of  water-supply. 

(c)  Character  of  Soil.  —  Cholera  attains  its  greatest  intensity  on  soils 
which  are  permeable  to  water,  but  not  sodden  with  it,  and  are  at  the 
same  time  capable  of  retaining  a  certain  degree  of  moisture  within  their 
interstices. 

The  relation  then  of  altitude,  neighbourhood  of  rivers,  and  character 
of  soil  may  all  resolve  themselves  into  this  —  that  cholera  is  most  likely 
to  take  on  its  epidemic  character  on  a  soil  which  is  porous,  more  or  less 
charged  Avith  decomposing  organic  matter,  moistened  with  water,  and 
having  its  interstices  filled  with  air.    On  such  a  soil  complete  dryness,  as 


CHOLERA   A  STATIC  A  877 


was  seen  in  the  famine  districts  in  India,  or  complete  saturation  as  is  seen 
in  the  rainy  season  in  certain  districts,  are  inimical  to  cholera :  while  a 
falling  ground  water,  leaving  the  soil  moist,  full  of  air,  and  charged  with 
organic  matter  from  the  surface,  disposes  to  cholera ;  not  only  by  favouring 
the  saprophytic  growth  of  the  cholera  bacillus,  but  also  by  facilitating  its 
access  to  wells. 

(rf)  Seasons  and  Weathers.  — In  like  manner  the  influences  of  season 
and  of  weather  can  be  reduced  to  those  of  temperature  and  rainfall.  A  cer- 
tain temperature  is  necessary  for  the  development  of  the  cholera  bacillus 
outside  the  body  ;  but  cholera  is  not  always  most  prevalent  in  the  hottest 
weather,  nor  is  it  always  stopped  by  winter.  It  seems  probable,  however, 
that  in  those  cases  in  which  cholera  has  occurred  in  winter  there  has 
either  been  a  direct  infection  of  a  water-supply,  as  in  the  case  of  the 
outbreak  at  Nietleben  in  January  1893,  described  by  Koch  (7),  or  the 
infection  has  gained  access  to  the  soil  under  houses  which,  as  in  Russia, 
have  been  kept  continually  at  a  high  temperature,  and  has  thus  reached 
the  drinking  water  indirectly.  In  temperate  climates  the  great  mortality 
from  cholera  takes  place  in  the  warm  weather ;  in  England  August  and 
September  are  the  most  fatal  months.  In  India,  however,  the  greatest 
prevalence  of  cholera  is  by  no  means  synchronous  in  the  different  parts 
of  the  country,  nor  does  it  uniformly  accord  either  with  greatest  heat  or 
with  the  maximum  or  minimum  of  rainfall.  Along  with  heat  there  must 
be  moisture  of  soil  for  cholera  to  prevail.  On  the  other  hand  the  soil 
must  not  be  sodden  with  water,  as  in  some  places  is  the  case  in  the  rainy 
season;  thus  it  happens  that  in  some  districts  with  dry  soil  the  rains 
by  introducing  the  moisture  necessary  for  its  development  and  by  wash- 
ing the  infection  into  the  water-supply,  seem  to  bring  cholera ;  while 
in  other  districts,  in  which  there  is  usually  a  certain  moisture  of  soil,  the 
rains  will  stop  an  epidemic  by  filling  up  the  pores  and  removing  the 
aeration  of  the  soil  necessary  for  the  continuance  of  the  saprophytic 
growth  of  the  bacillus.  Heat,  moisture,  aeration,  and  the  presence  of 
decomposing  organic  matter  in  the  soil  are  then  the  conditions  favourable 
to  the  local  development  of  cholera  when  once  introduced ;  and  the 
more  of  these  conditions  which  coincide  in  any  place  and  time  the  more 
likely  is  cholera  in  its  epidemic  form  to  prevail  at  that  time  and  place. 

(e)  Habits  of  Inhabitants. — Even  amidst  the  conditions  of  soil  and 
climate  most  favourable  or  most  inimical  to  cholera,  its  prevalence  largely 
depends  upon  the  habits  of  the  people;  however  largely  present  its 
contagium  may  be  it  is  harmless  unless  swallowed.  Thus  among  all  the 
influences  making  for  cholera,  the  most  important  are  those  habits  of 
carelessness  as  to  the  cleanliness  of  food  and  drink  which  make  it  easy 
for  either  the  one  or  the  other  to  be  tainted  with  faecal  material. 

if)  General  Sanitation.  —  As  is  the  influence  of  the  habit  of  cleanly 
living  to  the  individual,  so  is  that  of  general  sanitation  to  the  body 
corporate.  Good  drainage  and  good  water-supply  keep  cholera  at  bay 
by  making  it  impossible  for  the  faeces  of  one  person  to  gain  access 
to  the  drink  or  food  of  another. 


SYSTEM   OF  MEDICINE 


This  brings  us  back  to  the  key-note  of  the  etiology  and  epidemiology 
of  cholera,  namely,  the  ingestiou  of  infected  water  or  infected  food. 

The  act  of  swallowing  the  living  contagium  derived  from  the  excreta 
of  a  previous  sufferer  from  the  disease  is  the  immediate  cause  of  cholera 
in  the  individual ;  Avhile  the  means  by  which  facilities  are  given  for  the 
growth  of  this  contagium  outside  the  body,  for  its  wide-spread  dissemi- 
nation, and  for  its  introduction  into  the  food  or  drink  of  man,  are  the 
causes  of  cholera  epidemics. 

Ernest  Hart. 

SoLOMOiSr  Charles  Smith. 

Bacteriology  of  Cholera 

It  is  a  difficult  task  to  give  a  comprehensive  and  impartial  sketch  of 
the  bacteriology  of  cholera.  Opinions  have  constantly  changed  since 
Koch's  discovery  of  the  comma  bacillus,  and  from  the  very  outset  his 
conclusions  have  been  strongly  opposed.  More  recent  experience  has 
led  to  changes  of  opinion,  and,  however  impartial  our  endeavour,  we 
cannot  at  present  find  a  satisfactory  solution  of  the  matter.  We  shall  do 
our  best  to  present  it  in  a  more  or  less  historical  order.  In  this  conflict 
of  opinions  there  are  two  distinct  periods :  the  first,  dating  from  Koch's 
discovery  of  the  comma  bacillus  in  1883  until  the  recent  appearance 
of  cholera  in  Europe ;  and  the  second,  beginning  with  the  cholera 
epidemic  in  3892.  During  the  first  period  Koch  was  the  central  figure, 
and  the  study  of  the  cholera  organism  was  more  or  less  restricted  to 
laboratory  research :  on  account  of  the  scarcity  of  choleric  material 
general  criticism  was  impossible.  On  the  return  of  cholera  to  Europe 
pathologists  and  bacteriologists  were  enabled  to  make  independent  ob- 
servations, and  a  general  exchange  of  opinions  became  possible. 

First  Period  1883-1892.  —  In  1883  Koch  separated  a  characteristic 
curved  organism  from  the  dejecta  and  intestines  of  cholera  patients, 
the  comma  bacillus ;  this  he  declared  to  be  absent  from  the  stools  and 
intestinal  contents  of  healthy  persons,  and  of  persons  suffering  from  other 
affections.  The  organism  was  said  to  possess  certain  morphological  and 
biological  features  which  readily  distinguish  it  from  all  previously  de- 
scribed organisms.  It  was  absent  from  the  blood  and  viscera,  and  was 
found  only  in  the  intestines  ;  and  in  the  greater  number,  it  was  said,  the 
more  acute  the  attack.  Koch  also  demonstrated  an  invasion  of  the  mucosa 
and  its  glands  by  the  comma  bacilli.  The  organisms  were  found  in  the 
stools  on  staining  the  mucous  flakes  or  the  fluid  with  methylene  blue  or 
fuchsin,  —  and  sometimes  alone:  by  means  of  ciiltivation  on  gelatine 
they  were  readily  separated  from  the  stools.  During  his  stay  in  India, 
in  Egypt,  and  at  Toulon,  Koch  had  examined  more  than  a  hundred  cases, 
and  other  investigators  confirmed  his  statements.  Numerous  control  ob- 
servations, made  upon  other  diarrhoeic  dejecta  and  upon  normal  stools, 
were  negative  ;  the  comma  bacillus  was  found  in  choleric  material  only, 
or  in  material  contaminated  by  cholera.    Soon  other  observers,  however. 


CHOLERA    ASIATICA  879 


described  comma-shaped  organisms  of  non-ciioleraic  origin ;  Finkler  and 
Prior,  for  instance,  found  them  in  the  diarrhoeic  stools  of  cholera  nostras, 
Deneke  in  cheese,  Lewis  and  Miller  in  saliva.  All  of  these  organisms, 
however,  differed  in  many  respects  from  Koch's  comma  bacillus ;  and 
gradually  the  exclusive  association  of  Koch's  vibrio  with  cholera  became 
almost  generally  acknowledged.  In  1886,  indeed,  Flligge  maintained  that 
the  comma  bacilli  must  be  regarded  as  the  cause  of  cholera,  because  they 
occur  constantly  and  exclusively  in  this  disease. 

Koch  described  his  vibrios  as  short,  curved  organisms,  often  arranged 
as  spirals ;  the  curvature  of  the  individuals  varies  greatly,  the  latter  being 
sometimes  almost  straight,  and  at  other  times  nearly  semicircular.  Two 
commas  may  be  attached  so  as  to  form  an  S  ;  spirals,  even  of  great  length, 
may  indeed  be  found.  They  possess  the  power  of  spontaneous  movement 
in  a  marked  degree,  and  readily  undergo  involution,  becoming  round  and 
coccoid  or  irregular  in  appearance.  Hiippe  assumed  these  coccoid  forms 
'to  be  arthrospores ;  his  observations,  however,  are  by  no  means  convincing. 

On  the  surface  of  a  gelatine  plate  the  growth,  as  described  by  Koch, 
is  characteristic  during  the  early  stages,  the  colonies  appearing  as  small, 
whitish,  refractive  points,  so  that  the  gelatine  seems  to  be  sprinkled 
over  with  delicate  glass  splinters ;  as  the  liquefaction  of  the  nutrient 
medium  progresses  this  appearance  is  lost.  Stab-cultures  in  gelatine  are 
equally  characteristic :  there  is  a  whitish  growth  along  the  needle-track 
with  gradual  liquefaction,  which  at  first  is  most  marked  near  the  surface, 
so  that  a  funnel-shaped  depression  is  formed  which  appears  to  contain 
an  air-bubble.  Liquefaction  is  comparatively  slow,  but  after  six  days 
it  has  progressed  so  far  as  to  destroy  the  appearance  just  described. 
On  agar-agar  we  have  a  superficial  slimy  growth,  offering  no  special 
features ;  groAvth  occurs  on  potato  at  a  raised  temperature  only ;  milk 
is  not  coagulated.  Koch's  vibrio  is  capable  of  thriving  in  very  dilute 
broth  or  peptone  solution;  it  is  a  facultative  anaerobe,  and  grows  best 
between  30°  and  35°  C. ;  drying,  acids,  and  most  disinfectant  solutions 
destroy  it  quickly. 

Animal  experiments,  in  so  far  as  their  aim  was  to  reproduce  a  typical 
choleraic  lesion,  were  not  successful  in  Koch's  hands  ;  nor  can  those  per- 
formed by  iSTicati,  Eietsch,  and  Van  Ermengem  be  considered  convincing. 
Subcutaneous  inoculations  and  feeding  led  to  no  result ;  direct  inoculation 
into  the  duodenum,  with  or  without  previous  ligature  of  the  bile  duct, 
frequently  produced  fatal  diarrhoea  Avith  abundant  vibrios  in  the  dejecta, 
but  since  this  result  seemed  to  depend  to  a  great  extent  on  intestinal 
injury  they  are  not  free  from  doubt.  Koch  himself,  indeed,  asserted  that 
he  had  induced  a  choleraic  process  by  feeding  guinea-pigs  with  pure  cult- 
ures, after  previous  neutralisation  of  the  gastric  contents  and  injection 
of  tincture  of  opium  into  the  peritoneal  cavity,  in  order  to  paralyse  the 
intestinal  peristalsis.  Yet  as  other  vibrios  act  in  the  same  manner  these 
animal  experiments  have  not  established  the  specifically  j)at]iogenetic 
power  of  thf!  comma  bacillus.  The  stei'ilo  products  of  choleraic  cultures 
administered  to  a  guinea-pig  will  cause  distinct  intoxicative  symptoms 


88o  SYSTEM  OF  MEDICINE 

or  death,  as  first  shown  b}^  Nicati  and  Eietsch ;  these  symptoms,  how- 
ever, do  not  differ  from  those  produced  by  many  other  bacterial  toxins. 
We  shall  refer  to  human  experiments  later. 

Loffler  demonstrated  that  the  cholera  vibrio  possesses  a  single  terminal 
flagellum,  but  others  have  shown  that  it  may  possess  more  than  one.  Of 
more  interest,  however,  is  a  peculiar  chemical  reaction  which  Koch 
pronounced  to  be  characteristic,  the  so-called  cholera-red  reaction.  On 
adding  pure  hydrochloric  or  sulphuric  acid  to  a  culture  in  peptone  solu- 
tion or  in  peptone  broth,  a  pink  or  red  colour  (cholera-red)  appears.  This 
reaction  was  discovered  by  Polil,  Bujwid,  and  Dunham  in  1886  and 
1887,  and  was  explained  by  Salkowski,  who  at  the  same  time  proved  it 
to  be  of  no  specitic  value.  It  depends  merely  on  the  formation  of  indol 
from  the  albuminous  substances  in  the  culture  medium.  Many  organisms 
give  the  same  reaction :  some  on  the  addition  of  nitrites,  others  without 
this  addition;  the  latter  possess  the  power  of  converting  the  nitrates 
contained  in  the  broth  or  peptone  into  nitrites  first.  This  the  cholera 
vibrio  can  do,  but  many  other  vibrios  and  bacilli  do  likewise. 

This  short  description  of  Koch's  comma  bacillus  must  suffice.  He 
considered  it  to  be  the  one  specific  cause  of  cholera,  and  to  be  constant 
in  its  characters  :  any  vibrio  which  did  not  agree  in  its  features  with  the 
one  discovered  by  himself  was  at  once  put  aside  as  non-choleraic.  This 
ban  fell  upon  the  various  vibrios  described  by  Finkler-Prior,  Deneke, 
Gamaleia  (vibrio  Metschnicovi),  and  others. 

The  specific  germs  —  Koch's  comma  bacilli  —  are  shed  in  the  stools 
from  the  body  during  the  first  days  of  the  disease ;  and  only  these,  or  mat- 
ter contaminated  by  them,  as  for  instance  the  bed  linen,  vessels,  latrines, 
soil  or  drinking  water,  can  be  sources  of  infection.  Since  the  vibrio  is 
readily  destroyed  by  drying,  only  freshly -contaminated  objects  are  dan- 
gerous. Yet  it  has  been  shown  that  the  vibrio,  when  kept  moist,  may 
retain  its  vitality  for  a  considerable  time.  It  follows,  therefore,  that  the 
disease  to  be  carried  from  an  endemic  ai'eamust  either  be  uninterruptedly 
transmitted  from  one  individual  to  another,  or  must  pass  by  a  general 
source  of  infection,  as  for  instance  a  contaminated  water-supply.  Aerial 
infection  is  excluded ;  hence  there  must  be  either  direct  contact  with 
choleraic  material  or  the  consumption  of  contaminated  food  or  unclean 
water.  Moreover,  some  personal  disposition,  brought  about  perhaps  by 
dyspeptic  conditions,  or  by  the  general  debility  of  poverty,  starvation,  and 
overcrowding,  may  or  must  co-operate  with  the  specific  agent.  Nor  are 
locality  and  season  without  moment.  In  some  localities  the  disease  seems 
never  to  occur ;  and  the  exemption  finds  an  explanation  in  a  difference 
of  water-supply,  of  hygienic  and  economic  conditions,  and  is  independent 
of  the  particular  state  of  the  soil.  So  far  as  the  seasons  are  concerned,  the 
cholera  epidemics  in  the  temperate  zones  reach  their  climax  during  the 
late  summer  and  in  autumn ;  that  is,  during  those  months  when  insects 
abound,  when  raw  food  is  copiously  consumed,  and  when  gastric  derange- 
ments are  common.  Such  in  brief  is  the  mechanism  of  infection  as  it  was 
explained  by  the  contagionistic  school  which  believed  in  a  single  specific 
cholera  vibrio. 


CHOLERA   ASIATICA  88i 


Pettenkofer  was  one  of  the  earliest  opponents  of  this  school ;  and 
until  now  he  has  defended  the  "  localistic  "  view  against  those  of  Koch 
and  the  contagionists.  He  too  believed  in  a  transmissible  virus  {x),  but 
that  an  epidemic  cannot  arise  without  concomitant  conditions  which  de- 
pend on  differences  of  locality  and  season  iy)  ;  so  that,  although  x  alone 
may  cause  an  individual  case,  an  epidemic  can  only  appear  when  x  and 
y  coincide.  Pettenkofer  sought  and  still  seeks  y  more  particularly  in 
special  conditions  of  the  upper  layers  of  the  soil  which  affect  x  in  such  a 
way  as  to  render  it  infective.  He  denied  formerly  that  Koch's  bacillus  is 
X,  because  of  its  lack  of  resistance  to  external  influences.  Koch's  adher- 
ents maintained  that  Pettenkofer's  explanation  did  not  apply  to  cholera 
epidemics  generally,  and  that  the  receut  outbreaks  especially  failed  to 
satisfy  his  conditions.  Although  Pettenkofer  has  now  accepted  Koch's 
vibrio  as  the  factor  x,  he  still  adheres  to  the  unknown  y  on  epidemiologi- 
cal evidence.  After  the  Hamburg  epidemic  he  reminded  us  that  the 
cholera  germs  may  often  remain  quiescent,  so  that  the  epidemic  appear- 
ance of  cholera  depends  not  so  much  on  the  presence  of  comma  bacilli  or 
a  personal  disposition,  as  on  certain  associated  states  of  locality  and  sea- 
son. He  complains  that  contagionists  do  not  pause  to  consider  why  certain 
localities  and  areas  are  not  visited  by  an  epidemic,  although  sporadic  cases 
of  cholera  are  constantly  present  in  them.  He  alleges  that,  in  spite  of 
railways  and  steamers,  cholera  does  not  spread  quicker  or  more  generally 
than  formerly,  and  this  with  him  is  a  strong  argument  against  the  con- 
tagionist  theory.  Cholera  epidemics,  he  asserts,  appear  only  in  places 
with  a  local  disposition. 

The  staunchest  opponent  of  Koch's  school  has  been  Dr.  D.  D.  Cun- 
ningham, who  is  not  yet  reconciled  to  the  opinion  that  the  "  comma 
bacillus  "  is  a  specific  element.  In  1890  he  claimed  to  have  demonstrated 
that  several  distinct  species  of  vibrio  occur  in  association  with  cholera  in 
Calcutta,  the  home  of  the  disease ;  so  that,  according  to  him,  no  one 
species,  and  least  of  all  Koch's  which  he  never  found,  can  be  regarded  as 
the  cause  of  the  disease.  He  agreed  with  Koch  that,  as  regards  the  vast 
majority  of  cases,  the  presence  of  large  numbers  of  vibrios  in  the  intestines 
is  characteristic  and  even  diagnostic.  But  he  has  seen  ''  undoubted  "  cases 
of  cholera  without  comma  organisms ;  and  he  has  further  observed  that 
the  vibrios  separated  from  other  cases  were  not  of  one,  but  of  various 
species :  in  fact,  from  sixteen  cases  he  obtained  no  less  than  ten  distinct 
species,  distinct  morphologically,  biologically,  and  chemically.  He  there- 
fore concluded  that  Koch's  theory  of  cholera,  as  primarily  due  to  the 
access  of  a  specific  comma  bacillus  to  the  interior  of  the  intestinal  tract, 
must  be  abandoned;  and  if  comma-shaped  organisms  are  to  be  regarded 
as  entering  into  the  causation  of  cholera,  it  must  be  as  members  of  a 
group  of  various  species.  In  one  case  he  separated  three  distinct  species 
—  a  fact  which  suggested  to  him  that  the  special  morbid  condition  existing 
ill  choleraic  enteritis  is  the  cause  of  the  presence  of  the  comma  bacilli. 
Cunningham  has  followed  up  his  observations  for  some  years,  and  he  is 
confirmed  in  his  opinion  that  the  vibrios  which  he  found  in  association 

VOL.    T  3    L 


SYSTEM  OF  MEDICINE 


with,  cholera  are  not  of  one  kind,  nor  even  varieties  of  one  species,  but 
are  of  different  species.  He  has  continued  to  cultivate  the  forms  obtained 
for  long  periods  under  equal  conditions,  and  has  found  that  they  remain 
distinct,  and  that  there  is  no  approximation  in  morphological  and  biologi- 
cal characters.  He  states  that  some  of  his  choleraic  vibrios  differ  from 
others  as  much  as  the  organism  of  Finkler-Prior  differs  from  Koch's 
comma  bacillus,  or  as  the  B.  subtilis  from  the  anthrax  bacillus.  As  no  one 
regards  the  latter  bacilli  as  varieties  of  the  same  species,  there  is  no  justi- 
fication for  regarding  the  various  choleraic  vibrios  as  aberrant  forms  of  a 
common  stock.  Cunningham  is  indeed  disinclined  to  admit  that  cholera 
is  due  to  the  access  of  a  member  of  a  group  of  vibrios  ;  he  sees  in  cholera 
a  disease  caused  by  a  ptomaine  which  produces  certain  changes  in  the  in- 
testinal tract  favourable  to  the  growth  and  development  of  sundry  vibrios. 
Until  recently  Cunningham's  views  as  to  the  multiplicity  of  vibrios 
associated  with  cholera  were  either  left  unnoticed  or  generally  opposed  ; 
but  Dr.  Klein  has  fully  confirmed  Cunningham''s  statements  as  to  the 
permanently  different  cultural  characters  of  various  forms  of  choleraic 
comma  bacilli ;  though  he  does  not  discuss  their  specific  affinities.  Klein 
himself,  however,  until  recently,  based  his  doubts  as  to  the  causal  rela- 
tion between  cholera  and  Koch's  comma  bacillus  chiefly  on  animal 
experiments.  He  accepted  then,  as  he  does  now,  the  fact  that  vibrios  are 
almost  always  found  in  large  numbers  in  cholera ;  but  he  considered  that 
experimental  proof  was  wanting.  It  had  been  asserted  by  Koch  and  his 
school  that  comma  bacilli,  when  introduced  into  the  small  intestine  in  a 
living  state,  are  capable  of  setting  up  an  acute  illness  resembling  Asiatic 
cholera.  We  need  not  give  Klein's  arguments  in  full,  because  it  is  now 
generally  acknowledged  that  the  lesions  produced  in  guinea-pigs  and  other 
animals  by  subcutaneous,  intraperitoneal  or  intestinal  inoculations  have 
no  specific  characters,  and  may  be  caused  by  many  other  organisms  besides 
the  so-called  cholera  vibrio.  It  is  evident,  then,  that  since  choleraic 
symptoms  cannot  be  produced  in  animals,  and  since  lesions  identical  with 
those  following  on  inoculation  with  choleraic  vibrios  are  called  forth  by 
many  organisms,  the  animal  experiment  ca;nnot  be  used  in  support  of 
Koch's  thesis.  Intraperitoneal  inoculations  are  followed  by  fatal  peritoni- 
tis, but  this  does  not  differ  from  that  produced  by  similar  inoculations  with 
the  bacillus  prodigiosus,  the  vibrio  of  Finkler-Prior,  typhoid  germs  and 
other  micro-organisms.  Nor  can  it  be  maintained  that  the  intestinal  in- 
oculation has  any  specific  character,  for  identical  phenomena  may  follow  if 
we  use  other  vibrios,  such  as  the  spirilla  of  Finkler-Prior  and  of  Deneke. 
According  to  Klein,  then,  animal  inoculation  cannot  be  saidtohave  proved 
the  causal  relation  between  Koch's  vibrio  and  Asiatic  cholera.  Klein  has 
always  agreed  with  other  observers  that  vibrios  are  extremely  common, 
and  almost  constantly  found  in  the  intestinal  contents  in  cholera, 
although  he  could  not  confirm  Koch  in  the  assertion  that  the  more 
acute  and  severe  the  case  the  more  numerous  are  the  comma  bacilli 
in  the  lower  ileum ;  he  did  not  find  this  definite  relation,  and  indeed 
the  assertion  is  now  generally  withdrawn.     His  attitude  has  always  been 


CHOLERA   ASIATICA 


one  of  reserve,  which  is  justifiable,  and  indeed  imperative,  so  long  as  the 
chain  of  evidence  is  incomplete. 

Second  Period.  —  The  second  period  is  characterised  by  energetic 
investigation  of  the  morphology,  biology,  and  etiological  importance  of 
the  cholera  vibrios.  It  soon  became  evident  that  from  stools  derived  from 
cases  clinically  recognised  as  cholera  various  forms  of  curved  micro- 
organisms can  be  obtained,  which  morphologically  as  well  as  in  artificial 
cultivations  often  do  not  even  resemble  Koch's  comma  bacillus,  and 
differ  greatly  one  from  another,  or  at  least  sufficiently  so,  to  raise  the 
suspicion  in  our  minds  that  in  cholera  we  are  dealing  with  more  than  one 
kind  of  vibrio.  Even  the  unwavering  supporters  of  Koch's  views  became 
aware  that  there  is  more  than  a  grain  of  truth  in  Cunningham's  observa- 
tions on  the  variability  in  form.  Klein's  cholera  studies  in  England,  the 
only  complete  ones  in  this  country,  have  clearly  shown  that  several 
varieties  of  vibrios  are  associated  with  cholera — a  point  upon  which  most 
observers  are  now  agreed.  The  burning  question  is  whether  these  forms 
are  merely  varieties  of  one  choleraic  vibrio,  or  are  different  species.  If 
the  latter  be  the  case,  and  we  find  that  the  numerous  forms  associated 
v/ith  cholera  are  specifically  different,  one  vibrio  in  particular  cannot 
any  longer  be  regarded  as  an  invariable  antecedent.  This  difficulty 
has  been  felt  by  all  who  are  acquainted  with  the  bacteriology  of  cholera. 
These  inquirers  are  now  divided  into  two  camps  :  (1)  those  who  believe 
with  the  majority  that  cholera  is  due  to  one  organism  which  may  show 
certain  variations  —  in  other  words,  that  cholera  is  a  strictly  specific 
disease ;  (2)  those  who  contend  that,  as  supDuration  may  be  caused  by  any 
one  of  a  certain  number  of  micrococci,  so  likewise  may  cholera  be  caused 
by  more  than  one  vibrio.  The  present  confusion  therefore  is  great,  and 
much  ingenuity  has  been  manifested  by  the  adherents  of  the  one  view  to 
overthrow  the  assertions  of  those  who  accept  the  other.  As  yet  we 
have  not  reached  the  solution  of  the  problem. 

Those  who,  amid  numerous  existing  varieties  believe  in  the  unity  of 
the  choleraic  vibrio,  employ  special  tests  whereby  we  may  decide  whether 
we  are  dealing  with  the 'specific  vibrio  or  with  one  resembling  it ;  seeing 
that  a  number  of  vibrios  have  been  found  in  water  or  elsewhere,  for  which 
places  may  readily  be  found  in  the  long  series  of  the  varieties  of  the 
cholera  microbe.  Artificial  cultivation  on  ordinary  nutrient  media,  under 
usual  or  unusual  conditions,  has  shown  that  these  choleraic  vibrios  are 
highly  pleomorphic,  and  that  they  readily  change  morphologically  and 
biologically,  chemically  and  physiologically.  Thus  Dunbar,  a  firm 
believer  in  the  vibrionic  unity  of  cholera,  admits  that  typical  comma 
bacilli  when  kept  in  water  vary  and  differ  more  from  one  another  than 
non-choleraic  water  vibrios.  True  vibrios  may  become  so  altered  as  to 
belie  their  origin  altogether.  This  extraordinary  variability,  which 
readily  leads  to  xjermanent  changes,  is  a  property  which  must  not  be  left 
out  of  sight ;  it  must  make  us  cautious  in  our  criticism,  for  it  is  more  than 
probable  that  what  a  few  test-tube  processes  can  effect  nature  and  disease 
can  do  far  more  thoroughly.     The  collected  observations  of  the  last  few 


884  SYSTEM  OF  MEDICINE 

years,  if  they  remove  a  great  part  of  the  force  of  Cunningham's  opposi- 
tion, have  impressed  upon  us  the  difficulty  of  the  bacterioscopic  diagnosis 
of  the  choleraic  vibrios.  Koch  for  his  diagnosis  relied  on  microscopical 
preparations,  growth  in  peptone  solution,  on  gelatine  and  agar-agar  plates, 
on  the  indol  reaction,  and  on  the  positive  animal  experiment ;  bat  it  was 
soon  found  that  few,  if  any,  of  these  tests  could  be  relied  upon. 

(a)  Gruber,  after  patient  work,  came  to  the  conclusion  that  the  only 
certain  criterion  is  the  appearance  of  the  colonies  in  a  gelatine  plate. 
He  points  out  that  the  attempts  to  formulate  characteristic  differences 
in  the  microscopical  appearances  between  Koch's  and  the  other  comma 
bacilli  are  vain ;  seeing  that  one  and  the  same  race  of  Koch's  or  other  vibrio 
may  present  morphological  characters  varying  as  the  conditions  of  growth 
and  the  age  of  the  cultivation.  The  difference  in  the  microscopical 
appearance  between  individual  races  and  cultivations  is  often  greater  than 
that  between  different  species ;  so  that  it  is  impossible  by  this  method  to 
distinguish  the  cholera  vibrio.  Gruber  admits  that  the  variety  of  cholera 
vibrio,  first  described  by  Pasquale  in  an  epidemic  in  Massowah,  differs  in 
the  most  remarkable  way  from  that  of  Koch.  These  differences  have 
been  maintained  for  a  year  and  a  half  in  cultivations  on  various  media, 
and  after  passing  it  through  the  body  of  animals.  Further,  the  Massowah 
vibrio  possesses  from  four  to  six  fl^gella :  Koch's  generally  has  one  only ; 
but  in  cover-glass  preparations  some  were  always  found  to  possess  two  or 
three,  so  that  this  feature  is  not  a  constant  one,  and  it  is  possible  to  regard 
the  Massowah  vibrio  simply  as  a  variety  and  not  as  a  distinct  sj)ecies. 

For  a  long  time  it  was  considered  that  the  rapidity  and  manner  of 
liquefaction  of  gelatine  would  constitute  a  simple  method  of  diagnosis. 
But  it  was  found  that  the  different  generations  of  the  cholera  vibrio  show 
wide  differences  in  the  property  of  liquefying  gelatine ;  some  liquefy  it 
almost  as  rapidly  as  does  the  vibrio  of  Finkler-Prior,  some  hardly 
liquefy  it  at  all :  as  most  of  the  allied  species  of  vibrios  lie  within  these 
limits  Koch  himself  has  abandoned  this  test.  Gelatine  plate  cultiva- 
tions, according  to  Gruber,  are  of  much  more  value.  Here  it  is  impor- 
tant that  the  composition  of  the  gelatine  should  be  constant,  and  that  the 
temperature  be  kept  at  or  about  the  same  level  —  20°  to  22°  C.  being  the 
most  suitable.  The  thickness  of  the  layer  of  gelatine  on  the  plate, 
the  depth  of  the  colonies,  the  number  of  the  colonies,  the  presence  of 
other  bacteria,  all  are  factors  which  influence  the  appearance  of  colonies ; 
and,  finally,  the  distinguishing  characters  of  different  species  only  make 
their  appearance  at  certain  stages  of  development,  so  that  the  observation 
must  be  repeated  at  definite  intervals  of  time. 

The  superficial  and  the  deep  colonies  of  the  cholera  vibrio  differ  in 
appearance.  The  siiperficial  colonies  of  Koch's  vibrio  in  45  to  48  hours  old 
gelatine  plates  differ  from  all  other  known  vibrios  except  Deneke's  cheese 
vibrio:  (1)  The  superficial  colonies  of  the  earlier  stage  present  an  irregular 
(never  simply  round  or  oval)  shape,  and  have  either  a  coarsely  granular 
or  a  furrowed  or  striated  appearance;  while  the  colonies  of  all  other 
vibrios,  with  the  exception  of  Deneke's,  have  a  rounded  shape,  and  appear 


CHOLERA   ASIATIC  A  885 


quite  structureless,  or  at  most  finely  striated.  (2)  The  deep-seated 
colonies,  even  in  sparsely-sown  plates,  present  at  an  early  stage  an  irregular 
shape  and  a  wavy,  uneven  appearance.  In  the  case  of  old  and  attenuated 
cultivations  this  irregular,  uneven  appearance  may  be  but  slightly  marked, 
yet  it  is  always  present. 

On  the  other  hand,  all  other  vibrios  (excepting  Deneke's),  especially 
in  thinly-sown  plates,  appear  rounded,  quite  structureless,  and  with  a 
smooth  surface.  On  thickly-sown  plates  the  deep  and  superficial  appear- 
ances of  these  colonies  present  a  great  similarity  to  that  of  the  cholera 
vibrio ;  so  that  the  difficulties  surrounding  this  procedure  are  many,  and 
Gruber  admits  that  after  all  the  test  is  not  conclusive. 

With  certain  cholera  vibrios  these  characteristic  appearances  may  be 
only  slightly  marked  or  altogether  absent.  Thus  some  cholera  vibrios 
liquefy  very  slowly,  and  the  superficial  colonies  have  then  quite  an  aber- 
rant appearance  —  in  fact,  an  appearance  so  distinct  from  the  classical 
appearance  that  one  might  be  tempted  to  describe  two  kinds  of  cholera 
vibrios  simply  on  the  ground  of  these  differences. 

Yet  further  study  has  convinced  Gruber  that  it  is  possible  by  gelatine 
plates  to  distinguish  all  vibrios  from  that  of  Koch,  except  Deneke's  vibrio. 
But  seeing  that  external  conditions  have  so  great  an  influence,  and 
that  the  variations  in  mode  of  growth  of  a  particular  species  are  so  great, 
this  method  of  determining  the  species,  as  Gruber  admits,  is  extremely 
difficult  and  perhaps  uncertain ;  and  seeing  that  Gruber's  test  breaks 
down  with  Deneke's  vibrio,  for  this  reason  alone  it  must  be  regarded  as 
useless.  Recently  Gruber  himself  has  confessed  that  although  we  know 
with  certainty  that  the  vibrios  which  are  associated  with  the  choleraic 
processes  cause  the  symptoms  and  lesions  of  the  disease,  yet  we  cannot 
diagnose  the  true  nature  of  these  vibrios  with  like  certainty ;  hence,  at 
present,  we  cannot  definitely  state  whether  those  which  have  been  sepa- 
rated from  genuine  cases  of  cholera  belong  to  one  or  several  species,  or 
whether  they  are  identical  all  over  the  world.  The  fact  which  he  now 
also  accepts  —  that  copious  proliferation  of  these  vibrios  may  occur  in 
the  intestinal  tract  without  leading  to  serious  disease  —  while  it  com- 
pels him  to  assume  the  co-existence  of  certain  unknown  factors  necessary 
for  the  appearance  of  cholera  in  the  individual  or  in  a  locality,  renders 
his  position  somewhat  paradoxical. 

(6)  Pfeiffer,  who  has  never  doubted  the  correctness  of  Koch's  observa- 
tions and  deductions,  recognising,  nevertheless,  that  none  of  the  proposed 
tests  vouchsafe  a  certain  diagnosis,  introduced  a  novel  method  of  dis- 
tinguishing between  true  and  false  cholera  vibrios.  It  was  based  on  the 
fundamental  proposition  expressed  by  Behring,  that  the  serum  of  a  pro- 
tected animal  is  specific  in  its  action;  that  is,  if  injected  into  an  animal 
it  confers  on  it  an  immunity  only  from  the  lesion  against  which  the 
original  animal  had  lieen  protected.  Pfeiffer,  therefore,  rendered  animals 
proof  against  a  cholera  vibrio,  and  then  used  their  serum  as  a  test.  Its 
action  being  specific,  it  can  counteract  the  effects  only  of  one  species  of 
vibrio,  and  must  be  impotent  against  all  others.     His  method  of  proced- 


SYSTEM  OF  MEDICINE 


ure  is  as  follows :  lie  injects  a  mixture  of  anti cholera  serum  with  the 
suspected  organism  :  if  the  animal  succumb,  the  organism  in  question  can- 
not have  been  a  cholera  germ ;  if  the  animal  survive,  our  suspicions  have 
been  justified.  Those  who  dissent  from  him  object  that  this  argument 
entirely  begs  the  question  as  to  the  true  choleraic  vibrio.  Pfeiffer  selected 
at  the  outset  a  comma  bacillus  obtained  from  Hamburg,  and  used  it  as  the 
genuine  form  before  he  had  demonstrated  its  specific  value.  The  dis- 
senters, therefore,  refuse  to  accept  his  test :  it  may  distinguish  between 
varieties  or  species,  but  it  does  not  prove  the  specific  nature  of  the  vibrio 
under  suspicion.  Curiously  enough  it  led  to  the  confession,  on  Pfeiffer's 
part,  that  the  Massowah  variety  with  which  he  had  worked  for  some 
time,  and  which  had  formed  the  basis  of  his  cholera  studies,  is  an  impostor ; 
yet  this  vibrio  had  been  used  in  most  laboratories,  and  its  specific  nature 
had  never  been  doubted  by  bacteriologists.  On  the  other  hand,  a  vibrio 
separated  by  Ivanoff  from  a  case  of  typhoid  fever  was  declared  to  be 
genuine,  although  formerly  it  was  excluded  from  the  group  of  cholera 
vibrios.  Before  Pfeiffer's  method  can  be  convincing,  it  must  be  shown 
that  cholera  is  specific  in  the  sense  that  it  is  caused  by  one  form  of  vibrio, 
and  only  one.  If  this  be  so,  and  if,  under  such  conditions,  Pfeiffer  was 
fortunate  enough  to  secure  this  one  vibrio,  then  the  immunity  test  might 
become  absolute  ;  if  the  specificity  of  protective  serum  within  Pfeiffer's 
narrow  limitation  can  be  accepted. 

Sanarelli  objects  that  Pfeiffer  and  Issaeff  themselves  have  shown 
that  normal  horse's  serum  is  as  active  as  that  of  cholera-immune  ani- 
mals ;  and  E,oux  maintains  against  Behring's  law  that  antitetanic  serum 
can  destroy  the  lethal  effect  of  snake  poisons.  Further,  Sanarelli's  own 
serum  tests  led  to  results  very  different  from  those  of  Pfeiffer ;  for  he 
obtained  reciprocal  action  between  many  choleraic  and  non-choleraic 
vibrios :  he  concludes  that  "  it  is  established  that  the  serum  of  an 
animal  vaccinated  against  a  pathogenetic  organism  is  endowed  with  pro- 
tective action,  not  only  with  regard  to  varieties  of  the  same  species,  but 
also  with  regard  to  organisms  belonging  to  a  different  species.  The 
bacteriological  diagnosis  of  the  choleraic  vibrio  by  means  of  anticholera 
serum,  therefore,  is  a  practice  not  warranted  by  results." 

Dunbar  and  Klemperer  agree  with  Pfeiffer  in  regard  to  the  specificity 
of  the  cholera  serum  and  its  value  as  a  diagnostic  test ;  nevertheless  the 
former  acknowledges  that  a  true  vibrio  may  become  so  altered  in  its 
properties  that  it  will  eventually  react  negatively.  C.  Frankel  and  Gruber 
are  neither  of  them  willing  to  accept  the  absolute  validity  of  this  test. 
Bordet,  however,  applying  the  serum  test  in  a  ma,nner  differing  from 
that  of  Pfeiffer,  that  is,  by  studying  the  antimicrobic  power  of  the 
serum  outside  the  body,  to  some  extent  disagrees  with  Sanarelli,  and 
asserts  that  this  power  of  a  serum  is  always  more  marked  towards 
identical  vibrios  or  towards  varieties  of  a  species.  But  yet,  we  find  from 
his  researches  that  the  ''  Massowah  serum  "  reacts  on  a  Calcutta  vibrio, 
but  not  on  vibrios  obtained  from  Constantinople,  Hamburg,  East  Prussia, 
and  Casino;   and  that  the  "East-Prussia  serum"  reacts  also  on  the 


CHOLERA    A  SI  A  TIC  A  887 

Hamburg  and  Constantinople  varieties,  but  not  on  the  Massowah  vibrio. 
Bordet  believes  that  the  preventive  action  of  the  cholera  serum  is 
specific  to  the  same  extent  as  its  germicidal  action.  Pfeiffer  has  asserted 
that  if  vibrios  inoculated  into  the  peritoneal  cavity  of  a  cholera  proof 
guinea-pig  become  transformed  into  granidar  masses,  or  if  the  same  result 
follow  a  similar  injection  of  a  mixture  of  vibrios  with  specific  serum,  they 
are  genuine  comma  bacilli.  This  granular  transformation  is  called  Pf eif- 
fer's  phenomenon.  Bordet  states  that  the  same  phenomenon  can  be  ob- 
tained outside  the  animal  body  on  a  glass  slide,  if  a  little  of  the  suspected 
culture  and  normal  serum  be  mixed  with  a  few  drops  of  anticholeraic 
serum :  then  if  we  are  dealing  with  true  vibrios  they  are  at  once  changed 
into  a  granular  mass.  Those  vibrios  which  do  not  respond  toBordet's 
reaction  fail  to  respond  to  Pf eiffer's  test ;  and  Bordet  therefore  proposes 
his  method  as  a  quicker  and  readier  procedure,  and  also  as  a  less  expen- 
sive one,  since  it  requires  fewer  animals.  A  vibrio  which  gives  a  posi- 
tive reaction  may  be  considered  genuine ;  and  Bordet  acknowledges  that 
a  negative  reaction  must  be  accepted  with  reservation,  because  some  vibrios 
are  more  resistant  than  others.  Mr.  H.  E.  Durham,  simplifying  the  test, 
has  recently  come  to  the  same  conclusion ;  but  he  also  confesses  that  the 
limits  of  the  absolute  value  of  this  serum  test  for  the  diagnosis  of  cholera 
vibrios  has  yet  to  be  determined,  and  he  adds  that  a  series  of  gradations 
in  intensity  of  reaction  between  serum  and  vibrios  has  been  observed. 
It  is  evident,  then,  that  at  present  we  are  surrounded  by  contradictions, 
and  must  suspend  our  judgment. 

Metschnikoff  criticised  both  Gruber's  and  Pfeiffer's  tests  adversely ; 
the  latter,  because  it  leads  us  to  paradoxical  results.  Of  Gruber's  test 
he  says  that  it  is  precisely  the  regularity  and  circular  appearance  of 
young  colonies  of  Deneke's  vibrio  which  have  always  been  taken  to  dis- 
tinguish this  vibrio  from  the  cholera  vibrio :  yet  in  young  colonies  of 
Deneke's  vibrio  we  find  among  the  symmetrical  colonies  others  of  irregular 
contour  ;  and  among  the  varieties  of  cholera  vibrio,  on  the  other  hand,  we 
find  some  which  present  a  regular  contour.  Here  then  we  find  no  way 
out  of  our  difiiculties.  But  we  may  state  that  the  validity  of  Pfeiffer's 
tests  can  hardly  be  accepted,  unless  it  be  shown  that  morphological  and 
cultural  variation  is  never  accompanied  by  chemical  variation. 

Metschnikoff  is  also  of  the  opinion  that  among  the  water  vibrios 
found  independently  of  any  cholera  outbreak  there  are  choleraic  vibrios. 
(>f  these  we  shall  now  speak. 

id)  Sanarelli  discovered  a  number  of  vibrios  in  water,  which  often 
could  not  be  immediately  traced  to  any  epidemic  of  cholera,  present  or 
past ;  these  he  pronounced  to  be  choleraic  vibrios,  altered  or  modified  by 
saprophytic  conditions  of  life.  We  must  premise  that  he  accepts  the 
researches  of  those  who  maintain  that  there  are  varieties  of  comma  bacilli, 
and  who  doul)t  the  exclusive  specificity  of  Koch's  original  organism. 
This  doubt  he  rorisiders  still  more  justifiable  in  the  light  of  Eumpel's 
and  Metschnikoff's  discoveries  of  cholera  vibrios  in  the  faeces  of  healthy 
persons,  to  which  we  may  add  similar  observations  by  Cunningham, 


SYSTEM  OF  MEDICINE 


Pasquale,  Lesage,  and  Macaigne.  He  rejects  the  criticisms  of  Htlppe 
and  Friedrich,  who  attempted  to  show  that  all  these  various  forms 
are  merely  physiological  varieties  of  one  and  the  same  species,  and  he 
rejects  Koch's  six  tests  also,  namely,  (1)  microscopical  examination ;  (2) 
cultivation  in  peptone  solution ;  (3)  appearances  on  a  gelatine  plate ;  (4) 
appearances  on  an  agar-agar  plate;  (5)  the  nitros-indol  reaction;  and 
(6)  the  animal  test.  Sanarelli  obtained  altogether  32  water  vibrios  of 
extreme  variability,  many  of  which  satisfied  even  Koch's  conditions; 
and  his  conclusion  was  that,  in  the  absence  of  an  epidemic,  vibrios  may 
be  found  which  are  identical  with  the  true  choleraic  germs.  Now  an 
animal  protected  against  any  one  of  these  varieties  is  not  necessarily 
proof  against  the  others.  Sanarelli  abandons  the  narrow  conception  of 
morphological  and  biological  uniformity ;  he  believes  there  are  different 
races  of  vibrio  all  capable  of  causing  true  cholera;  and  that  we  must 
consider  many  of  the  non-pathogenetic  forms  as  varieties  which  under 
special  conditions  may  become  virulent.  Yet  since,  taken  collectively, 
they  resemble  one  another  in  many  respects,  it  is  very  probable  that  all 
the  varieties  obtained  from  choleraic  stools  or  from  water  have  a  common 
origin,  their  differences  being  caused  by  the  saprophytic  conditions  which 
they  find  in  water. 

In  continuing  his  researches,  Sanarelli,  after  having  produced  diarrhoea 
in  normal  guinea-pigs,  separated  12  vibrios  from  their  intestinal  tract, 
which  also  he  regarded  as  choleraic  forms.  Pfeiffer's  serum  test,  as 
already  mentioned,  he  declares,  more  or  less  on  the  same  grounds  as 
Metschnikoff,  to  be  utterly  inadeqviate.  Sanarelli  also  disagrees  with 
Pfeiffer  in  regard  to  certain  varieties  which,  in  his  own  hands,  by  means 
of  the  serum  test,  reacted  as  true  choleraic  organisms,  though  Pfeiffer 
on  the  strength  of  the  same  test  had  considered  them  to  be  non-choleraic ; 
he  goes  further  than  this,  for  he  denies,  from  experiments  of  his  own, 
the  specificity  of  protective  serum,  since  he  succeeded  in  conferring  an 
immunity  on  guinea-pigs  against  choleraic  infection  by  means  of  anti- 
typhoid serum,  and  again  by  means  of  a  serum  obtained  from  an  animal 
inoculated  against  the  vibrio  of  Metschnikoff,  Avhich  is  generally  acknowl- 
edged not  to  be  choleraic.  It  is  not  quite  easy  to  follow  all  Sanarelli's 
arguments,  but  it  seems  that,  although  he  believes  in  a  common  origin  of 
all  the  various  choleraic  vibrios,  he  is  an  opponent  of  those  who  insist  on 
a  specific  comma  bacillus  ;  for  in  his  last  paper  he  thus  expresses  him- 
self :  "  Noias  pouvons  conclure  qu'il  y  a  des  races  diverses  de  vibrions 
choleriques  inegalement  virulents." 

(cZ)  In  connection  with  Sanarelli's  work  Ave  may  consider  that  of  Mr. 
Hankin,  who  regards  the  many  varieties  of  vibrios  as  degenerate  forms 
of  Koch's  organism.  In  his  opinion  the  discoveries  of  vibrios  in  the  Avater 
and  elsewhere  throw  doubt  rather  on  the  tests  for  the  cholera  microbe 
described  by  Koch,  than  on  the  authenticity  of  the  cholera  microbe  as  the 
cause  of  cholera.  He  summarises  his  results,  obtained  in  India,  as  follows : 
In  a  large  number  of  localities,  situated  often  under  very  different  climatic 
and  other  conditions,  microbes  resembling  that  of  cholera  are  extremely 


CHOLERA   A  SI  A  TIC  A  889 


rare,  except  in  places  in  which  cholera  has  recently  existed.  During  the 
epidemic,  according  to  his  experiments,  they  generally  show  virulence, 
power  of  giving  the  indol  reaction,  and  other  characters  regarded  as  typi- 
cal of  the  cholera  microbe.  After  the  cessation  of  the  epidemic  they  are 
greatly  diminished  in  virulence  for  guinea-pigs ;  and  in  their  limited  abil- 
ity of  growing  on  agar-agar  they  betray  a  diminution  of  vitality,  which 
he  regards  as  an  indication  of  diminished  virulence.  Such  degenerated 
vibrios  show  a  great  tendency  to  die  out  in  ordinary  cultures,  so  that 
it  is  difficult  to  keep  them  alive  for  any  long  time.  The  conclusion 
he  draws  is  that  these  vibrios  are  the  cholera  microbe  in  various  states 
of  degeneration.  The  cessation  of  an  epidemic  is  due  to  a  weaken- 
ing of  the  microbe.  Whether  the  degenerate  microbes  can  binder  any 
conditions  regain  their  virulence,  and  thus  again  become  capable  of  start- 
ing an  epidemic,  is  a  question  he  leaves  unanswered.  Such  a  view  is 
simple,  but  it  is  too  simple ;  and  Hankin  evidently  relies  on  a  guinea-pig 
test,  which  all  other  workers  consider  unsatisfactory.  We  cannot  allow 
that  all  the  varieties  described  by  Cunningham  and  others  can  on  such 
evidence  be  neglected  as  degenerate  forms  of  one  and  the  same  microbe. 

It  is  manifest  that  at  present  the  argument  is  extremely  involved,  and 
that  it  is  impossible  to  come  to  a  definite  decision.  It  appears  that  most 
observers  who  have  studied  the  question  associate  comma  bacilli  closely 
with  cholera :  some  of  these  uphold  the  unity  of  the  vibrio,  others  accept- 
ing this  unity  declare  that  its  forms  are  manifold;  and  forms  which 
some  regard  as  varieties  of  one  species  of  organism,  others  describe  as 
distinct  species.  Eumpf  sums  up  his  experiences  gathered  during  the 
Hamburg  epidemic  in  the  former  sense,  and  concludes  that  undoubtedly 
Koch's  comma  bacillus  is  the  cause  of  Asiatic  cholera,  and  that  its  home  is 
the  Ganges.  Human  intercourse  diffuses  it,  but  a  phase  outside  the  human 
body,  that  is,  an  ectanthropic  period  of  existence  and  development  there 
must  be.  This  phase  is  frequently  passed  in  the  water  where  the  comma 
bacilli  experience  changes  in  infective  virulence.  Long  seasons  of  warmth 
favour  their  development,  rains  and  cold  inhibit  it ;  but  beyond  India 
they  cannot  gain  a  permanent  footing,  although  they  may  survive  for 
months  and  years  under  suitable  surroundings,  gradually  losing  their 
original  features ;  these,  however,  they  may  regain  under  given  conditions 
and  for  a  given  time.  Carried  away  by  the  rivers  and  streams^  they 
reach  the  digestive  tract  through  the  water,  in  some  cases  perishing  at 
once,  in  others  passing  away  harmlessly,  andinyet  others  producing  lesions 
varying  in  intensity  from  diarrhoea  to  typical  cholera.  Personal  disposi- 
tion in  this  connection  is  of  far  reaching  importance.  These  views  are  evi- 
dently a  modification  of  those  oricinally  held  by  the  contagionist  school, 
but  years  must  elapse  before  a  complete  solution  of  the  problem  is  found. 

A  few  matters  still  remain  to  be  discussed  in  the  light  of  recent 
knowledge :  these  are  (1)  the  pathogenetic  properties  of  the  comma 
bacilli ;  (2)  their  chemistry;  (S)  the  production  of  immunity  in  animals 
and  in  man ;  and  (X)  the  vitality  of  the  vibrios  outside  the  human  body. 

1.    The  Pathogenetic  Properties  of  the  Comma  Bacilli.  —  (a)  We  have 


890  SYSTEM   OF  MEDICINE 

already  referred  to  earlier  animal  experiments  on  the  pathogenetic  proper- 
ties of  the  cholera  vibrios.  These,  however,  were  hardly  convincing,  and, 
a  few  exceptions  apart,  it  has  generally  been  admitted  that  it  is  impossi- 
ble to  produce  a  true  choleraic  state  in  animals.  Recent  researches  have 
shown  that  intraperitoneal  inoculation  of  guinea-pigs  is  generally  fol- 
lowed by  death ;  and  this  reaction  at  one  time  was  thought  by  Koch  and 
Pf eiffer  to  be  characteristic  of  the  true  vibrios :  we  now  know,  however, 
that  no  reliance  can  be  placed  on  this  test.  It  was  further  thought  that 
the  results  following  such  intraperitoneal  inoculation  are  specific,  and 
therefore  of  great  value  for  the  purpose  of  diagnosis.  But  Klein  has 
conclusively  demonstrated  that  the  same  symptoms  and  the  same  ana- 
tomical changes  follow  intraperitoneal  injections  of  other  bacterial  forms, 
such  as  the  vibrio  of  Finkler-Prior,  the  bacterium  coli,  the  bacillus 
prodigiosus,  proteus,  and  others ;  and  his  observations  have  been  con- 
firmed by  Sobernheim,  Gruber,  and  others.  Hence  there  is  nothing 
specific  in  this  animal  reaction.  Sanarelli  likewise  maintains  that  the 
enteritis  which  may  be  produced  by  infection  with  choleraic  vibrios  is 
not  specific,  and  is  identical  with  that  produced  by  other  organisms 
or  their  toxins.  According  to  Gamaleia.,  on  inoculation  a  disease  not 
unlike  cholera  appears  in  dogs,  with  the  symptoms  of  vomiting,  diarrhoea, 
convulsions,  cold  and  cyanosis. 

In  considering  the  immunity  of  man  under  certain  conditions  of 
season  and  locality,  the  tAvo  factors  especially  dwelt  upon  by  Pettenkof er, 
the  question  arose  in  the  mind  of  Metschnikoff  whether  the  presence  of 
other  micro-organisms  in  the  intestinal  tract  may  co-operate  in  this  result. 
Kitasato  had  worked  at  this  problem  in  1889 :  using  artificial  media,  he 
found  that  the  growth  of  cholera  vibrios  was  generally  not  arrested  by 
the  presence  of  other  micro-organisms  —  on  the  contrary,  that  cholera 
vibrios  checked  and  even  destroyed  a  variety  of  bacilli  in  a  fcAv  days. 
Kitasato,  however,  found  some  exceptions  to  this  general  statement ;  the 
bacillus  pyocyaneus,  for  instance,  is  stronger  than  the  cholera  vibrio. 
Metschnikoff  was  able  to  confirm  this  latter  statement,  and  found,  by 
culture  on  artificial  media,  that  cholera  vibrios  are  extremely  sensitive 
to  the  presence  of  other  organisms,  and  when  subject  to  these  conditions 
undergo  certain  developmental  and  morphological  changes.  He  then 
proceeded  to  inquire  whether  the  immunity  of  animals  against  intesti- 
nal cholera  could  be  explained  by  postulating  some  action  of  intestinal 
micro-organisms  antagonistic  to  the  cholera  vibrios. 

For  this  purpose  Metschnikoff  used  suckling  rabbits,  in  whose  intes- 
tinal canal  micro-organisms  are  scanty  and  of  few  kinds.  By  experi- 
ments on  artificial  media  he  found  that  certain  species  of  torula  and 
sarcina  were  favourable  to  the  development  of  cholera  vibrios.  On 
infection  by  the  mouth  with  the  Massowah  vibrio,  together  with  a  torula 
and  a  sarcina,  four  rabbits,  aged  4  to  8  days  old,  were  attacked  with  fatal 
cholera;  but  death  did  not  occur  for  7  to  9  days.  In  a  second  series  of 
experiments  he  used  a  combination  of  cholera  vibrios,  as  arcina,  a  torula, 
and  a  bacillus  (related  to  B.  coli) ;  of  twenty-eight  rabbits  two  only  sur- 


CHOLERA   ASIATICA 


vived,  and  death  frequently  occurred  in  36  to  48  hours.  On  section  the 
small  intestine,  especially  the  ileum,  was  hyperaemic,  and  the  ceecum  was 
distended  with  a  fluid  which  often  recalled  the  characteristic  appearance 
of  the  watery  stools  in  man.  Microscopically  the  small  intestine  more 
especially  contained  the  cholera  vibrios ;  in  the  majority  of  cases  in  pure 
culture.  The  csecum,  while  also  presenting  numerous  vibrios,  always 
contained  other  bacilli  besides.  By  examining  animals  at  various 
stages  of  the  process  it  was  found  that  the  torula,  sarcina,  and  colon 
bacillus,  originally  added,  disappeared  in  a  few  hours ;  so  that  the  result 
was  not  a  mixed  infection,  but  jDossibly  one  similar  to  that  seen  in  inocu- 
lations with  the  tetanus  bacillus  which  requires  the  association  of  other 
organisms  or  of  its  own  toxin  to  produce  the  fatal  spasms.  Nor  can  the 
process  be  regarded  as  a  simple  intoxication ;  for  Metschnikoff  describes 
thirteen  cases  of  spontaneous  infection  among  broods  of  rabbits  suckled 
by  the  same  mother.  Here  the  quantity  of  infective  material  had  been 
small,  too  small  to  account  for  the  fatal  result  on  the  hypothesis  of  intoxi- 
cation. These  results  were  only  obtained  with  suckling  rabbits ;  when 
the  young  had  fed  on  green  food  they  were  no  longer  susceptible. 

Of  young  guinea-pigs  similarly  treated  thirteen  out  of  seventeen 
died ;  but  diarrhoea  was  a  rare  occurrence,  and  the  post-mortem  appear- 
ances were  far  less  pronounced.  On  the  other  hand  the  vibrios  were 
found  in  the  blood  of  the  heart  in  thirteen  cases. 

Dunbar  maintains  that  the  specificity  of  Koch's  cholera  vibrio  has 
actually  been  proved  by  the  experiments  of  Sabolotny  who,  like  Metsch- 
nikoff, asserts  that  he  has  produced  true  cholera  in  animals.  He  fed 
Marmots  {SpermophUus  guttatus)  with  common  bacilli,  and  thereby  pro- 
duced an  infection  presenting  the  classical  symptoms  of  Asiatic  cholera; 
of  this  malady  50  per  cent  of  the  animals  died.  They  became  prostrate, 
refused  food,  their  temperature  fell  from  38°  C.  to  32°  C,  clonic  spasms 
and  cyanosis  appeared,  and  after  death  the  gut  was  filled  with  fluid,  often 
sanguineous,  and  containing  white  flocculi,  which  consisted  to  a  great 
extent  of  cholera  vibrios.  However  interesting  these  observations  of 
Metschnikoff  and  Sabolotny  may  be,  they  carry  less  conviction  on  account 
of  the  very  special  nature  of  the  animals  used.  It  is  practically  useless 
to  look  to  inoculations  of  rodents  or  dogs  or  of  any  animal  for  positive 
proof.  Inoculations  of  pigeons  by  some  observers  are  stated  to  be  a  dis- 
tinguishing test  between  true  and  spurious  cholera  vibrios,  the  former 
having  no  effect  on  these  animals.  Sawtschenko  and  Weichselbaum,  how- 
ever, showed  that  though  generally  immune,  pigeons  succumb  occasion- 
ally ;  and  Salus  found  that  they  can  frequently  be  infected  with  the  true 
cholera  vibrio  as  readily  as  with  Metschnikoff's  vibrio:  herein  he  is 
confirmed  by  Rumpel,  Weibel,  and  others,  so  that  this  test  also,  once 
vaunted,  had  to  be  abandoned. 

(b)  Experiments  on  man  have  contributed  much  towards  establishing 
the  infective  nature  of  the  cholera  vibrios.  Pettenkofer,  Emmerich, 
Metschnikoff,  and  Hasterlik  collectively  report  observations  made  on 
eighteen  persons,  who  swallowed  pure  cultures  of  vibrios.    In  some  cases 


892  SYSTEM  OF  MEDICINE 

severe  symptoms  followed,  in  others  none,  in  others  again  slight  diarrhoea. 
The  cases  described  by  Macnamara,  who  saw  five  persons  out  of  nineteen 
fall  victims  to  cholera  after  drinking  water  which  had  been  contaminated 
with  choleraic  dejecta ;  the  well-known  case  of  Orgel  of  Hamburg ;  Koch's 
equally  famous  ease ;  as  well  as  that  of  Freymuth  and  Lickfelt,  where 
cholera  had  been  acquired  in  the  laboratory ;  or  the  experiments  of  Boche- 
f ontaine  and  Klein,  cannot  be  used  as  arguments  for  or  against  the  question 
under  discussion :  there  is  no  evidence  that  pure  cultures  had  been  used  in 
these  cases.  We  may  ask,  indeed,  whether  the  other  cases  are  convincing  ? 
The  doubtful  critic  may  maintain  with  some  justice  that  they  are  not,  for 
amongst  the  eighteen  persons  not  one  succumbed  to  the  infection.  Yet 
Metschnikoff,  whose  opinion  is  of  great  value,  declares  that  in  at  least 
one  case  he  observed  the  symptoms  of  true  cholera  to  follow  the  drink- 
ing of  a  pure  culture  of  Koch's  vibrio;  and  that,  in  spite  of  the  variability 
of  the  comma  bacillus,  there  is  no  reason  to  doubt  that  it  is  the  specific 
cause  of  cholera.  We  must  refrain  from  expressing  a  positive  opinion, 
for  evidence  based  on  young  sucklings  and  marmots,  and  on  a  few  cases 
of  diarrhoea  is  insufficient,  although  it  brings  us  nearer  to  a  solution  of 
this  vexed  question.  Pettenkofer,  indeed,  who  for  more  than  ten  years 
was  an  avowed  opponent  of  Koch's  views,  has  been  constrained,  on  the 
strength  of  the  observations  of  the  last  three  years,  to  acknowledge  the 
vibrio  as  the  specific  organism  of  cholera. 

We  must  also  point  out  that  Haffkine's  patient  anticholeraic  vaccina- 
tions in  India  have  contributed  much  to  establish  this  hypothesis.  Haff- 
kine  is  firmly  convinced  that  the  cause  of  cholera  is  one  variable  vibrio ; 
and  for  the  purpose  of  vaccination  he  uses  living  cultures  of  that  which 
he  considered  to  be  the  choleraic  vibrio.  He  originally  prepared  two  vac- 
cines, a  weakened  first  virus  and  a  strengthened  second  virus  ;  so  that  the 
principle  of  his  inoculations  is  the  same  as  that  practised  in  the  case  of 
anthrax.  jSTow  if  his  operations  have  been  accompanied  by  adequate 
success,  it  may  be  argued  that  they  will  go  far  to  establish  the  specific 
action  of  the  cholera  vibrio,  and  also  to  prove  that  we  are  dealing  with 
one  organism  of  protean  shapes.  His  results  up  to  this  date  have  been 
very  satisfactory.  Thus  in  Calcutta  he  found  that  the  mortality  among 
the  inoculated  was  17-24  times  less,  and  the  incidence  of  cholera  19-27 
times  less  than  among  the  non-inoculated ;  so  that  the  present  evidence  is 
certainly  in  favour  of  the  anticholeraic  vaccination.  If  further  observa- 
tions confirm  the  results  already  obtained,  we  can  hardly  any  longer 
doubt  the  specificity  of  the  cholera  vibrio.  The  test  of  experience  on 
man  is  therefore  that  best  calculated  to  carry  conviction. 

2.  Chemistry  of  the  Cholera  Vibrio.  —  A  few  words  on  the  nature  of 
the  cholera  toxin  will  suffice,  since  our  knowledge  of  it  is  still  very  im- 
perfect. Scholl  obtained  from  cultures  in  eggs  a  toxic  peptone  which, 
however,  according  to  Gruber  and  Wiener,  can  be  obtained  from  unin- 
fected eggs.  Emmerich  and  Tsuboi  explained  cholera  as  a  nitrate  in- 
toxication, but  their  fallacies  were  disproved  by  Klemperer,  who  showed 
that  cholera  vibrios  which  have  lost  the  power  of  forming  nitrites  remain 


CHOLERA   A  SI  A  TIC  A  893 


virulent  nevertheless.  Pfeiffer  assumed  that  the  poison  is  protoplasmic, 
and  contained  in  the  bacterial  cells ;  others  assumed  that  this  poison  is  not 
specific,  but  is  a  substance  common  to  many  bacteria  (a  protein,  Klein's 
intracellular  poison).  Brieger,  it  may  be  remarked,  had  formerly  sepa- 
rated six  ptomaines  from  impure  cholera  cultures ;  and  Gamaleia  had 
anticipated  Pfeiffer  when  he  described  two  poisons  belonging  to  the 
group  of  nucleins  and  nucleo-albumins  which  he  had  extracted  from 
the  bodies  of  the  vibrios :  while  Wesbrook  showed  that  the  nature  of 
the  cholera  products  varies  with  the  medium  in  which  the  vibrios  grow. 
Passing  over  the  numerous  observations  made  by  various  writers,  it  may 
sufhce  to  say  that  none  of  the  substances  separated  so  far,  whatever 
their  nature  may  be,  is  capable  of  producing  in  animals  the  symptoms 
characteristic  of  the  disease  in  man ;  the  chemical  identity  of  the  prod- 
ucts formed  in  the  body  of  choleraic  individuals  and  of  those  developed 
in  artificial  media  has  not  yet  been  proved.  It  must  be  remarked,  how- 
ever, that  with  most  of  the  substances  mentioned,  different  as  their 
nature  may  be,  an  artificial  immunity  may  be  produced  in  the  animal. 

3.  On  Artificial  Immunity  little  need  be  said  since,  as  we  have  seen, 
animal  experiments  have  not  as  yet  been  of  much  assistance ;  indeed, 
they  have  contributed  rather  to  our  confusion.  Haffkine,  as  already 
mentioned,  employed  Pasteur's  method  of  vaccination  with  attenuated 
and  strengthened  living  virus.  Immunity  by  means  of  living  cultures 
may  be  produced  by  subcutaneous  or  intraperitoneal  injections,  but  also 
by  means  of  the  introduction  of  vibrios  through  the  mouth ;  indeed,  some 
observers  maintain  that  the  highest  degrees  of  immunity  are  obtained  by 
feeding.  With  regard  to  the  methods  of  protection  there  exist  two  views 
of  the  pathogenesis  of  cholera.  Some  consider  the  lesions  naturally  occur- 
ring in  man,  and  artificially  produced  in  animals,  to  be  due  to  intoxication; 
so  that  in  order  to  produce  an  immunity  all  that  is  required  is  to  render 
the  body  toxin  proof :  the  seat  of  infection  is  of  secondary  importance. 
Others  believe  that  the  locality  where  the  vibrio  thrives  cannot  be 
neglected;  and  that  an  immunity  of  the  skin  or  peritoneum,  for  ex- 
ample, does  not  imply  an  immunity  of  the  intestinal  tract.  The  latter 
experimenters  assert  that  guinea-pigs,  immune  on  subcutaneous  or  intra- 
abdominal inoculation,  are  still  susceptible  to  an  infection  by  the  mouth. 
There  is,  however,  considerable  diversity  of  opinion  on  this  point. 
Metschnikoff,  experimenting  on  man,  was  inclined  to  believe  that  the 
intestinal  tract  cannot  be  rendered  cholera  proof  by  any  form  of  arti- 
ficial infection;  while  Sanarelli,  maintaining  that  cholera  is  a  toxic 
enteritis,  contends  that  a  cholera  immunity  must  depend  on  an  acquired 
tolerance  of  the  cholera  poison  by  the  intestinal  walls.  Sabolotny  agrees 
with  Metschnikoff  that  subcutaneous  or  intraperitoneal  treatment  does 
not,  in  the  case  of  marmots  at  least,  protect  against  gastric  infection. 

It  is  important  to  know  whether  one  form  of  choleraic  vibrio  protects 
against  all  others.  According  to  Pfeiffer,  the  action  of  all  true  comma 
bacilli  is  reciprocal,  but  there  is  no  reciprocity  in  protection  between  the 
true  and  false  vibrios.     An  immunity  established  by  intraperitoneal  in- 


894  SYSTEM  OF  MEDICINE 

jection  of  one  organism  may  lead  to  a  merely  transitory  immunity  from 
another  and  different  organism,  but  to  a  lasting  immunity  from  identical 
organisms.  An  animal  protected  against  the  cholera  vibrio  is  still  sus- 
ceptible to  the  vibrio  of  Metschnikoff.  This  is  the  fundamental  principle 
of  his  serum  test.  On  the  other  hand,  Sabolotny  asserts  that  artificial 
immunity  procured  with  one  variety  does  not  necessarily  imply  protec- 
tion against  others;  and  many  observers  —  such  as  Salus,  Weibel,  and 
Sanarelli  —  maintain  that  there  is  a  reciprocal  protective  action  between 
the  vibrios  of  Metschnikoff  and  the  true  cholera  vibrios.  This  seems 
to  be  so  well  established,  that,  if  we  accept  the  theory  of  the  unity  of 
the  vibrios,  we  are  almost  forced  to  find  a  place  for  this  organism  in 
the  long  series  of  choleraic  forms ;  an  admission  hardly  calculated  to 
make  matters  easier,  but  nevertheless  the  logical  outcome  of  laboratory 
observations.  Haffkine's  experiment  in  India  seems  to  show  that  by 
means  of  one  variety  of  the  comma  bacillus  an  immunity  can  be  pro- 
duced in  pj.an  against  all  other  true  vibrios.  Thus  once  more  we  come 
face  to  face  with  contradictions  which  may  find  their  natural  explana- 
tion in  the  variable  conditions  of  experiment. 

Numerous  experiments  have  also  been  made  with  serum,  and  the 
fact  is  established  that  an  animal  may  be  protected  against  a  cholera 
peritonitis  by  means  of  a  specific  serum.  Klemperer  and  others  showed 
that  the  serum  obtained  from  individuals  who  have  recovered  from 
cholera  has  a  marked  protective  action,  and  that  the  serum  of  arti- 
ficially protected  animals  is  equally  potent.  These  observations  ought 
to  be  regarded  as  an  additional  proof  of  the  specificity  of  the  comma 
bacillus;  but  Metschnikoff  and  others  have  shown  that  normal  serum 
is  frequently  thus  active,  and  we  have  said  that  horse's  serum,  accord- 
ing to  Pfeiffer  and  Issaeff,  possesses  similar  protective  power.  Never- 
theless it  is  generally  accepted  that  to  confer  an  immunity  from  cholera 
upon  an  animal  is  to  render  its  serum  anticholeraic;  and  experiments 
have  further  shown  that  by  gastric  inoculations  also  this  result  can  be 
obtained.  We  have  referred  above  to  the  conflict  of  opinion  on  the 
specificity  of  the  serum  of  protected  animals,  and  we  do  not  wish  to 
reopen  the  matter.  Whether  a  therapeutic  serum  will  ever  be  found  for 
cholera  must  be  left  to  the  future ;  suffice  it  to  state  here  that  Behring 
is  firmly  convinced  of  its  possibility,  and  is  at  the  present  time  striv- 
ing hard  to  secure  it.  The  various  views  held  from  time  to  time  with 
regard  to  a  natural  cholera  immunity  need  not  detain  us  further  than 
just  to  allude  to  the  ingenious  explanation  put  forward  by  G.  Klem- 
perer, who  believes  that  it  depends  on  the  nuclein  substances  of  the 
intestinal  epithelium  which  possess  marked  antimicrobic  power. 

4.  Vitality  of  the  Cholera  Vibrio.  —  If  Ave  assume  that  the  vibrios  are 
the  cause  of  cholera,  we  are  forced  to  meet  the  objections  of  those  who 
deny  their  aetiological  importance  on  the  ground  of  their  want  of  resist- 
ance to  external  influences.  If  we  are  to  accept  the  opinion  mentioned 
above,  that  the  various  water  vibrios  are  but  degenerated  or  altered 
forms  of  one  species,  we  shall  find  less  dilficulty  in  explaining  outbreaks 


CHOLERA    A  SI  A  TIC  A  895 


or  sporadic  cases  of  cholera.  But,  apart  from  this  unproved  hypothesis, 
recent  observations  have  shown  that  the  choleraic  vibrios  are  more 
resistant  than  is  generally  supposed,  (a)  These  organisms  may  find  an. 
abode  in  persons  actually  or  apparently  healthy.  Thus  during  the 
winter  epidemic  of  1892-1893  the  presence  of  Koch's  vibrio  was  demon- 
strated in  the  Hamburg  Hygienic  Institute,  in  twenty-eight  healthy 
persons ;  and  also  in  the  members  of  certain  families  similar  observa- 
tions were  made.  These  twenty-eight  persons  had  been  in  contact  with 
cholera  patients,  and  their  stools  were  solid  or  semi-solid.  Abel  and 
Claussen  found  vibrios  in  the  faeces  of  13  out  of  17  healthy  persons 
who  had  been  in  daily  intercourse  with  cholera  patients.  (6)  In  the 
stools  of  convalescents  from  cholera  vibrios  were  found  after  50,  47,  27, 
16,  10,  and  8  days ;  and  (c)  it  has  been  shown  that  they  may  remain 
alive  and  capable  of  proliferation  in  choleraic  dejecta  for  a  considerable 
time.  Thus  Gruber  isolated  vibrios  from  a  stool  which  had  been  kept 
for  15  days;  Karlinski  from  stools  52,  37,  and  28  days  old;  while 
Dunbar  succeeded  in  the  same  search  after  76,  143,  and  163  days,  and 
occasionally  even  after  8  months,  (c?)  As  regards  artificial  cultivation,  the 
cholera  vibrio  has  been  shown  to  be  highly  saprophytic.  Thus,  according 
to  Frankel,  it  thrives  in  solutions  of  0-4  per  cent  aspartate  of  sodium,  and 
in  water  it  will  also  remain  alive  for  some  time  ;  on  potato  boiled  in  salt 
solution  it  grows  well  at  the  ordinary  temperature,  and  even  at  8°  C. 
In  ordiiiary  milk  it  survives  12  hours  to  6  days;  on  fruit  and  fish  for 
some  days,  (e)  From  flies  fed  on  choleraic  material  the  vibrios  could  be 
separated  after  14  days ;  on  silk  threads  they  remained  in  a  vital  con- 
dition for  13  to  86  days,  and  dried  on  glass  for  120  days.  (/)  Even 
severe  degrees  of  cold  can  be  resisted  for  a  few  days ;  the  concurrence  of 
saprophytes,  according  to  Kitasato,  has  but  little  influence  on  them ;  but 
acids  soon  destroy  them,  {g)  In  water  they  remain  alive  for  many  days ; 
in  sterile  distilled  water  for  73  days  to  a  year;  in  sterile  well-water  for 
months,  but  in  unsterilised  water  for  from  4  to  25  days.  Orgel,  indeed, 
succeeded  in  keeping  them  alive  in  ordinary  Elbe  water  for  almost  a  year. 
Hence  these  vibrios  are  possessed  of  no  little  tenacity ;  and,  if  they  be  the 
cause  of  cholera,  there  is  no  difficulty  in  explaining  the  spread  of  an 
epidemic,  so  that  Pettenkofer's  early  objection  —  already  withdrawn  by 
himself  —  falls  to  the  ground. 

Summary.  — ■  If  we  now  review  shortly  our  position  with  regard  to 
the  bacterial  ffitiology  of  cholera,  we  find  that  (1)  vibrios  are  so  con- 
stantly associated  with  the  disease  that  their  absence  may  justly  be  taken 
as  an  error  in  observation ;  (2)  vibrios  are  frequently  found  in  pure 
culture  to  the  exclusion  of  other  organisms.  (3)  These  vibrios  are  pos- 
sessed of  great  variability,  both  morphologically  and  biologically ;  so 
that  new  forms,  widely  different  from  the  original  stock,  can  readily  be 
produced  in  the  laboratory.  We  have,  therefore,  some  justification  in 
regarding  the  various  kinds  of  vibrios  obtained  from  cholera  dejecta 
as  descendants  of  one  species;  but  we  have  as  yet  no  means  of  proving 
this  assumption.     (4)  None  of  the  various  tests,  taken  singly,  suffice  to 


896  SYSTEM  OF  MEDICINE 

establish,  the  unity  or  specificity  of  the  vibrios ;  but  the  circumstantial 
evidence  is  fairly  strong  —  indeed,  so  far  as  our  present  knowledge  goes, 
almost  convincing,  (a)  Ffeitfer's  test,  with  its  modifications,  although 
not  an  absolute  one,  has  proved  the  true  nature  of  a  very  large  number 
of  vibrios  obtained  from  undoubted  cholera  cases,  or  from  sources  where 
contamination  had  taken  place ;  though  in  some  instances  it  has  broken 
down.  (jS)  Further,  there  is  the  evidence  of  Klemperer  that  the  serum 
of  persons  who  have  recovered  from  cholera  has  protective  powers  against 
inoculations  of  animals  with  cholera  vibrios ;  and  that,  conversely,  the 
serum  of  animals  rendered  immune  by  means  of  choleraic  vaccination 
displays  the  same  powers.  True,  normal  serum  often  has  the  same  action, 
but  certainly  to  a  less  degree,  (y)  Within  certain  limits  this  action  of 
the  serum  of  protected  animals  is  specific.  (8)  Lastly,  there  are  the 
observations  of  Haffkine  in  India,  who  finds  that  the  subcutaneous  inocu- 
lation of  a  true  vibrio  will  protect  man  against  Asiatic  cholera.  The 
various  lines  of  argument  all  then  converge  towards  one  point,  namely, 
the  unity  and  specificity  of  the  choleraic  vibrios.  Time  will  show  how 
far  this  classification  is  final. 

We  shall  conclude  this  account  with  directions  to  guide  the  physician 
in  the  bacteriological  diagnosis  of  cholera ;  but  we  must  premise  that, 
comparatively  simple  as  this  is  in  skilled  hands,  it  cannot  be  under- 
taken by  persons  unfamiliar  with  bacteriological  methods. 

Bacterial  Investigation  of  Bowel  Contents  and  of  Dejecta.  —  The 
methods  here  summarised  were  those  used  by  Dr.  Klein  in  his  examination 
of  reputed  cholera  material  during  the  occurrence  of  cholera  in  England 
in  1893.  The  cases  may  be  classified  broadly  in  two  kinds :  (1)  Those  in 
which  microscopical  examination  showed  croiods  of  comma  bacilli  in  the 
mucous  flakes ;  and  (2)  Those  in  which  at  the  outset  comma  bacilli,  as  com- 
pared with  other  bacilli,  were  in  a  small  minority.  It  is  in  cases  of  the  latter 
kind,  which  present  the  greater  difficulty,  that  the  value  of  Method  3  is 
recognised.  On  the  other  hand,  when  the  comma  bacilli  are  originally 
present  almost  in  pure  culture,  other  methods  are  equally  good. 

Method  1.  —  A  flake  from  the  dejecta  is  placed  in  peptone  broth,  and 
incubated  at  37°  C.  In  24  hours  an  abundant  crop  of  vibrios  is  found  in 
the  superficial  layers  of  the  broth.  This  pellicle  consists  of  a  practically 
pure  culture,  or  at  any  rate  is  a  culture  which  easily  allows  of  pure  sub- 
cultures being  obtained. 

Method  2.  —  A  flake  is  placed  in  sterile  salt  solution  or  broth ;  it  is 
shaken  up,  and  from  this  gelatine  or  agar  tubes  are  inoculated,  and  plates 
are  made.  In  agar  plates  incubated  at  37°  C,  numerous  colonies  may  be 
found  in  20  to  30  hours.  In  the  gelatine  plates,  after  2  to  3  days' 
incubation  at  20°  to  22°  C,  numerous  typical  colonies  can  be  got. 

Method  3.  — A  flake  is  placed  directly  into  Dunham's  peptone  salt  solu- 
tion (1  per  cent  peptone,  0-5  per  cent  sodium  chloride),  or  the  Dunham's 
solution  is  inoculated  after  previous  dilution  of  the  material.  The  peptone 
solution,  after  6,  8,  to  10  hours'  incubation  at  37°  C,  shows  a  definite  tur- 
bidity, due  to  the  rapid  growth  of  the  comma  bacilli ;  and  the  cholera-red 


CHOLERA    ASIATICA  897 


reaction  may  be  obtained.  For  speedy  diagnosis  tliis  method  is  most 
valuable :  in  6  to  12  hours,  or  at  latest  in  IG  hours,  comma  bacilli  can  be 
found  in  the  superficial  layers  of  the  peptone  solution,  so  that  in  24 
hours  pure  sub-cultures  and  the  cholera-red  reaction  can  be  obtained  in 
secondary  peptone  tubes.  Also  a  positive  result  may  be  got  by  this 
method  in  cases  in  which  the  microscopical  examination  has  failed  to 
give  definite  evidence  of  the  presence  of  vibrios. 

A.  A.  Kanthack. 

J.  W.  W.  Stephens. 

Clinical,  Pathological,  and  Therapeutical  Aspects  of 
Asiatic  Choleka 

Symptoms  of  Cholera.  —  In  different  epidemics  and  different  indi- 
vidual cases  these  present  considerable  variation.  It  will  be  most  con- 
venient to  describe,  in  the  first  place,  the  phenomena  of  an  ordinary 
seizure  —  the  form  of  disease  most  frequently  met  with  ;  and  then  briefly 
to  delineate  those  less  common  manifestations  which  are  seen  during 
the  course  of  epidemic  outbreaks,  and  seem  to  owe  their  exceptional 
character  to  variations  in  the  strength  and  amount  of  the  poison,  or 
to  peculiarities  in  the  constitution  and  proclivities  of  individuals  w,ho 
have  been  subjected  to  its  influence. 

The  Ordinary  Form.  —  In  a  characteristic  case  of  cholera  it  is  always 
possible  to  distinguish  certain  well-marked  stages  which  have  been  desig- 
nated by  their  most  striking  features.  A  premonitory  or  incubative 
stage  can  be  recognised  in  a  large  proportion  of  cases,  followed  by  the 
stage  of  evacuation,  of  which  purging,  vomiting  and  muscular  cramps 
are  the  most  prominent  phenomena ;  to  this  succeeds  a  stage  of  collapse, 
characterised,  as  the  name  implies,  by  profound  depression  of  all  the 
functions  of  the  body  ;  finally,  a  stage  of  reaction,  in  which  more  or  less 
febrile  excitement  is  manifested,  ends,  in  favourable  cases,  in  recovery. 

The  stage  of  incubation  is  that  which  intervenes  between  the  recep- 
tion of  the  poison  and  the  manifestation  of  serious  and  characteristic 
disturbance  of  health.  Its  duration  varies  from  a  few  hours  to  a  few 
days,  probably  not  exceeding  ten.  Three  to  six  days  appear,  inferen- 
tially,  to  be  the  usual  length  of  this  stage ;  though  precise  and  positive 
knowledge  is  wanting,  owing  to  the  lack  of  exact  information  as  to  what 
enters  the  body  and  hoAv  and  when  it  effects  an  entrance.  The  symp- 
toms of  deranged  health  which  may  be  felt  or  observed  during  this 
period  are  referable  to  gastro-intestinal  irritation,  and  to  a  disturbed  or 
depressed  condition  of  the  nervous  system.  Diar-rhoea  is  the  most  common 
precursor  of  cholera :  it  may  last  for  hours  or  even  days,  and  is  apt  to 
be  copious  and  watery,  motions  being  passed  three  or  four  times  a  day ;  it 
may  be  painless  or  accompanied  with  griping.  There  is  often  a  feeling 
of  weight  or  oppression  at  the  pit  of  the  stomach,  and  there  is  reason  to 
believe  that  in  this  stage  the  function  of  digestion  is  seriously  impaired 
(Choversj.     The  nervous  symptoms  take  the  form  of  malaise,  depression 

VOL.  1  3  m 


SYSTEM   OF  MEDICINE 


of  spirits,  pallor,  anxious  expression,  exhaustion,  giddiness,  tinnitus  and 
headaclie. 

In  most  cases  premonitory  symptoms  are  not  noticeable  or  are  very 
transient ;  and  the  disease  sets  in  without  warning,  with  violent  purging 
and  vomiting,  speedily  followed  by  cramps  and  progressive  exhaustion. 
These  are  the  essential  phenomena  of  the  stage  of  evacuation,  which 
may  last  from  two  to  twelve  hours  or  longer  —  the  duration  depending 
probably  on  dosage  and  vital  resistance.  The  purging  is  frequent,  copious 
and  watery.  The  earlier  stools  are  fseculent,  the  later  pale,  resembling 
whey  or  water  in  which  rice  has  been  boiled  —  a  flocculent  or  curdy  sedi- 
ment being  deposited  on  standing.  Later  motions  are  sometimes  sanious. 
Successive  evacuations  shoidd  be  received  in  separate  vessels  for  observa- 
tion and  comparison.  •  There  may  be  griping  or  abdominal  pain ;  more 
frequently  there  is  neither.  The  bulk  of  material  passed  in  this  stage 
is  often  very  large.  Vomiting  generally  begins  later  than  purging: 
the  contents  of  the  stomach  are  first  expelled ;  and  it  has  been  observed 
that  these  are  often  undigested,  though  they  have  been  in  the  stomach 
for  some  time.  The  later  rejections  are  watery  and  copious,  emitted  with 
force,  and  occasionally  tinged  with  blood.  Vomiting  is  easily  excited  by 
ingesta,  and  these  are  generally  returned  sooner  or  later.  In  some  cases 
distressing  and  exhausting  retching  occurs  without  much  result.  The 
reaction  of  the  vomited  material  varies ;  it  is  sometimes  very  acid. 
Muscular  cramps  are  a  painful  feature  of  this  stage ;  they  may  begin 
with  the  purging,  and  be  prolonged  into  the  next  stage.  The  legs  are 
their  most  frequent  seat ;  but  the  muscles  of  the  abdomen  and  back,  and 
in  some  cases  the  whole  muscular  system  may  be  affected;  the  cramped 
muscles  feel  hard  and  knotty,  and  in  many  cases  the  pain  is  very  severe. 
The  temperature  of  the  body  falls  somewhat  as  this  stage  proceeds,  the 
surface  becoming  cold,  dusky,  clammy,  or  covered  with  sweat.  The 
features  are  drawn,  eyes  sunk,  expression  anxious  or  blank,  fingers  and  toes 
shrivelled,  tongue  white  and  cold.  There  is  great  thirst  and  much  rest- 
lessness. The  breathing  is  not  thus  far  much  affected,  but  the  pulse  rises 
in  rate  and  loses  in  force.  The  patient  becomes  greatly  exhausted,  and, 
though  generally  sensible,  is  apathetic.  Kecovery  may  take  place  in  this 
stage  by  cessation  of  purging,  vomiting  and  cramps,  and  gradual  restora- 
tion of  strength ;  but  in  the  majority  of  cases  a  more  profound  depression 
of  vitality  sooner  or  later  supervenes.  This  is  the  stage  of  collapse,  into 
which  the  patient  may  lapse  gradually  or  s-uddenly.  It  may  last  from 
two  or  three  to  forty-eight  hours,  or  even  more,  the  attention  being 
withdrawn  from  the  evacuations,  and  arrested  by  the  signs  of  alarming 
exhaustion.  Liquid,  colourless  motions  may  still  be  occasionally  passed 
involuntarily ;  or  the  presence  of  watery  material  may  be  detected  in 
the  intestines  by  palpation  or  succussion.  Vomiting  or  attempts  to  vomit 
may  persist,  and  cramps  are  often  jDresent,  sometimes  terribly  painful. 
But  these  symptoms  are  overshadowed  by  the  evidences  of  failing  power: 
the  pulse  flickers  and  fails  at  the  wrist,  and  is  sometimes  imperceptible 
in  the  brachial  and  almost  so  in  the  femoral  arteries ;  its  rate,  always 


CHOLERA   ASIATICA  899 


accelerated,  may  rise  to  120  or  140,  or  even  higher.  The  heart  sounds 
get  less  distinct,  especially  the  first :  in  some  cases  strange  murmurs  and 
friction  sounds  are  detected  in  this  stage  (Wall),  which  betoken  disturbed 
and  inco-ordinate  contraction  of  its  walls  or  the  existence  of  clots  in  its 
cavities. 

The  capillary  circulation  becomes  slow  and  feeble,  the  surface  gets 
livid ;  respiration  is  quick  and  shallow,  painful  and  often  paroxysmal 
dyspnoea  arises,  compelling  the  sufferer  to  struggle  for  breath ;  the  ex- 
pired air  is  cold  and  deficient  in  carbonic  acid.  The  face  presents  the 
characteristic  choleraic  expression  —  features  pinched,  skin  drawn,  eye- 
balls sunken  and  surrounded  by  a  dark  areola,  lids  half  closed,  pupils 
contracted,  mouth  open,  teeth  covered  with  sordes,  tongue  cold,  counte- 
nance apathetic.  The  general  surface  is  cyanotic  and  clammy  or  be- 
dewed with  cold  sweat :  the  fingers  and  toes  are  wrinkled.  There  is  great 
restlessness  and  profound  debility.  The  intelligence  is  clouded,  the 
senses  impaired,  the  muscular  power  diminished:  in  some  cases  sense 
and  sensibility  and  capacity  of  movement  are  retained  ;  in  others  coma 
or  a  semi-comatose  state  exists.  The  voice  is  husky  and  feeble,  or  the 
patient  can  speak  only  in  faint  whispers.  Thirst  is  imperative,  and  a 
feeling  of  coldness  is  felt.  The  urine  is  suppressed ;  the  bladder  is 
generally  emptied  in  the  preceding  stage,  and  no  further  accumulation 
of  urine  takes  place.  The  temperature  of  the  surface  and  mouth  is 
greatly  and,  in  fatal  cases,  increasingly  depressed,  and  may  fall  below 
90°  F. ;  the  temperature  of  the  axilla  is  higher,  but  yet  below  normal, 
readings  of  95°  to  97°  F.  being  not  uncommon  in  this  stage ;  the  rectal 
temperature  may  be  slightly  subnormal  or  normal,  but  in  time  it  shows 
a  tendency  to  rise  above  the  normal. 

In  this  stage  a  peculiar  and  characteristic  odour  may  be  detected  in 
the  breath  and  from  the  skin.  The  motions  are  devoid  of  smell  unless 
they  are  retained,  in  which  case  they  quickly  become  offensive.  It  is 
in  this  stage  of  cholera  that  death  most  frequently  occurs ;  and  the 
fatal  event  may  happen  early  or  late,  very  suddenly  or  after  some 
lingering  hours  while  life  and  function  are  slowly  waning.  Death  may 
occur  by  apncBa,  asthenia  or  coma. 

The  starje  of  reaction  is,  generally  speaking,  characterised  by  a 
gradual  restoration  of  power  and  resumption  of  function.  The  pulse 
returns  to  the  wrist,  feebly  and  fitfully  at  first ;  but  there  is,  in  favour- 
able cases,  a  progression  in  steadiness  and  strength.  The  breathing 
becomes  easy  and  the  patient  tranquil.  Blueness,  coldness,  shrinking 
and  clamminess  of  the  skin  give  way  to  roundness  and  warmth.  Tem- 
])erature  is  normal  or  slightly  raised.  The  stomach  regains  its  tone,  and 
food  is  retained.  The  stools  resume  their  proper  colour  ;  some  looseness 
may  persist,  but  the  motions  are  less  frequent  and  less  watery,  and  ex- 
hibit successively  deepening  tints  of  gray  and  brown.  Urine  is  passed, 
though  its  reappearance  may  be  delayed  for  many  hours;  it  is  at  first 
scanty,  liigh  coloured,  of  strong  smell  and  high  specific  gravity,  albumi- 
nous, and  containing  indoxyl  and  casts  ;  then  it  becomes  watery  and 


god  SYSTEM   OF  MEDICINE 

copious.  Mental  activity  and  muscular  power  return,  and  coraplete 
recovery  may  take  place  within  a  few  days. 

So  happy  a  result  is,  however,  by  no  means  invariable.  In  a  con- 
siderable proportion  of  cases  (from  10  to  25  per  cent)  events  occur  dur- 
ing the  stage  of  reaction  which  constitute  a  serious  departure  from  the 
normal  sequence,  and  prolong  the  illness  or  cause  death. 

The  variations  which  take  place  in  the  symptoms  and  course  of 
cholera  are  numerous  and  well  marked,  and  have  led  to  the  distinction  of 
several  forms  of  the  disease.  These  varieties  of  cholera  are  apt  to  pre- 
sent themselves  more  or  less  prominently  in  different  epidemics  and  at 
different  periods  of  the  same  epidemic ;  and,  for  purposes  of  diagnosis 
and  treatment,  it  is  highly  important  to  take  them  into  account.  They 
are  best  described  in  the  order  of  succession  of  the  phases  of  the  ordi- 
nary disease. 

1.  The  disturbance  of  health  may  be  slight  and  transient.  During 
an  epidemic  of  cholera  many  persons  complain  of  slight  malaise,  anorexia 
and  looseness  of  bowels  which  pass  off  with  or  without  treatment.  This 
is  the  so-called  ambulatory  form.  The  disease  appears  to  be  arrested  or 
abortive  in  the  incubative  stage. 

2.  In  other  and  more  frequent  cases  the  diarrhoea  is  more  pronounced 
and  persistent  —  painless,  accompanied,  perhaps,  with  nausea  or  vomit- 
ing, and  sometimes  with  cramps.  The  stools  are  copious  and  watery, 
inclining  gradually  to  the  rice  water  type.  There  is  no  suppression  of 
urine.  Cases  of  this  kind  occur  in  anticipation  of  or  during  an  epidemic, 
and  contribute  to  that  excessive  prevalence  of  diarrhoea  which  statistics 
indicate  as  generally  concomitant  with  cholera.  With  or  without  the 
aid  of  medicine  recovery  usually  takes  place  within  twenty-four  hours ; 
but  not  unfrequently  such  cases,  especially  if  untreated,  lapse  into  true 
cholera.  This  form  of  disease  has  received  the  name  of  choleraic  diarrhcea 
or  cholerine,  and  appears  to  represent  an  arrest  in  the  stage  of  evacuation. 

3.  On  the  other  hand,  tliis  stage  may  seem  to  be  absent,  patients 
passing  quietly  into  fatal  collapse  without  either  vomiting  or  purging. 
Cases  of  this  sort  have  been  described  as  occurring  at  Karachi  in  the 
year  1846,  and  at  Teheran  in  the  same  year.  On  post-mortem  examina- 
tion, however,  the  characteristic  lesions  and  evacuations  of  cholera  are 
found  in  such  cases.  The  absence  of  evacuation  and  the  rapid  prostra- 
tion have  been  attributed  to  the  large  dose  or  special  virulence  of  the 
poison  which  rapidly  overpowers  vital  resistance  and  energy.  This  form 
of  disease  is  very  rare ;  it  has  been  called  cholera  sicca. 

4.  The  stage  of  collapse  is  very  short ;  death  takes  place  suddenly 
from  apnoea,  with  symptoms  of  gravely  disturbed  cardiac  action  and 
impeded  circulation  through  the  lungs.  This  may  depend  on  spasm  of 
the  pulmonary  arterioles,  on  the  difficulty  of  transmission  of  the  inspis- 
sated blood  from  the  right  heart  into  the  lungs,  or  on  the  formation  of  clots 
in  the  right  cavities.  Dr.  Wall  has  described  murmurs  and  friction  sounds 
which  he  attributes  to  this  cause  :  the  condition  is  not  necessarily,  though 
frequently  fatal.     It  may  be  called  the  embolic  form  or  phase  of  cholera. 


CHOLERA    A  SI  A  TIC  A  901 


5.  On.  the  other  hand  the  cold  stage  may  be  prolonged  np  to  thirty- 
six  or  forty-eight  hours.  Recovery  sometimes  takes  place  in  such  cases, 
but  the  unfavourable  contingencies  of  the  reaction  stage  are  more  likely 
to  occur  under  these  circumstances. 

6.  The  intelligence  of  the  patient  —  in  other  words,  the  activity  of  the 
brain  and  nervous  system  —  is  in  some  cases  marvellously  keen  during 
the  stages  of  evacuation  and  collapse ;  but  a  condition  of  growing  pros- 
tration and  apathy  is  the  rule.  In  some  instances  the  clouding  of  the 
intellect  and  dulling  of  the  senses  are  early  and  profound,  and  out  of 
harmony  with  the  other  symptoms.  This  prirnari/  choleraic  stupor  has 
been  attributed  to  the  direct  effects  of  the  choleraic  poison  on  the  nerve 
tissue  (Wall). 

The  varieties  of  cholera  depending  upon  variations  in  the  phenomena 
and  course  of  events  in  the  stage  of  reaction  are  numerous  and  important. 

7.  The  reaction  may  be  imjjerfect.  Some  revival  from  collapse  may 
occur,  but  the  temperature  remains  subnormal,  purging  and  vomiting 
continue,  the  pulse  does  not  regain  power,  exhaustion  is  progressive,  and 
the  patient  in  time  sinks  from  asthenia,  or  may  pass  into  a  fatal  typhoid 
phase. 

8.  In  other  cases,  after  temporary  amelioration,  there  is  a  relapse  of 
the  purging  or  vomiting,  and  death  by  exhaustion  sooner  or  later  ensues, 
though  recovery  from  the  relapse  is  possible.  The  relapse  may  be  in- 
duced by  the  use  of  purgatives  or  indiscretion  in  diet. 

9.  A  very  serious  variety  of  cholera  is  the  hyperthermic  form,  in  which 
during  cojlapse  the  rectal  temperature  is  found  rising  to  100°  F.  and 
over.  The  axillary  temperature  soon  follows  suit,  and  a  very  high  degree 
of  heat  (as  much  as  107°  F.  in  the  axilla,  and  109°  F.  in  the  rectum  — 
Wall)  may  be  reached.     Such  cases  are  very  fatal. 

10.  During  the  stage  of  reaction  patients  not  unf  requently  lapse  into 
a  typhoid  state.  This  does  not  depend  on  excessive  temperature  or  on 
suppression  of  urine,  but  seems  to  correspond  rather  with  the  state  of 
"  prostration  with  excitement "  met  with  under  other  circumstances. 
The  symptoms  are  those  of  the  typhoid  condition  however  caused  — 
moderate  elevation  of  temperature  (101°  to  102°  F.),  excitement  of  pulse 
and  respiration,  failing  power,  restlessness,  delirium,  subsultus,  dry 
tongue  and  lips,  sordes,  stupor  merging  into  coma,  and  in  prolonged 
cases  purpura  and  bed-sores.  This  condition  is  generally,  but  not  nec- 
essarily fatal.  Convalescence  is  very  slow  in  the  non-fatal  cases.  There 
are  cases  which  seem  to  occupy  an  intermediate  position  between  the 
hyperthermic  and  the  typhoid  cases ;  in  these  mild  fever  of  an  inter- 
mittent or  remittent  form  complicates  and  delays  recovery. 

11.  In  these  febrile  states  eruptions  sometimes  make  their  appearance. 
The  more  common  are  urticaria  and  erythema:  the  latter  may  be  bright 
in  colour  and  widely  diffused,  lloseola,  maculae  and  bullae  have  been 
described.  The  eruption  in  such  cases  may  perhaps  be  considered  a 
sort  of  exanthem. 

12.  Suppression  (jf  ui'ino,  and  the  consequent  wrcemm,  constitute  the 


902  SYSTEM  OF  MEDICINE 

most  important  and  anxious  feature  of  an  abnormal  reaction.  The  re- 
appearance of  urine  is  sometimes  delayed  for  many  hours  or  even  days 
without  serious  results ;  but  such  delay  is  always  a  cause  of  anxiety, 
and  in  most  cases  of  prolonged  suppression  cerebral  symptoms  attest  the 
retention  of  waste  matters  in  the  blood.  Stupor  Avitli  restlessness,  mut- 
tering delirium,  spasmodic  contraction  of  muscles,  bloodshot  eyes,  con- 
tracted pupils,  dry  lips  and  tongue,  sordes,  vomiting,  slow  pulse  are 
the  chief  symptoms ;  the  patient  often  relapsing  into  fatal  coma.  The 
bowels  may  remain  relaxed ;  this  is  favourable  and  should  not  be  checked. 
Vomiting  of  grass  green  material  has  been  noted  in  this  state.  The 
secretion  or  discharge  of  bile  may  be  suspended,  and  this  adds  to  the 
gravity  of  the  case.  Chevers  has  described  this  dual  suppression  as 
choloursemia.  On  the  re-establishment  of  the  urinary  secretion  the 
alarming  symptoms  may  subside  and  convalescence  proceed. 

The  Sequelae  of  Cholera.  —  A  number  of  untoward  events  may  arise 
during  the  stage  of  convalescence ;  they  may  be  classified  as  follows :  — 

1.  Functioned.  —  Under  this  head  are  included  anaemia,  debility, 
nervous  depression,  jaundice  (a  rare  but  dangerous  complication),  gas- 
tric irritability,  persistent  hiccough,  insomnia,  dementia,  paraplegia, 
anasarca,  irregularity  of  bowels  and  chronic  diarrhoea.  In  pregnant 
women  abortion  is  almost  invariable ;  the  child  dies  during  the  algide 
stage  and  is  sooner  or  later  expelled.  Signs  of  cholera  are  often  found 
in  the  foetus  (Wall). 

2.  Inflammatory.  —  (Edema  of  the  lungs,  bronchitis,  pneumonia  and 
pleurisy  are  not  unfrequently  met  with,  especially  in  conjuuction  with 
suppression  of  urine.  Meningitis,  conjunctivitis,  arthritis  and  parotitis 
have  also  been  described.  The  parotid  inflammation  sometimes  ends  in 
abscess.  Dysentery  is  an  occasional  complication  of  convalescence,  but 
it  is  mild  in  type  and  amenable  to  treatment. 

3.  Destructive.  —  Ulceration  of  the  cornea  is  not  uncommon.  Bed- 
sores sometimes  form  in  low  cases  of  typhoid  character  and  uraemia  if 
the  nursing  be  defective,  (rangrene  of  the  nose,  ears,  penis  and  scrotum, 
more  rarely  of  the  fingers  and  toes,  are  also  met  with,  especially  among 
natives  of  India.  The  dead  parts,  if  limited,  may  be  separated  and  cast 
off,  but  extensive  gangrene  is  generally  fatal. 

Pathology  and  Pathological  Anatomy.  —  The  morbid  changes  dis- 
closed by  post-mortem  inspection  of  cholera  cases  vary  with  the  stage  of 
the  disease  in  which  death  took  place.  As  a  general  rule  alterations  in 
blood  distribution  are  the  most  prominent  feature  of  early  deaths. 
Epithelial  disorders  of  mucous  tracts  and  evidences  of  glandular  irrita- 
tion occur  later ;  and  in  more  protracted  cases,  indications  of  more 
serious  structural  changes — inflammatory  or  necrotic  —  maybe  seen. 
The  morbid  anatomy  of  typical  cholera  is  characteristic  and  constant. 
The  surface  of  the  body  retains  the  peculiarities  already  described,  which 
need  not  be  repeated.  Post-mortem  rigidity  appears  early  and  lasts 
long.  In  some  cases  muscular  contractions  occur  soon  after  death  and 
cause  distortions  of  the  body. 


CHOLERA    ASIATIC  A  903 


The  digestive  tract  reveals  signs  of  grave  disorder  which  are  usually 
most  marked  towards  the  termination  of  the  ileum.  The  stomach  is 
generally  empty  ;  its  lining  membrane  is  usually  congested,  the  degree 
of  hypersemia  varying ;  ecchymoses  are  occasionally  seen  and,  rarely, 
haemorrhage  into  the  cavity;  a  state  of  catarrhal  inhammation  is  some- 
times found;  the  contents  may  be  acid,  neutral,  or  alkaline;  the  duo- 
denum and  jejunum  usually  exhibit  hypersemia,  eitlier  continuous  or 
patchy,  arborescent  or  capillary.  The  lining  membrane  is  generally 
swollen  and  sodden,  and  a  pulpy  material  can  be  scraped  off  it,  which 
consists  mostl}''  of  granular  cells  and  amorphous  protoplasmic  masses. 
Enlargement  of  Brunner's  glands  has  been  described  (G-riesinger),  and 
denudation,  often  extensive,  is  frequently  seen.  Whether  this  shedding 
of  epithelium  be  the  result  of  a  necrotic  process  during  life  or  a  post- 
mortem detachment  is  a  subject  of  doubt  and  dispute. 

The  ileum  participates  in  the  changes  occurring  higher  up,  but  the 
last  twelve  or  eighteen  inches  of  it  exhibit  them  more  strongly  and 
sometimes  this  portion  shows  special  signs  of  diseased  action.  The 
solitary  glands  are  enlarged  and  stand  out  prominently,  and  Peyer's 
patches  are  congested  and  swollen.  This  portion  of  the  gut  ra^j  also 
be  covered  with  a  croupous  or  diphtheritic  pellicle,  more  or  less  adherent 
to  the  surface,  and  flocculent  processes  may  project  into  the  lumen  of 
the  tube,  and  may  occasionally  fill  and  obstruct  it.  Separation  of  this 
material  may  give  rise  to  excoriation  or  even  to  ulceration.  Ecchymoses 
of  the  walls  and  haemorrhages  into  the  cavity  of  the  small  intestine 
sometimes  occur. 

The  large  intestine  is  generally  less  seriously  diseased  than  the  small. 
Congestion  and  catarrhal  inflammation  may  occur,  and  in  rare  cases 
ulceration  giving  rise  to  haemorrhage. 

The  walls  of  the  intestinal  tube  are  generally  thickened,  and  the 
lumen  contracted.  The  peritoneal  surface  is  injected,  and  presents,  as 
Dr.  Wilks  has  observed,  a  characteristic  rosy  colour.  The  peritoneal 
cavity  contains  no  fluid.-  The  mesenteric  glands  are  enlarged,  hypersemic, 
and  infiltrated  with  a  whitish  granular  exudation  (Aitken). 

The  contents  of  the  intestines  vary  in  quantity  according  to  the 
amount  of  vomiting  and  purging  during  life  ;  they  vary  in  quality  accord- 
ing to  the  stage  of  the  disease  and  intensity  of  the  morbid  process. 

The  cholera  stool  is  a  turbid,  gray  or  grayish  white  liquid,  resembling 
water  in  which  rice  has  been  boiled.  On  standing,  a  granular,  curdy  or 
flaky  material  subsides,  leaving  a  whey-like  supernatant  fluid.  The 
reaction  of  the  material  is  alkaline,  and  its  specific  gravity  from  1005  to 
lOlo.  The  material  found  in  the  intestines  after  death  resembles  the 
sediment  which  settles  from  the  evacuations  passed  during  life.  The 
solid  elements  in  a  motion  amount  to  from  10  to  30  parts  per  1000,  the 
soluble  salts  from  5  to  10,  and  albumin  and  extractives  from  2  to  20 
(Parkes).  The  amount  of  albumin  is  small,  but  of  salts  —  sodium  and 
potassium  chhu-ide,  sodium  ])liosphat(!,  carbonate  and  sulphate  —  con- 
siderable.    Nitric  acid  sometimes  gives  a  red  reaction.     Considered  as  a 


904  SYSTEM  OF  MEDICINE 


derivative  from  the  blood  the  cholera  evacuation  accounts  for  a  large  loss 
of  water,  a  large  loss  of  soluble  salts,  and  a  moderate  loss  of  albumin 
and  animal  matter. 

The  microscopy  of  the  hitestnial  discharges  and  contents  has  been  the 
subject  of  laborious  investigations.  The  objects  found  are  embraced  in 
the  following  categories :  — 

1.  Debris  of  food. 

2.  Results  of  epithelial  proliferation  and  glandular  irritation — amor- 
phous, granular,  and  protoplastic  masses,  granixlar  cell  forms,  and  cloudy 
epithelia.  The  amount  of  epithelial  cells  foimd  in  the  contents  after 
death  exceeds  that  discovered  in  the  stools  during  life. 

3.  Red  blood  cells  and  leucocytes.  Much  of  the  protoplasmic  gran- 
ular material  which  forms  so  large  a  proportion  of  the  solid  constituent 
of  the  stool  is  held  to  be  derived  from  changes  which  have  taken  place 
in  white  cells  that  have  migrated  from  the  blood  (Lewis). 

4.  Organisms  ;  some  peculiar  to  cholera,  others  incidental  to  it.  The 
bacteriology  of  the  disease  has  been  already  described. 

The  liver  is  generally  affected  with  venous  congestion,  the  colour  being 
dark,  and  venous  blood  escaping  on  section.  The  gall  bladder  is  full  of 
bile,  Avhich  in  later  stages  is  thin  and  watery.  Shedding  of  the  epithelium 
of  the  bile  ducts  has  been  described.  There  is  no  mechanical  impediment 
to  the  discharge  of  bile  through  the  ducts. 

The  spleen  is  not  enlarged ;  on  the  contrary  it  presents  signs  of  con- 
traction and  expulsion  of  liquid. 

The  kidneys  exhibit  evidence  of  grave  pathological  disturbance.  They 
are  increased  in  size  and  much  congested.  Ecchymotic  spots  and  patches 
are  sometimes  seen  beneath  the  capsule  and  throughout  the  parenchyma. 
The  tubes  are  blocked  with  a  granular  and  protoplastic  material.  The 
epithelial  cells  are  cloudy  and  swollen,  their  contents  granular,  and  in 
later  stages  fatty.  In  advanced  cases  the  tubes  are  devoid  of  epithelial 
covering.  The  cells  undergo,  in  fact,  an  acute  process  of  degeneration 
and  destruction. 

The  state  of  the  urine  accords  with  these  conditions.  The  secretion 
is  at  first  suppressed,  then  scanty,  of  high  specific  gravity,  albuminous, 
and  containing  casts  —  epithelial,  granular  and  hyaline ;  and  ultimately, 
in  prolonged  cases,  abundant  in  quantity,  watery  and  devoid  of  albumin. 
The  proportion  of  saline  materials  is  greatly  diminished  in  the  urine  of 
cholera,  and  of  urea  somewhat.  Indican  is  a  conspicuous  constituent 
(Crombie).  Bright's  disease  is  a  rare  sequel  of  cholera.  -  .TCpmporary 
glycosuria  is  sometimes  met  with.  The  bladder  is  generally  found  empty 
and  firmly  contracted  in  cases  fatal  during  the  early  stages  of  the  disease. 

The  circulatory  system  and  blood  undergo  serious  and  characteristic 
changes  in  cholera. 

The  heart  is  not  altered  in  structure,  but  in  some  cases  haemorrhagic 
spots  and  patches  may  be  observed.  The  right  cavities  are  generally 
distended  with  dark  tarry  blood ;  the  left,  as  a  rule,  are  empty.  The 
distension  extends  into  the  venae  cavee  and  into  the  pulmonary  arteries  as 


CHOLERA   ASIATIC  A  905 


far  as  the  lungs.  In  a  considerable  proportion  of  cases  white  clots  are 
found  in  the  right  cavities,  and  extending  into  the  pulmonary  arteries : 
detached  thrombi  have  also  been  found  in  the  latter.  Dr.  Wall  con- 
cludes from  clinical  and  post-mortem  observations  that  thrombosis  is  a 
common  incident  of  the  collapse  stage  of  cholera,  and  that  the  clots  in 
the  heart  and  vessels  undergo  liquefaction,  fragments  of  them  sometimes 
remaining  as  pulmonary  emboli  and  infarcts.  The  pulmonary  veins  are 
found  empty  and  contracted  in  cases  fatal  during  the  stage  of  collapse. 
The  distribution  of  blood  in  the  body  is  abnormal,  the  veins  and  their 
tributaries  are  distended  with  thick  dark  blood,  and  the  arteries  and 
capillaries  empty.  The  solid  organs  exhibit  well-marked  venous  con- 
gestion. In  the  later  (reactive)  stages  of  the  disease  these  conditions 
of  the  circulation  undergo  change ;  also  when  recourse  has  been  had  to 
warm  saline  intravenous  injections  —  the  change  being  towards  a  restora- 
tion of  the  ordinary  distribution  and  balance  of  the  blood. 

The  physical,  chemical  and  microscopic  conditions  of  the  blood  have 
been  made  the  subject  of  elaborate  research.  Three  osmotic  processes 
appear  to  exist  during  the  progress  of  choleraic  disease :  1st,  an  exos- 
motic  effusion  from  the  vessels  into  the  intestinal  canal ;  2nd,  an  exos- 
motic  current  from  the  corpuscles  into  the  surrounding  fluid ;  and,  3rd, 
an  endosmotic  transit  of  fluid  from  the  tissues  into  the  vessels.  By  these 
processes  the  blood  becomes  profoundly  altered  physically  and  chemically. 
The  outflow  of  constituents  has  been  deterinined  by  Schmidt  to  take 
place  in  the  following  order :  the  water  transudes  before  the  solids  of 
the  serum,  the  inorganic  before  the  organic  solids,  the  chlorides  before 
the  phosphates,  the  salts  of  soda  before  the  salts  of  potash.  The  same 
law  applies  to  the  other  currents  which,  however,  are  smaller  and  later, 
and  fail  to  replace  the  material  which  has  escaped.  The  blood  in  acute 
cholera  is  therefore  found  to  be  of  high  specific  gravity,  very  dark  and 
inspissated,  and  deficient  in  water  and  salts.  Cells  and  albumin  are  in 
excess,  but  authorities  differ  as  to  the  amount  of  fibrin  factors  and  the 
coagulability  of  the  blood.  The  amount  of  oxygen  in  the  blood  cells  is 
seriously  diminished.  The  blood  regains  its  brightness  on  exposure  to 
air  in  thin  layers,  and  on  contact  with  the  intestinal  discharges  (Parkes). 
Urea  has  been  found  in  it  in  cases  fatal  in  the  algide  stage.  Detach- 
ment of  the  epithelium  of  the  vessels  and  adhesion  of  the  blood  to  the 
denuded  surface  have  been  described  (Thudichum). 

An  excess  of  leucocytes  was  discovered  by  Virchow,  and  confirmed  by 
Lewis  and  Cunningham,  who  found  the  red  corpuscles  diffluent ;  they 
observed  that  the  leucocytes  underwent  a  series  of  changes  —  becoming 
granular,  rounded,  still,  and  then  vacuolated —  and  ultimately  discharged 
their  granular  contents.  The  empty  cell  walls  constitute,  according  to 
these  observers,  the  peculiar  hyaline  vesicles  which  are  found  in  the 
evacua,tions.  Mu(!h  of  the  protoplasmic  granular  material  which  forms 
so  large  a  proportion  of  the  latter  is  held  to  be  derived  from  the  blood, 
tlirf)ugh  thea'rency  of  leucocytes,  wliif;li  imdergo  aftertransit  the  changes 
described.     No  special  organism  or  material  of  the  nature  of  virus  or 


9o6  SYSTEM  OF  MEDICINE 

poison  has  been  detected  in  the  blood  of  cholera  either  by  the  microscope 
or  by  chemistry. 

The  langs  in  a  case  of  death  in  the  collapse  stage  are  found  to  be  light, 
dry  and  shrunken.  There  is  a  deficiency  both  of  blood  in  the  vessels 
and  of  air  in  the  alveoli.  These  are  the  characteristic  cholera  lungs ; 
bat  in  later  stages  they  may  be  congested,  oedematous  or  collapsed. 
The  pleurm  are  usually  healthy. 

The  hrain  and  its  membranes  exhibit  venous  congestion.  Signs  of 
meningitis  are  sometimes  present  in  advanced  cases. 

The  tissues  are  dry,  doughy,  and  shrunken  from  removal  of  water. 
The  muscles  are  also  dry  and  contain  an  unusual  amount  of  urea.  They 
are  sometimes  found  ruptured. 

Theory  of  Cholera.  —  The  phenomena  observed  during  life  and  the 
appearances  seen  after  death  undoubtedly  indicate  that  the  choleraic 
process  is  due  to  the  entry  into  the  system  of  a  poison  which  causes,  in 
the  first  instance,  violent  functional  disturbances ;  then  sets  up  serious 
organic  disorders,  and  finally  results,  if  life  be  prolonged,  in  important 
structural  changes.  This  poison  has  not  as  yet  been  isolated,  but  there 
is  every  reason  to  believe  that  it  is  of  organic  constitution,  and  a 
strong  probability  that  it  is  elaborated  either  within  or  without  the 
body  by  a  microJae,  and  recent  research  points  to  this  microbe  being 
a  vibrio.  The  early  incidents  of  cholera  cases — more  particularly  the 
varying  duration  of  the  incubative  stage,  the  general  occurrence,  but  fre- 
quent absence,  of  initial  signs  of  intestinal  irritation  and  nervous  dis- 
turbance and  depression  —  would  suggest  that  the  disease  may  be  due 
either  to  ingestion  of  a  poison  elaborated  elsewhere,  in  which  case  the 
invasion  would  be  sudden,  and  the  effects  depend  on  the  dose  ;  or  to  the 
reception  into  the  intestinal  tube  of  a  microbe  under  circumstances  fa- 
vourable for  its  multiplication  ;  in  the  latter  case  symj)toms  of  intestinal 
derangement,  of  longer  or  shorter  duration,  would  precede  the  general 
poisoning  by  absorption  of  the  elaborated  product. 

This  theory  would  also  account  for  the  failure  to  find  a  specific  organ- 
ism in  a  certain  proportion  of  cases  —  a  fact  attested  by  good  authority 

—  as  well  as  for  isolated  outbreaks  on  board  ship  and  elsewhere,  which 
might  be  due  to  conveyance  of  a  limited  quantity  of  the  elaborated 
product. 

The  phenomena  of  cholera,  especially  of  its  later  stages,  constitute  a 
remedial  reaction ;  and  the  disease  has  with  plausibility  been  likened  to 
a  febrile  paroxysm  Avith  a  severe  and  jDrolonged  algide  stage.  Cases  and 
outbreaks  of  malarial  fever  have  been  observed  which  it  was  found  al- 
most impossible  to  distinguish  from  cholera.  On  the  other  hand,  in  some 
cases  and  outbreaks  of  the  latter  disease  the  febrile  phenomena  assume 
a  marked  prominence.     The  poison  seems  to  exercise  a  special  influence 

—  deleterious  and  destructive  —  on  the  epithelial  elements  of  the  intesti- 
nal and  urinary  tubes,  and  on  the  gland  sacs  and  follicles  of  the  former ; 
but  a  strong  impression  on  the  nervous  system,  leading  to  contraction 
of  arterioles  and  disturbance  of  the  balance  of  the  circulation,  with  pre- 


CHOLERA   ASIATIC  A  907 


ponderance  towards  the  venous  side,  is  a  very  early  effect  of  the  poison 
in  the  blood,  which  soon  undergoes  important  dynamical,  organic,  and 
chemical  alterations.  Many  of  the  later  incidents  of  cliolera  are  due,  no 
doubt,  to  absorption  from  the  tubes  and  tissues  of  secondary  poisons  of 
bacterial  or  degenerative  origin.  The  theory  that  the  intestinal  disturb- 
a,nce  is  sufficient  to  account  for  all  the  other  phenomena  of  cholera  as 
secondary  and  consequential  effects  is  no  longer  tenable ;  and  the  chol- 
eraic process  cannot  be  satisfactorily  explained  otherwise  than  as  the 
effect  of  one  of  those  organic  poisons  which  constitute  a  very  early  stage 
of  decomposition  of  proteids,  or  result  from  the  metabolism  of  these  by 
the  agency  of  micro-organisms. 

When  the  virulence  of  the  poison  has  been  spent,  or  its  removal 
effected,  the  primary  disturbances  set  up  by  it  are  very  soon  and  com- 
pletely recovered  from.  The  secondary  changes  occurring  during  the 
stage  of  reaction  are  more  serious  and  prolonged;  but  these  likewise 
very  seldom  leave  permanent  structural  defects. 

Diagnosis.  —  The  maladies  which  most  closely  resemble  cholera  are 
ptomaine  poisoning;  mushroom  poisoning;  certain  varieties  of  diarrhoea ; 
and  some  rare  malarial  fevers,  Avith  intestinal  complications,  and  a  pro- 
found and  prolonged  algide  stage.  The  identification  of  Asiatic  cholera 
turns  upon  clinical,  epidemic  and  bacteriological  considerations.  The 
clinical  features  which  mark  an  ordinary  case  of  cholera  are :  the  copious, 
painless  passage  of  watery  motions,  devoid  of  bile  colouring,  resembling 
rice  water  and  exhaling  a  characteristic  odour ;  the  profound  nausea  and 
frequent  vomiting  of  watery  material ;  the  suppression  of  urine ;  the  mus- 
cular cramps;  the  cyanosis  and  shrinking  of  skin;  the  cold  breath  and 
whispering  husky  voice;  the  dyspnoea  and  restlessness;  the  prostration, 
torpor  and  failing  pulse ;  the  cold  sweats  and  depression  of  the  surface 
temperature,  with  a  tendency  to  rise  of  internal  temperature.  These  con- 
stitute a  group  of  symptoms  which  may  be  imitated,  but  are  seldom  if  ever 
identical  with  those  of  any  other  flux.  If  cholera  is  known  to  prevail 
in  the  locality  or  neighbourhood,  or  circumstances  permitting  or  favouring 
importation  exist,  suspicion  naturally  attaches  to  all  bowel  complaints; 
even  if  they  do  not  present  the  extreme  form  just  pictured.  Similarly, 
cases  of  diarrhoea,  however  mild,  arising  in  the  midst  of  an  epidemic  of 
cholera  are  viewed  with  apprehension.  If  numerous  seizures  occur  in 
groups,  and  the  mortality  equals  or  exceeds  50  per  cent,  the  identi- 
fication is  rendered  more  easy  and  certain.  Cases  of  ptomaine  and 
muscarine  poisoning,  which  most  resemble  cholera,  generally  occur  singly, 
or  in  small  groups  ;  and  usually  follow  the  eating  of  fish,  shell-fish,  tinned 
provisions  or  mushrooms  ;  fragments  of  mushroom  may  be  found  in  the 
stools.  The  association  with  prevalent  malarial  fever,  the  absence  of 
epidemic  cholera  in  the  place  or  vicinity,  the  periodicity,  the  better 
marked  febrile  stage,  the  lower  mortality,  and  the  amenability  to 
quinine,  serve  to  distinguish  the  cases  of  malarial  fever  which,  in  the 
algide  stage,  may  assume  a  choleraic  character.  The  suppression  of  bile 
and  urine,  the  cyanosis,  cramps,  collapse  and  cold,  and  the  high  mortal- 


9o8  SYSTEM   OF  MEDICINE 


ity,  are  the  chief  circumstances  which  distinguish  cholera  from  other 
diarrhoeas.  The  bacteriological  conditions  are  also  important.  The 
detection  of  Koch's  vibrio  in  the  evacuations  constitutes,  according  to  our 
present  knowledge,  a  means  of  separating  cholera  from  every  other  disease. 
The  negative,  however,  is  not  true.  In  a  certain,  though  small,  propor- 
tion of  cases  the  vibrio  cannot  be  found.  It  is  also  alleged  that  several 
varieties  or  species  of  spirillum,  exhibiting  different  morphological  and 
physiological  characters,  develop  in  the  intestinal  discharges  of  cholera 
(Cunningham).  These  matters  are  at  present  the  subject  of  keen  and 
searching  investigation,  and  a  detailed  discussion  of  them  would  be 
premature  and  unprofitable.     [  Vide  section  on  Bacteriology.] 

Prognosis.  —  The  death-rate  of  cholera  varies  with  the  character  of  the 
epidemic  and  the  period  of  the  outbreak.  Fifty  per  cent  may  be  accepted 
as  an  average  death-rate,  but  it  is  often  exceeded  in  specially  severe 
outbreaks,  and  in  the  early  stage  of  any  outbreak.  The  very  young  and 
very  old  succumb  more  readily  than  the  middle  aged ;  sucklings  are  seldom 
attacked.  Women  are  rather  less  frequently  seized  than  men ;  pregnancy 
is  a  dangerous  complication.  Organic  disease  of  the  kidneys  is  a  specially 
unfavourable  condition,  and  organic  disease  of  the  liver  almost  equally  so. 
Drunkards  are  bad  subjects  of  cholera;  so  are  persons  of  feeble  and 
damaged  constitution;  ill  health,  however  caused,  is  an  unfavourable 
introduction  to  the  choleraic  struggle.  During  the  progress  of  a  case 
signs  of  good  or  evil  omen  are  observable  at  every  step. 

Evil  signs,  in  the  order  of  the  stages,  are  —  Sudden  seizure,  early  pros- 
tration, early  stupor,  quick  advent  of  collapse,  restlessness  and  fighting 
for  breath,  failing  pulse,  great  depression  of  temperature,  prolonged  cold 
stage,  hyperpyrexia,  severe  abdominal  pain,  blood  in  vomit  and  stools, 
persistent  suppression  of  bile  and  urine,  permanent  muscular  contrac- 
tions, jaundice,  lung  complications,  recurrent  purging  and  vomiting, 
delayed  restoration  of  body  heat,  typhoid  symptoms  and  indications  of 
uraemia  or  cholo-urgemia,  insomnia  and  delirium. 

Good  signs  axe  —  Maintenance  of  pulse  during  collapse,  moderate 
depression  of  temperature,  early  and  not  excessive  reaction,  return 
of  colour  in  the  motions,  cessation  of  cramps,  restoration  of  urinary 
secretion,  resumption  of  warmth  and  dryness  of  skin  and  normal  colour 
and  plumpness  of  face,  quiet  breathing,  tranquillity,  sleep. 

The  violence  of  vomiting  and  purging  in  the  early  stages  are  not 
necessarily  indicative  of  a  severe  seizure,  but  their  persistence  is  apt  to 
result  in  delayed  convalescence  or  fatal  exhaustion. 

Treatment.  —  The  fact  that  about  one-half  of  those  attacked  Avith 
cholera  recover,  with  or  without  treatment,  indicates  that  processes 
antagonistic  to  the  poison  a.nd  curative  of  its  effects  arise  within  the 
organism,  and  are  effective  in  that  proportion  of  cases.  What  the  precise 
nature  of  these  processes  may  be  it  is  impossible,  in  the  present  state  of 
science,  to  affirm.  Whether  the  poison  of  cholera  lose  its  power  by  lapse 
of  time,  or  be  diluted,  eliminated,  or  destroyed ;  or  whether  there  be  formed 
in  the  tissues  or  blood  or  intestinal  tube  some  antagonistic  principle — an 


CHOLERA   ASIATIC  A  909 


alexin  or  antitoxin,  to  adopt  the  language  of  modern  bacteriology  —  we 
know  not :  in  our  ignorance  of  the  process  of  natural  cure  it  is  impos- 
sible to  formulate  a  rational  system  of  treatment  in  imitation  and 
furtherance  thereof.  Two  principles  may,  however,  be  confidently  stated, 
namely,  (1)  that  it  is  obviously  irrational  and  improper  unduly  to 
interfere  with  or  thwart  processes  which,  though  apparently  morbid 
and  injurious,  result,  as  a  matter  of  fact,  in  restoration  to  health  in  a 
moiety  of  seizures  ;  and  (2)  that,  in  estimating  the  value  of  any  system  or 
method  of  cure,  the  law  of  natural  and  unaided  recovery  must  lae  taken 
into  account,  allowing  for  the  character  and  period  of  tlae  outbreak. 

Prevention.  —  The  sanitary  measures  by  which  a  community  may  be 
protected  from  cholera,  by  which  its  entry  may  be  prevented,  its  spread 
controlled,  its  incidence  and  mortality  minimised,  are  discussed  in  the 
section  relating  to  the  history  and  etiology  of  the  disease  considered 
epidemiologically. 

Personal  prophylaxis^  however,  constitutes  an  important  item  of  the 
treatment  of  cholera  as  affecting  individuals.  Certain  circumstances  and 
conditions  have  been  recognised  as  rendering  persons  specially  liable  to 
attack.  The  chief  of  these  are  —  bodily  fatigue,  mental  worry,  panic, 
disorder  of  stomach  caused  by  consumption  of  raw  fruits  and  vegetables 
(melons,  cucumbers,  and  the  like  have  been  specially  blamed),  decompos- 
ing animal  food,  particularly  fish  and  shell-fish,  excessive  use  of  alcohol, 
drinking  impure  water  or  milk,  the  use  of  purgative  medicines  especially 
salines,  exposure  to  cold,  and  generally  anything  tending  to  depress  the 
general  vigour  and  derange  health.  The  conduct  and  regimen  necessary 
to  avoid  these  risks  need  not  be  detailed. 

On  grounds  of  reason  and  experience  the  most  efficient  preventive  of 
cholera,  both  for  individuals  and  bodies  of  men,  is  removal  from  the 
infected  locality  to  another  place,  higher  and  drier  if  practicable,  where 
the  disease  is  not  prevalent.  New  comers  to  infected  places  are  specially 
prone  to  attack.  Although  the  disease  does  not  appear  to  be  often,  if 
ever,  communicated  directly  from  person  to  person,  avoidance  of  associa- 
tion with  the  sick  is  advisable,  because  such  association  may  involve 
exposure  to  the  morbific  conditions  surrounding  the  sick. 

Chemical  disinfection  of  excreta  and  discharges,  and  of  articles  which 
have  been  soiled  thereby,  is  obviously  advisable ;  and  the  free  use  of  such 
agents  as  carbolic  and  sulphurous  acids  highly  commendable.  Protec- 
tion against  attack  by  the  administration  of  drugs,  such  as  quinine  and 
the  mineral  acids,  has  been  tried  without  satisfactory  results. 

Anticholeraic  Vaccination.  —  Various  attempts  have  been  made  to  ren- 
der the  system  immune  to  choleraic  infection  by  the  injection  of  anti- 
toxins. The  latest  is  the  method  devised  by  M.  Haffkine.  It  has  been 
amply  proved  that  the  use  of  the  weak  virus,  prepared  by  his  method, 
mitigates,  Iwth  in  animals  and  men,  the  local  and  general  effects  sub- 
sequently produced  by  the  strong;  and  that  an  immunity  against  the 
latter  may  be  thus  produced.  Extensive  inoculations  of  human  subjects 
have  been  carried  out  hy  M.  Haffkine  in  India.     Upwards  of  42,000 


910  SYSTEM   OF  MEDICINE 

persons  have  been  vaccinated  without  accident  or  harm.  Evidence  has 
been  gained  that  recent  inoculations  are  protective ;  but  the  experience 
is  as  yet  too  meagre  and  incomplete  to  justify  final  conclusions  as  to  the 
merits  and  uses  of  the  system. 

Medicinal  Treatment,  Nursing,  and  Dieting.  —  The  drugs  and  com- 
pounds which  have  been  administered  empirically  in  cases  of  cholera  are 
legion.  It  is  safe  to  assert  that  not  one  of  them  has  established  a  claim 
to  cure  the  disease.  It  were  useless,  therefore,  to  catalogue  or  discuss 
them.  Four  plans  of  treatment  stand  out  prominently  among  others  as 
possessing  some  basis  of  reason,  and  offering  some  promise  of  success ; 
namely,  the  astringent,  the  eliiiiinative,  the  antiseptic,  and  tl:ie  stimulant. 
To  these  may  be  added  the  antispasmodic  and  the  counter-irritative. 
The  astringent  plan  contemplates  the  choleraic  process  as  a  hypercathar- 
sis,  and  its  danger  as  depletion ;  rice  water  evacuations  being  regarded 
as  potentially  hemorrhage  (Chevers).  Astringents,  mineral  and  vege- 
table, in  combination  with  opium,  antispasmodics  and  stimulants, 
have,  in  accordance  with  this  view,  been  administered  by  mouth  and 
rectum,  in  the  hope  that  if  the  dangerous  flux  be  checked,  the 
margin  of  recuperative  power  thus  saved  will  suffice  to  avert  fatal 
exhaustion  and  to  restore  health.  It  is  possible,  however,  that  the 
results  thus  to  be  prevented  or  cut  short  —  the  tremendous  drain  of 
serum,  corpuscles  and  salts  from  the  veins  into  the  intestinal  tube,  the  re- 
versal of  the  normal  currents,  and  the  abeyance  of  absorption  —  may  have 
a  salutary  purpose,  and  Avithin  limits  a  curative  function;  it  is  doubtful 
whether  the  checking  of  these  discharges  is,  as  a  dominant  principle,  a 
sound  basis  of  action.  Still  the  principle  has  its  place  in  that  scheme  of 
treatment  which,  as  we  shall  presently  show,  experience  has  sanctioned. 

The  eliminative  plan,  on  the  other  hand,  looks  upon  the  flux  as 
adjuvant  —  as  a  means  of  conveying  the  cholera  poison  out  of  the  system, 
and  seeks  to  aid  it  by  administering  purgatives.  But,  apart  from  the 
well-established  fact  that  purgation  is  of  itself  exhausting,  especially 
so  in  the  early  stages  of  cholera  when  it  ought  to  be  most  effective  and 
beneficial,  it  is  questionable  whether  it  is  wise  to  remove  materials 
artificially  from  the  intestinal  tube  —  such,  perhaps,  as  leucocytes  or 
their  alexins,  or  innocuous  bacteria  —  which  may  tend  to  neutralise  or 
destroy  the  poison  of  cholera.  As  a  matter  of  fact.  Sir  George  Johnson's 
castor  oil  treatment  has  been  extensively  tried  and  found  wanting. 
Stimulation  of  the  kidneys  by  diuretics  has  also  been  tried  under  the 
guidance  of  this  hypothesis,  and  found  to  do  more  harm  than  good. 

The  antiseptic  plan  aims  at  neutralising  the  poison  in  the  intestinal 
tube,  or  setting  up  conditions  there  which  may  render  its  elaboration 
impossible.  Acids  and  germicides  of  many  kinds  have  been  administered 
with  this  view ;  but  this  plan  may  simply  result  in  adding  poison  to 
poison,  or  irritant  to  irritant ;  in  hindering  a  process  of  salutary  decom- 
position, or  in  destroying,  the  leucocytes  or  innocuous  organisms  and 
their  products  whi(;h  may  be  doing  good  work.  Practically,  the  plan 
has  failed  to  cure  cholera. 


CHOLERA   ASIATIC  A  911 


The  stimulant  or  restorative  plan  simply  endeavours  to  avert  death 
frojn  exhaustion,  and  to  sustain  the  flagging  vital  powers  under  circum- 
stances of  terrible  depression.  Alcohol,  ammonia  and  ether  administered 
by  mouth  or  rectum,  or  hypodermically,  are  the  favourite  remedies  of 
this  class,  supplemented  by  strong  soups  and  niitrient  enemata.  Even 
this  method  is  not  without  its  drawbacks.  Gastro-intestinal  irritation 
may  be  increased,  mischief  may  arise  during  the  reactive  stage,  or  per- 
haps undue  disturbance  of  the  collapse  stage  may  be  hurtful.  These  con- 
siderations suggest  caution  in  the  use  of  stimulants. 

The  antispasmodic  plan  is  based  on  the  fact  that  the  muscles  of  the 
intestines,  arterioles,  bile  ducts,  limbs  and  trunk  are  thrown  by  the 
action  of  the  poison  into  violent  contraction  ;  pain  and  exhaustion 
tending  to  death  are  thus  caused.  The  clamping  of  the  pulmonary 
arterioles,  impeding  the  circulation  and  banking  back  the  blood  — -  hinder- 
ing, that  is,  its  aeration  in  the  lungs,  the  nutrition  of  the  brain,  the 
action  of  the  kidneys  and  skin,  and  promoting  flux  —  is  considered 
specially  jDerilous.  Warm  baths,  chloroform  inhalation,  sedative  and 
antispasmodic  drugs,  nitrite  of  amyl  and  nitro-glycerine,  and  warm 
intravenous  injections,  have  been  given  to  relieve  spasm.  This  treat- 
ment has  proved  useful  as  a  means  of  relieving  some  symptoms. 

The  use  of  counter-irritants  is  intended  to  remove  morbid  action 
from  within  to  the  surface,  where  it  may  be  less  hurtful  and  more  under 
control.     Measures  of  this  kind  may  be  useful  as  auxiliaries. 

It  may  be  asserted  with  confidence  that  in  the  present  state  of  our 
knowledge  no  single  principle  or  plan  of  treating  cholera  has  met  with 
much  success.  It  is  possible,  ne\iertheless,  to  lay  down  certain  rules  of 
action  which,  as  experience  has  taught  us,  may  aid  the  patients  in  under- 
going the  terrible  struggle  for  life  which  the  choleraic  process  entails. 
These  will  be  briefly  stated  as  they  apply  to  successive  stages  of  the 
disease. 

1.  Check  the  Preliminary  Diarrhrea.  —  All  authorities  are  agreed  as 
to  the  advantage  of  this  measure,  which  promptly  cures  mild  cases  and 
prevents  others  from  becoming  dangerous.  Combinations  of  opium 
with  astringents  and  antispasmodics  constitute  the  favourite  formulae. 
The  remedy  may  be  given  in  pill  or  mixture.  The  "cholera  pill"  of 
India  consists  of  opium,  assafoetida  and  black  pepper.  Goodeve  used 
acetate  of  lead  and  opium.  Chevers  preferred  vegetable  astringents. 
The  cholera  tinctures,  which  have  often  proved  so  serviceable,  are 
generally  composed  of  laudanum  or  liquor  opii  sedativus  with  catechu  or 
kino,  compound  tincture  of  lavender  or  cardamoms  and  chloric  ether. 
Chlorodyne,  with  or  without  brandy,  according  to  the  state  of  the  patient, 
is  an  admirable  remedy  of  similar  composition,  fulfilling  the  same  end. 
The  dose  and  frequency  of  repetition  must  depend  on  the  age  and 
condition  of  the  patient,  the  degree  of  irritability  of  the  stomach,  and 
the  effect  of  the  remedy.  The  practitioner  must  exercise  a  careful 
observation  and  judgment  on  these  points;  it  is  inexpedient  to  lay 
down   precise  rules  or  formulae.     If   the  stomach  be  very  irritable  a 


912  SYSTEM  OF  MEDICINE 

mustard  poultice  or  chloroform  should  be  applied  to  the  epigastrium,  and 
lumps  of  ice  given  to  suck.  If  medicines  are  still  rejected  the  hypo- 
dermic injection  of  morphia  may  be  resorted  to.  It  must  be  clearly  under- 
stood that  the  treatment  now  recommended  is  applicable  to  the  pre- 
liminary and  evacuatory  stages  only.  When  collapse  has  fairly  set  in 
opium  and  astringents  must  be  stopped  ;  for  absorption  being  now  in 
abeyance  they  are  useless,  and  in  the  stage  of  reaction,  when  absorption 
again  sets  in,  they  may  do  harm. 

2.  Maintain  Physical  and  Physiological  Rest.  —  The  patient  must  be 
kept  in  bed  and  the  evacuations  received  in  a  bed-pan.  Fussy  changing 
of  clothes  and  bedding  must  be  avoided.  Violent  rubbing,  rough  lifting 
into  baths  and  other  beds,  transfer  to  another  room  or  house,  and,  above 
all,  a  journey  are  dangerous.  Medicines,  food  and  stimulants  shoidd  not 
be  forced  on  an  irritable  stomach ;  they  provoke  vomiting,  excite  irritation, 
and  increase  exhaustion.  The  indication  is  to  refrain  from  anything 
that  may  add  to  the  wearing  effect  of  a  most  weakening  malady. 

3.  Restore  a  Failing  Circulation.  —  If  the  pulse  be  maintained  in  the 
collapse  the  less  done  the  better.  If  the  pulse  gradually  lose  volume 
and  power,  and  become  feeble  and  thready,  a  mild  stimulant  should  be 
given — iced  champagne  and  soda  water,  weak  brandy  and  water  (iced)  — 
in  teaspoonf  uls,  or  amiiionia  or  chloric  ether  well  diluted.  Should  the  ptdse 
respond  nothing  further  is  needed.  If,  however,  the  pulse  become 
imperceptible  at  the  wrist,  and  hardly  perceptible  in  the  brachial  and 
femoral  trunks  —  if,  at  the  same  time,  cyanosis  and  dyspnoea  are  well 
marked  —  the  condition  is  one  of  imminent  danger.  Hypodermic  injec- 
tions of  sulphuric  ether,  or  cautious  doses  of  nitrite  of  amyl  or  nitro- 
glycerine, followed  up  by  champagne  or  brandy,  may  restore  the  pulse ; 
but  nothing  effects  this  so  speedily  and  surely  as  the  intravenous  injec- 
tion of  warm  saline  solutions.  Sixty  grains  of  'sodium  chloride  and  30 
of  sodium  carbonate  are  dissolved  in  1  litre  (about  35  ounces)  of  distilled 
water.  The  fluid  should  be  sterilised  by  boiling,  and  injected  slowly  at 
a  temperature  of  about  98'4°  F.,  with  strict  antiseptic  precautions,  into 
one  of  the  veins  of  the  arm.  A  reservoir  containing  five  or  six  litres 
should  be  kept  ready  and  placed  on  a  stand  about  four  feet  above  the 
level  of  the  patient's  head.  The  injection  flows  by  gravitation  through 
a  flexible  tube,  by  pressure  on  which  the  rate  of  flow  is  regulated.  The 
rate  of  entry  should  be  slow,  say  one  litre  in  twelve  minutes.  The 
amount  injected  will  depend  on  the  effect;  one  to  three  litres  may  be 
required  in  different  cases  to  restore  the  pulse  (Wall). 

In  most  cases  the  fluid  leaves  the  blood-vessels  and  passes  into  the 
intestinal  tube,  and  the  symptoms  of  collapse  recur.  They  may  neverthe- 
less be  removed  again  and  again  by  a  repetition  of  the  injection,  and  in  some 
cases  a  permanent  cure  results.  Experience  has,  however,  shown  that  the 
proportion  of  recoveries  has  not  been  materially  increased  by  the  use  of 
saline  intravenous  injections.  Still,  distress  is  for  the  time  relieved,  life 
is  undoubtedly  prolonged,  some  cases  seem  to  be  saved ;  and  in  the  face 
of  impending  death  anything  that  offers  the  faintest  hope  of  rescue  is 


CHOLERA    A  SI  A  TIC  A  913 


justifiable.  Intravenous  injection  of  milk  and  transfusion  of  blood  liave 
been  tried  without  much  benefit,  if  any.  It  has  been  sought  to  restore 
fluid  to  the  blood  by  injecting  saline  fluids  and  plain  water  into  the 
cellular  tissue,  peritoneum,  bladder  and  rectum.  No  harm  has  resulted 
from  such  procedures,  and  little  if  any  good.  The  fluid  is  readily 
absorbed,  but  as  readily  passes  away  through  the  intestines.  It  is 
possible  that  these  artificial  means  of  restoring  water  and  salts  to  the 
blood  simply  keep  the  exosmotic  current  flowing,  which  might  otherwise 
cease  or  be  reversed  through  the  altered  specific  gravity  of  the  blood. 
It  has  also  been  sought  to  remedy  stagnation  of  the  circulation  by  the 
v/arm  bath  and  mild  rubbing  of  the  limbs.  These  measures  should  be 
applied  with  the  utmost  gentleness.  Rubbing  with  dry  powdered  ginger 
is  a  routine  practice  in  India ;  clamminess  and  moisture  of  skin  are  thus 
removed,  and  mild  stimulation  of  the  cutaneous  vessels  and  nerves 
attained.  The  practice,  if  cautiously  followed,  does  no  harm,  and  prob- 
ably does  some  good. 

4.  Conserve  the  Body  Heat.  —  The  great  depression  of  surface  tempera^ 
ture  which  takes  place  in  the  collapse  stage  of  cholera  is  no  doubt  due  to 
luany  causes  —  amongst  them  the  direct  effect  of  the  poison  on  the  nerve 
centres,  the  disturbance  of  circulation,  and  the  loss  of  fluids  from  the 
intestinal  and  cutaneous  surfaces.  It  is  probably  more  a  sign  than  a 
cause  of  exhaustion.  Still,  it  seems  desirable  to  prevent  the  evitable 
escape  of  body  heat.  The  temperature  of  the  room  should  not  be 
allowed  to  fall  below  70°  F.,  and  the  air  in  the  immediate  vicinity  of  the 
patient  should  be  warmed  by  a  few  hot  bricks  or  bottles :  this  is  better 
than  loading  him  with  bedding.  Ventilation  should  be  free,  but  draughts 
avoided;  in  hot  climates  the  punkah  should  be  gently  pulled.  The 
surface  should  be  kept  as  dry  as  possible,  and  gentle  wiping  with  soft 
cloths  or  rubbing  with  dry  ginger  powder  resorted  to.  The  warm  bath 
also  tends  to  restore  the  surface  temperature. 

5.  Allay  Thirst.  —  The  craving  for  fluids  in  cholera  is  astonishing, 
and  ought  to  be  gratified  ;  but  large  draughts  excite  violent  vomiting 
and  so  lead  to  exhaustion.  Giving  lumps  of  ice  to  suck  is  perhaps  the 
best  method  of  quenching  thirst ;  still  small  quantities  of  iced  soda  wa.ter, 
iced  champagne  and  soda,  barley  or  arrowroot  water,  milk  and  soda,  or 
teaspoonfuls  of  cold  jelly  or  clear  soup  may  be  administered  at  short 
intervals.  The  injection  of  fluids  into  cavities  and  tissues  tends  indirectly 
to  fulfil  the  same  indication. 

G.  Relieve  Distress  and  Pain.  —  The  cramps  undoubtedly  constitute  the 
most  painful  symptom  of  cholera,  and  it  is  not  easy  to  relieve  them. 
Probably  the  opiates  administered  in  the  early  stages  exercise  an 
analgesic  effect.  Hot  applications,  the  warm  bath,  gentle  frictions  with 
anodyne  liniments,  or  even  moderate  counter-irritation  with  chloroform, 
turpentine,  or  mustard  may  be  tried ;  but  nothing  relieves  cramps  so 
well  as  moderate  and  intermittent  chloroform  inhalation.  Camphor 
lias  been  rocornmendcd  internally,  externally  and  hypodermically.  For 
the  scv(!re  abdominal  pains  which  are  sometimes  mot  with,  hot  api^licar 

VOL.    I  3   N" 


914  SYSTEM  OF  MEDICINE 

tions  and  counter-irritatiou  with  chloroform  or  mustard  give  relief.  In 
early  stages  a  moderate  dose  of  liquid  extract  of  opium  may  be  injected 
over  the  seat  of  pain.  The  relief  of  general  distress  is  best  accomplished 
by  warm  baths  and  intravenous  injections,  but  these  must  be  used  Avith 
caution  and  judgment.  Dr.  Lauder  Brunton  has  recommended  the 
hypodermic  injection  of  atropine  in  cholera,  but  rather  on  the  ground 
of  its  known  antagonism  to  muscarine,  which  causes  symptoms  closely 
resembling  cholera,  than  on  account  of  its  anodyne  properties.  Suffi- 
cient trial  has  not  as  yet  been  made  of  the  drug  to  warrant  its  confident 
recommendation. 

7.  Check  Persistent  Diarrhoea.  —  Persistent  or  recurrent  purging,  caus- 
ing exhaustion  and  delaying  recovery,  sometimes  occurs  in  the  stage  of 
reaction.  Vegetable  astringents  or  mineral  acids  may  be  given  in  small 
doses  well  diluted,  but  the  large,  warm,  astringent  rectal  injections 
recommended  by  Catani  are  more  efficient.  Twenty  grammes  (308 
grains)  of  tannic  acid  and  as  much  gum-arabic  are  dissolved  in  one  litre 
of  water.  The  injection  is  made  very  slowly  by  gravitation  to  such 
amount  aS  the  patient  can  comfortably  bear.  Blood  heat  is  the  best 
temperature,  and  the  material  should  be  retained  as  long  as  possible 
(Wall). 

8.  Check  Irritability  of  Stomach.  —  This  may  be  manifested  as  obsti- 
nate vomiting  or  incessant  hiccough  ;  or  signs  of  severe  gastritis,  induced 
perhaps  by  injudicious  administration  of  food  and  stimulants,  may  be 
present.  There  is  no  special  cure  for  this  condition,  which  is  to  be 
treated  on  ordinary  principles. 

9.  Reduce  Excessive  Temperature.  — It  is  extremely  difficult  to  fulfil 
this  indication ;  and  this  is  the  more  to  be  regretted  inasmuch  as  the 
hyperpyretic  form  of  cholera  is  very  fatal.  Ice  sucking  and  the  slow 
injection  of  bulky  cold  enemata  may  be  tried;  antipyretics  should  be 
avoided.  Tepid  baths  gradually  cooled  may  be  resorted  to,  but  great 
caution  is  necessary  in  any  such  adventures. 

10.  Restore  the  Secretion  of  Bile  and  Urine.  —  As  regards  the  bile,  very 
little  if  anything  can  be  done  to  promote  its  secretion  or  evacuation; 
in  most  cases,  fortunately,  nothing  need  be  done.  Usually,  virhen  the 
cold  stage  has  passed  and  spasmodic  closure  of  the  ducts  is  relaxed,  the 
flow  is  resumed.  Sometimes  the  outpouring  of  the  imprisoned  bile  is 
excessive  and  gives  rise  to  bilious  vomiting.  In  those  cases  in  which  the 
function  of  the  liver  has  been  so  much  impaired  that  a  watery  material 
is  poured  into  the  ducts  instead  of  bile,  no  means  have  been  discovered 
of  correcting  the  condition.  Calomel  has  been  given  in  large  and  small 
doses,  with  the  intention  of  stimulating  the  secretion  and  discharge  of 
bile.  Large  doses  are  undoubtedly  injurious,  and  small  doses,  even 
when  combined  with  soda,  are  of  very  doubtful  value. 

The  restoration  of  the  urinary  secretion  is  a  more  important  object; 
its  prolonged  suppression  is  fatal.  Dry  cupping,  hot  fomentations 
and  poultices  may  be  applied  in  cases  of  delayed  return;  and  water, 
milk  and  water,  barley  water,  etc.,  freely  given.     Diuretics  should  be 


CHOLERA    ASIATIC  A  915 


avoided.  When  head  symptoms  are  severe  and  the  bowels  confined, 
mild  enemata,  or  even  a  little  castor  oil  emulsion,  may  be  given ;  but 
great  caution  is  necessary  in  the  use  of  such  measures.  The  bladder 
should  be  examined  by  catheter  occasionally  if  necessary. 

Special  symptoms,  comjdications,  and  sequelae  are  treated  according  to 
the  appropriate  methods,  always  bearing  in  mind  the  great  strain  to 
which  the  system  has  been  subjected  by  the  choleraic  process,  the  spe- 
cial danger  of  re-exciting  gastro-intestinal  irritation,  or  of  putting  addi- 
tional stress  on  the  damaged  liver  and  kidneys,  on  whose  restoration  to 
healthy  function  life  so  greatly  depends. 

In  most  cases  of  recovery  from  cholera  health  and  strength  are 
rapidly  regained,  and  the  patient  in  a  few  days  seems  none  the  worse 
of  his  attack.  In  some  cases  anaemia,  emaciation,  debility,  deranged 
stomach  and  bowels,  and  general  enfeeblement  and  bad  health  of  a 
persistent  and  intractable  description,  ensue.  Change  of  air  is  the  best 
means  of  combating  this  state.  Tonics  and  careful  dieting  and  regimen 
are  also  necessary. 

The  dietimj  of  cholera  subjects  is  a  difficult  task.  The  simplest 
possible  liquid  food  should  be  given  in  small  quantities  during  the 
attack,  and  ordinary  food  be  very  gradually  resumed  during  convales- 
cence. It  is  needless  to  catalogue  here  the  articles  of  diet  which  may 
be  administered  [yid.  art.  on  "  Dietetics  and  Sick  Feeding "].  These 
directions  must  be  left  to  the  discretion  of  the  practitioner,  but  fatal 
relapses  have  not  infrequently  been  caused  by  injudicious  dieting. 
Finally,  it  may  be  asserted  with  confidence  that,  although  no  "  cure  "  of 
cholera  has  as  yet  been  discovered,  careful  attention  to  the  state  of  the 
patient  with  a  view  to  the  fulfilment  of  the  needs  which  I  have  indi- 
cated above,  will  relieve  much  suffering  and  save  many  lives. 

Kenneth  Macleod. 

REFERENCES 

1.  Macrae.  "  Flies  and  Cholera  Diffusion,"  Indian  Medical  Gazette,  1894,  pp.  407, 
412. — 2.  Hart,  Ernest.  Nurseries  of  Cholera,  p.  4.  Smith,  Elder,  and  Co.  —  3. 
Koch,  Professor.  The  Cholera  in  Germany  during  the  Winter  of  1892-93,  translated  by- 
George  Duncan,  M.A.,  p.  79. — 4.  Hirsch.  Geographical  and  Historical  Pathology,  trans- 
lated by  Creighton,  vol.  i.  pp.  4.39.-5.  Hirsch.  Op.  cit.  p.  438.-6.  Davidson.  Geo- 
graphical Pathology,  vol.  i.  p.  436.-7.   Koch.     Op.  cit.  p.  119  et  seq. 

E.  H. 

s.  c.  s. 

1.  Ap.KLandCLAUssRN.  Centi'.  f.  i?.M?if?  P.xvii.3,4.  — 2.  Bordet.  Pasteur'. -i  Annates, 
June  ]8!)5.  —  3.  Cijnninghan,  D.*D.  Scientif.  Mem.  by  the  Medical  Officers  of  the  Army 
of  India,  1885,  ]88f),  1890,  1891.- 4.  Durham,  H.  Y..  Proc.  Royal  Soc.  London,  1896.  — 
5.  Dcmjar.  Dputsch.  med.  Woch.  189.5  and  Ergebnisse  der  allg.  Aetiologie  (edited  by 
Lubarsc.h  and  Ostertag)  1890,  i.  p.  804,  where  a  useful  list  of  references  will  be  found. 
—  ft.  Emmkrich  and  Tsunoi.  MilncJiener  nied.  Wochenschr.  1893,  Nos.  25  and  20. — 
7.  FrJjofjE.  Die  Mikroorgani.tm.en;  Verbrrdtung.wei.se  u.  Abivehr  der  Cholera.  Leipzig, 
1893.-8.  Frankel,  C. '  JL/gienische  /?uw,dsr'/ifm,  1802,  1894,  and  1895.— 9.  Frank- 
land  and  Fkan'kf.and.  Miero-organisms  in  Water,  1894.  — 10.  Grurer  and  Wtkner. 
Wifn/T  kiln.  Wocher/srhr.  1892,  iind  Arch.  f.  Ilyq.  xv.  1892. —  11.  Grxjrer.  Milnch. 
med.  Woch.  1895,  13,  14. —12.    Gunthek.      Eliifdhrung  in  das  iStudium  der  liakleH- 


916  SYSTEM  OF  MEDICINE 

ologie,  1895,  where  also  useful  references  will  be  found.  — 13.  Haffkine.  Brit.  Med. 
Journal,  1895,  Dec.  21,  and  Antlcholera  Inoculation,  Calcutta,  1895.  — 14.  Hankin. 
Indian  Med.  Gazette,  March  1895. —  15.   Karlinski.     Centr.  f.  B.  und  P.  xvii.  5,  6. 

—  l(j.  Klein,  E.  Treatise  on  Hi/giene  and  Public  Health  (Stevenson  and  Murijhy), 
1893,  chapter  xxi.  p.  172;  Brit.  Med.  Journal,  1893,  i.  p.  632  ;  Local  Government  Boai^d 
Report  and  Papers  on  Cholera  in  England  in  1893,  Appendix  B. — 17.  Klemperer. 
Zeitschr.f.  klin.  Med.  xxv.  5,  6. —  18.  Koch,  R.  Zeitschr.f.  Hygiene,  xiv.  p.  319.-19. 
Metschnikoff.  Various  articles  in  Pasteur's  Annates,  1893-i)5.  —  20.  Pettenkofer. 
Mdnchener  msd.  Wochenschr.  1892,  4(i,  9t),  and  1891,  12;  Arch.  f.  Hygiene,  xviii.  1, 
p.  91. —21.  Pfeiffer.  Numerous  papers  in  the  Zeitsch.  f.  Hygiene,  xi.  xiv.  xviii. 
xix.  and  XX. — 22.  Pfeiffer  and  Issakff.  Zeitschr.  f.  Hyg.:s.w\\.  —  23.  Rumpf.  Volk- 
mann'sche  Vortr.  N.  F.  1894,  109,  110.  — 24.  Sabolotny.  Centr.  /.  B.  und  P.  xv. 
pp.  150-157.  — 25.  Salus.  Arch.  f.  Hyg.  xix.  i.—'IG.  Sanarelli.  Pasteur's  Annates, 
1893-95.  — 27.  Simpson,  W.  J.  Cholera  in  Calcutta,  1894.— 28.  Sobernheim.  Hyg. 
Rundschau,  1893,  p.  91(5.-29.  Sternberg.  Manual  of  Bacteriology ,  where  also  numer- 
ous references  are  found.  — 30.   Uffelmann.     Berl.  klin.  Wochenschr.  1892  and  1893. 

—  31.  Weibel.  Arch.  f.  Hyg.  xxi.  —  32.  Wesbrook.  Hyg.  Rundschau,  18\)5;  Pasteur's 
Annales,  lS\)i.  —  33.   Kanthack  and  Wesbrook.    Brit.  Med.  Journal,  lH^'d,  vol.  ii. 

A.  A.  K. 

J.  W.  W.  S. 

The  following  works  may  be  consulted  with  advantage  as  regards  the  aspects  of 
cholera  presented  in  the  foregoing  article  ;  —  1.  Jameson,  J.  Report  on  the  Epidemic 
Cholera  Morbus  as  it  visited  the  Territories  subject  to  the  Presidency  of  Bengal  in  the 
Years  1817-1818-1819.  Drawn  up  by  order  of  the  Government  under  the  superintend- 
ence of  the  Medical  Board,  Calcutta.  Printed  at  the  Government  Gazette  Press. — 
2.  Annesley,  J.  Sketches  of  the  most  Prevalent  Diseases  of  India,  comprising  a 
Treatise  on  the  Epidemic  Cholera  of  the  East.  8vo.  London,  1825. — 3.  Macpherson, 
J.  Cholera  in  its  Home,  with  a  Sketch  of  the  Pathology  and  Treatment  of  the 
Disease.  8vo.  London,  18(56.  Annals  of  Cholera  from  the  Earliest  Periods  to  the 
Year  1817.  8vo.  London,  1872.  —  4.  Macnamara,  C.  N.  A  History  of  Asiatic 
Cholera.  8vo.  London,  1870  and  1876.  Also  articles  in  Quain's  Dictionary  of 
Medicine  and  Davidson's  Hygiene  and  Diseases  of  Warm  Climates. — 5.  Parkes, 
E.  A.  Researches  into  the  Pathology  and  Treatment  of  the  Asiatic  or  Algide  Cholera. 
8vo.  London,  1847.  Also  British  and  Foreign  Medico-Chirurgical  Review,  1848,  i.  2.36; 
London  Journal  of  Medicine,  February  1849,  on  the  "  Intestinal  Discharges  of  Cholera," 
and  numerous  articles  in  the  Reports  of  the  Army  Medical  Department. — 6.  Goodeye, 
E.  "Epidemic  Cholera,"  in  Reynolds' System  o/il/ed/cme.  —  7.  Schmidt,  C.  Beitrag 
sur  Lehre  von  der  Cholera.  8vo.  Wiirzburg,  1837.  Charakteristik  der  epidemischen 
Cholera  gegeniiber  venoandten  transsudations-anomalien.    Leipzig  und  Mitau,  1S50.  — 

8.  Murray,  J.     Report  on  the   T/'eatment  of  Epidemic   Cholera.      Calcutta,  1869. — 

9.  Lewis,  T.  and  Cunningham,  D.  D.  Numerous  papers  on  the  Microscopy  and 
Pathology  of  Cholera  appended  to  the  Reports  of  the  Sanitary  Commissioner  viith  the 
Government  of  India  since  1870.  — 10.  Koch  and  Gaffky.  Report  of  the  German 
Cholera  Commission  of  1883-1884.  Also  numerous  papers  by  Koch  in  German 
medical  periodicals. — 11.  Wall,  A.  J.  Asiatic  Cholera:  its  History,  Pathology, 
and  Modern  Treatment.  8vo.  London,  1893.  —  A  more  extended  bibliography  will  be 
found  in  Hirsch's  Handbook  of  Geograplfical  and  Historical  Pathology,  and  in  the 
Index  Catalogue  of  the  Library  of  the  Surgeon-General's  Office,  U.  S.  Army,  vol.  iii. 

K.  M. 


PLAGUE  917 


PLAGUE 


Synonyms.  —  Oriental  Plague,  Bubonic  plague,  Pestis,  Pestilentia  : 
Pali  plague  or  Mahamurrie  (in  India).  The  Black  Death  (fourteenth 
century  in  Europe). 

Definition. — An  acute  infective  febrile  disease,  accompanied  by  in- 
flammation of  lymphatic  glands;  partly  miasmatic,  partly  communi- 
cable, caused  by  a  micro-organism,  the  bacillus  pestis. 

History  of  the  Plague.  —  The  first  historical  notice  of  a  disease  like 
bubonic  plague  records  its  occurrence  in  Libya  in  the  third  century 
before  Christ,  or  earlier ;  but  this  notice  is  only  contained  in  a  fragment 
from  the  writings  of  a  much  later  physician,  Bufus  of  Ephesus  (about 
100  A.D.),  who  also  speaks  of  its  occurrence  in  his  own  time  in  Libya, 
Egypt,  and  Syria.  Whether  it  was  clearly  known  to  the  classical  Greek 
writers  on  medicine  is  doubtful,  but  Aretaeus  speaks  of  /3ov/3(Lv€<;  Xoifjua- 
8es,  or  pestilential  buboes.  The  plague  of  Athens  described  by  Thucyd- 
ides  was  apparently  not  this  disease ;  nor  was  the  destructive  pestilence 
of  the  reign  of  Marcus  Aurelius  alluded  to  by  Galen.  We  meet  with 
bubonic  plague  again,  however,  in  the  great  Plague  of  Justinian,  which 
started  from  Egypt  542  a.d.,  and  spread  over  a  large  part  of  Europe ; 
it  was  described  in  Gaul  as  lues  inguinaria.  Epidemics  succeeded  one 
another  in  this  and  the  succeeding  century ;  but  after  that  time  it  is 
difficult  to  follow  the  track  of  plague.  Many  European  pestilences  are 
spoken  of  in  mediaeval  histories,  which  may  or  may  not  have  been 
bubonic  plague ;  no  sufficiently  clear  record  remains. 

In  the  fourteenth  century  a  new  era  began.  All  previous  European 
plagues  could  be  traced  back,  directly  or  remotely,  to  Africa,  especially 
to  Egypt ;  but  now  a  new  epidemic  invaded  Europe  from  Asia  by  way 
of  the  Crimea  and  the  Black  Sea,  its  origin  being  referred  to  Cathay  or 
China.  This  terrible  pestilence,  afterwards  known  as  the  "  Death,"  or 
the  "  Black  Death,"  appeared  in  Southern  Italy  in  1346-47,  and  made 
its  way  over  the  whole  of  Europe.  It  reached  England  early  in  1348 
and  for  several,  probably  five  or  six  years,  was  prevalent  in  various 
parts  of  the  country.  Scotland  and  Ireland  were  affected  in  their  turn ; 
and  no  country  in  Europe  seems  to  have  escaped.  A  second  epidemic 
occurred  in  1361,  and  a  third  in  1368.  The  details  of  this  great  calam- 
ity have  often  been  dwelt  upon  by  historians  and  cannot  be  given  here. 
It  is  calculated  by  Hecker  that  25,000,000  of  persons,  one-fourth  of 
the  population  of  Europe,  died  of  this  disease.  Although  it  has  been 
doubted  whether  this  was  the  true  bubonic  plague,  as  the  first  epidemic 
presented  some  peculiar  features,  yet  it  must  now  be  accepted  that  the 
Black  Death  was  that  disease  in  a  peculiarly  malignant  form. 

The  great  importance  of  this  fact  in  epidemic  history  is  that  from 
this  time  forth,  whether  j)reviously  or  not,  plague  was  established  as 
an  endemic  disease  in  England  and  other  parts  of  Europe ;  though  it 


9i8  SYSTEM   OF  MEDICINE 

is  quite  possible  that,  as  Hirsch  and  others  think,  fresh  importations  of 
the  virus  from  the  East  took  place  from  time  to  time.  The  successive 
epidemics  in  Britain  through  the  fifteenth,  sixteenth,  and  seventeenth 
centuries  are  fully  recorded  in  Dr.  Creighton's  History  of  Epidemics  in 
Britain.  Finally  they  culminated  in  that  called  the  Great  Plague  of 
London  in  1665,  in  which  about  70,000  persons  died,  and  which  ex- 
tended widely  over  the  country.  Soon  after  that  the  disease  vanished, 
never  to  recur  on  English  soil. 

During  these  centuries  most  countries  in  Europe  suffei-ed  from  re- 
peated epidemics.  It  was  noticed  that  the  epidemic  wave  passed  on  the 
whole  from  East  to  West,  or  from  the  Mediterranean  countries  north- 
ward ;  which  led  to  the  belief  that  many  European  epidemics  were 
derived  from  more  persistent  foci  of  plague  in  Turkey,  the  Levant,  and 
Egypt.  Hence  the  system  of  quarantine,  by  sea  and  land,  was  intro- 
duced to  stem  the  tide  of  infection.  This  belief,  which  is  that  of  many 
epidemiologists,  receives  support  from  the  fact  that  the  disease  died 
out  earlier  in  Western  than  in  Eastern  Europe.  Holland,  Erance, 
Spain,  and  Italy  became  exempt,  with  one  notable  exception,  a  little 
later  than  England  —  about  the  end  of  the  seventeenth  century.  East- 
ern Germany  suffered  somewhat  longer,  while  in  Poland,  Russia,  parts 
of  the  Austrian  Empire,  and  the  Danubian  countries,  epidemics  were 
repeated  throughout  the  eighteentli  century.  There  was  thus  a  general 
eastward  recession ;  the  chief  exception  to  which  was  the  great  epidemic 
of  Southern  France,  1720-21.  This  was  generally  attributed  to  the  arri- 
val, in  the  port  of  Marseilles,  of  a  ship  from  Syria  infected  with  plague, 
which  then  spread  to  the  populous  and  insalubrious  city.  The  invasion 
of  islands  like  Sicily  and  Malta  in  the  eighteenth  century  was  clearly 
due  to  the  same  cause,  namely,  to  a  contagion  impoi'ted  by  sea. 

During  the  first  lialf  of  the  nineteenth  century  plague  prevailed  in 
Turkey,  and  made  occasional  advances  into  the  Danubian  countries, 
to  the  shores  of  the  Adriatic  seas,  and  to  the  south  of  Russia.  Being 
still  almost  constantly  present  in  Egypt  and  Syria,  it  seemed  to  be  a 
disease  peculiarly  of  the  Eastern  Mediterranean,  and  thus  acquired 
the  name  of  Levantine  Plague,  which  has  lasted  to  our  day ;  and  the 
strictest  precautions  were  still  taken  in  all  the  Mediterranean  ports  to 
prevent  its  invasion. 

Finally  in  1841  plague  left  Europe  by  its  Eastern  gate,  Constanti- 
nople ;  and  in  1843-45  it  became  extinct  also  in  S3* ria  and  Egypt,  so  that 
the  old  Levantine  Plague  seemed  to  have  entirely  vanished.  It  is  clear, 
however,  that  in  Asia  Minor  it  did  not  die  away,  but  only  receded  east- 
ward. At  the  beginning  of  this  centiiry,  the  Caucasus,  according  to  Thol- 
ozan,  was  the  centre  from  which  epidemics  radiated;  but  in  the  latter  half 
of  the  century  that  centre  has  been  shifted  to  the  mountains  of  Kurdistan. 

Good  authorities  still  held  that  the  disease  was  probably  not  extinct ; 
and  these  suspicions  were  confirmed  by  accounts  received  at  Constanti- 
nople, in  1853,  of  an  outbreak  in  the  Azir  district  of  Arabia  already  men- 
tioned :  this  outbreak  has  been  followed  repeatedly  by  others  at  intervals 


PLAGUE  919 

of  some  years ;  the  last  was  in  1889.  In  1858  the  same  disease  was  heard 
of  in  Benghazi,  where  it  must  have  prevailed  at  least  two  or  three  years 
before ;  and  there  it  appeared  again  in  1874,  and  possibly  again  latei'. 
The  plague  also  in  the  province  of  Tripoli  so  lately  as  1837,  has  recurred 
in  the  form  of  epidemics  which  were  relics  of  the  former  wide  distribu- 
tion of  plague  along  the  Avhole  northern  coast  of  Africa. 

The  more  recent  accoimts  of  plague  in  the  Kurdistan  district,  on  the 
frontiers  of  Turkey  and  Persia  and  Mesopotamia,  begin  with  1863 ;  but 
it  must  not  be  supposed  that  this  was  the  first  appearance  of  the  disease 
in  that  part  of  the  world  —  Baghdad  and  the  neighbourhood  had  suffered 
severely  at  the  beginning  of  the  century,  and  for  all  we  know  to  the 
contrary,  for  centuries  before  that. 

The  chief  known  recent  epidemics  of  Persia  and  Kurdistan  were  in 
1863,  in  1870-72,  and  in  1876-77 ;  in  1877  a  terrible  epidemic  occurred 
also  in  the  town  of  Resht  on  the  Caspian,  which  is  an  important  occurrence 
in  relation  to  the  epidemic  of  1878  on  the  Volga.  The  latest  recorded 
appearance  of  plague  in  Persia  was  in  1885 ;  but  it  was  probably  not 
the  last. 

In  Mesopotamia  (Irak-Arabi),  from  1856  onward  for  several  years, 
there  prevailed  what  is  now  known  to  have  been  the  mild  form  of  plague. 
In  1867  a  definite  epidemic  was  recorded ;  in  1873-74  another  extending 
over  a  much  wider  area ;  and  in  1876-77  one  still  more  extensive,  and 
very  severe.  A  further  outbreak  occurred  in  1880-81,  which  is  said  to 
have  destroyed  one-quarter  or  one-third  of  the  population ;  and  another 
in  1884. 

The  above  short  record  is  of  interest  as  showing  how  plague  may 
extend  its  area  in  successive  epidemics ;  and  also  as  leading  up  to  the 
comparatively  small  epidemic  on  the  Volga  in  1879,  which  caused  so 
much  alarm. 

As  has  been  shown,  in  the  years  1876  and  1877  the  plague  was  very 
active.  In  June  1877,  and  also  in  the  two  years  following,  a  febrile 
malady  accompanied  by  buboes  appeared  in  Astrakhan  on  the  northern 
shore  of  the  Caspian,  a  place  in  direct  communication  with  Resht  on  the 
Persian  shore,  and  it  extended  to  neighbouring  villages.  Though  it  was 
of  a  mild  type  and  caused  but  few  deaths,  it  was  certainly  the  mild  or 
minor  form  of  plague.  In  October  1878,  a  similar  but  more  severe 
epidemic  broke  out  in  the  Cossack  settlement  of  Vetlanka,  130  miles  up 
the  Volga;  and  by  December  it  assumed  the  character  of  the  most 
virulent  plague.  The  epidemic  lasted  in  this  village  till  24th  January 
1879  ;  but  in  December  it  had  already  spread  to  other  villages,  in  which 
nearly  every  patient  died.  The  last  death  in  the  district  occurred  on 
9th  February.  Though  affecting  a  small  jjopulation  it  was  very  fatal, 
causing  382  deaths  in  a  population  of  1700.  The  mortality  was  nearly 
90  per  cent. 

I'his  is  the  simple  history  of  the  epidemic  which  caused  a  panic 
through  Europe.  It  is  easily  explained  when  we  see  its  filiation  with 
the  mild  epidemic  of  Astrakhan  and  the  severe  one  of  Resht;  and  tlie 


920  SYSTEM   OF  MEDICINE 

general  prevalence  of  plague  m  Persia  in  previous  years.  A  minor  epi- 
demic in  1877  at  Baku,  on  the  western  shore  of  the  Caspian,  furnishes 
another  link.  Why  the  disease  was  so  mild  in  Astrakhan  and  so  viru- 
lent in  Vetlanka  we  cannot  tell ;  but  a  like  sudden  development  of  the 
severe  out  of  the  mild  form  of  the  disease  is  frequently  observed. 

History  of  Plague  in  India.  — Plague  has  been  little  known  in  India; 
the  climate  generally  seems  too  hot  for  it :  three  centres  have,  however, 
been  known  in  this  century.  In  1815  an  outbreak,  following  a  famine, 
occurred  in  Cutch,  Guzerat  and  Katty  war.  The  next  year  it  reappeared, 
but  went  away  in  1820.  In  1836  an  epidemic  which  broke  out  in  Pali 
in  Rajputana  became  known  as  the  Pali  plague,  but  it  ceased  in  1837. 
In  a  different  locality,  the  districts  of  Gurwhal  and  Kumaon  on  the 
south-west  of  the  Himalayas,  a  disease  known  locally  as  Mahamurrie 
(which  is  undoubtedly  bubonic  plague)  has  recurred  several  times  since 
1823.  The  last  great  epidemic  was  in  1876-77,  but  it  recurred  in  1886 
and  1888.  No  connection  can  be  traced  between  the  above-mentioned 
localities  of  plague,  nor  between  them  and  any  other. 

In  1883-84  a  malady  was  observed  in  Candahar  (Afghanistan),  which 
presented  some  features  of  plague,  but  was  not  certainly  identitied. 

History  of  Plague  in  China.  — The  first  definitely  known  epidemic  of 
plague  in  Yunnan  was  about  1860;  but  it  is  believed  to  have  existed 
there  at  least  since  1850,  and  probably  long  before,  as  it  has  all  the 
characters  of  an  endemic  disease.  It  is  said  to  have  recurred  nearly 
every  year  up  to  1893.  In  Pakhoi  it  is  also  frequent,  but  Avas  absent 
from  1884  to  1893.  Some  think  the  epidemics  of  Pakhoi  were  derived 
from  Yunnan.  It  is  impossible  to  trace  the  derivation  of  the  disease 
from  any  other  district.  Prom  Pakhoi  it  must  in  some  way  have  found 
its  way  to  Canton,  where  it  broke  out  in  1894.  Dr.  Eennie  of  Canton 
thinks  it  passed  by  land,  since  in  1891  a  severe  epidemic  occurred  in  the 
district  of  Kaochao,  lying  to  the  north  of  Pakhoi ;  and  in  the  spring  of 
1894  it  prevailed  in  towns  to  the  south  of  Canton.  Prom  Canton  to 
Hong-Kong  it  was  carried  by  numerous  persons  suffering  from  the 
disease,  or  in  the  stage  of  incubation. 

General  Pathology  of  Plague. — Plague  occupies  an  intermediate  posi- 
tion between  the  miasmatic  or  malarial  diseases  proper,  such  as  ague, 
and  the  true  contagious  fevers ;  there  is  clear  evidence  that  its  virus 
may  be  acquired  both  direct  from  the  soil,  and  from  infected  persons 
and  objects  above  the  soil.  It  will  be  convenient,  therefore,  to  consider 
it  in  this  twofold  relation,  as  an  endemic  soil-disease  and  as  a  communi- 
cable epidemic.  Under  both  conditions  its  existence  and  propagation  are 
explicable  by  the  recent  discovery  of  a  micro-organism. 

The  Bacillus  of  Plague.  —  The  phenomena  of  plague  can  hardly  be 
accounted  for  except  on  the  hypothesis  of  a  living  organic  cause,  one 
capable  of  living  in  the  human  body,  and  also  in  some  way  outside  the 
body  also.  Great  interest,  therefore,  attaches  to  the  recent  discovery, 
in  Hong-Kong,  by  Kitasato,  confirmed  by  Yersin,  of  a  micro-organism 


PLAGUE  921 

which  seems  to  fulfil  all  the  conditions  required  by  the  problem,  and  is 
probably  the  specific  cause  of  the  disease. 

Kitasato  found  in  the  bodies  of  patients  with  plague  a  short,  rather 
thick  bacillus,  which  stains,  with  various  dyes,  in  such  a  way  that  the 
poles  are  deeply  coloured,  while  the  central  part  is  pale ;  thus  it  some- 
what resembles  a  diplococcus.  Yersin's  description  precisely  corresponds 
with  that  of  Kitasato.  This  bacillus  may  be  grown  on  ordinary  cultiva- 
tion mediums  —  especially  agar-agar,  with  glycerine,  blood  serum,  and 
bouillon  —  temperatures  from  97°  to  102°  F.  being  the  most  suitable. 
It  is  killed  in  thirty  minutes  by  a  temperature  of  170°  F.,  and  in  a  few 
minutes  by  212°  F.  According  to  both  observers  the  bacillus  is  most 
abundant  in  the  lymph  glands ;  the  pulp  of  softened  buboes  is  indeed 
little  more  than  a  pure  cultivation  of  the  bacillus ;  it  is  almost  equally 
abundant  in  the  spleen.  But  few  are  found  in  the  blood,  and  then  chiefly 
in  very  severe  cases  of  plague  (Yersin).  Kitasato  detected  them  in  the 
blood  of  twenty -five  out  of  twenty-eight  patients,  but  says  that  the  detec- 
tion is  difficult,  and,  except  in  the  hands  of  a  skilled  observer,  does  not 
furnish  a  satisfactory  means  of  diagnosis.  Cultivation  from  the  blood, 
however,  is  more  satisfactory. 

Inoculation  of  matter  from  buboes  into  rats,  mice,  guinea-pigs,  or 
rabbits  gives  them  a  febrile  disease  (temperature  105°  F.,  Kitasato),  fatal 
in  from  one  to  five  days.  The  bodies  show  characteristic  enlarged  glands, 
and  bacilli  are  present  in  large  numbers  in  the  glands  and  spleen,  and  a 
few  in  the  blood.  Yersin  passed  the  disease  by  inoculation  from  one 
animal  to  another  with  increasing  virulence.  Inoculation  of  cultures  of 
the  bacillus  produces  the  same  result,  and  bacilli  are  found  in  the  organs 
after  death.  It  is  thus  clear  that  the  organism  is  the  cause  of  the  disease 
in  animals,  and  that  this  disease  is  the  same  as  the  human  disease.  The 
bacillus  thus  fulfils  all  the  conditions  required  to  prove  it  to  be  the  true 
pathogenetic  organism  of  plague. 

The  channels  of  reception  of  the  bacillus  are,  according  to  Kitasato, 
the  respiratory  organs,  the  digestive  tract,  and  inoculation.  According  to 
Yersin  rats  and  mice,  especially  the  former,  fed  with  fragments  of  organs 
of  animals  dead  of  the  disease  acquired  plague,  and  died  with  character- 
istic lesions  and  bacilli  in  their  organs.  It  is  also  stated  that  bacilli  are 
found  in  the  faecal  dejections  of  patients,  showing  a  mode  of  infection  in 
plague  previously  unsuspected :  indeed  the  bacillus  is  not  known  to  leave 
the  body  by  any  other  channel.  Yersin  established  contagion  of  plague  by 
keeping  inoculated  rats  and  healthy  mice  in  the  same  place.  All  the 
latter,  as  well  as  the  former,  died  with  numerous  bacilli  in  their  organs. 

Under  certain  circumstances  a  remarkable  diminution  of  virulence  of 
the  bacillus  was  observed  by  Yersin.  Some  colonies  in  cultures  were 
observed  to  grow  much  more  rapidly  than  the  others,  and  if  cultivated 
separately  were  found  to  be  much  diminished  in  virulence.  Bacilli 
obtained  from  convalescent  patients  were  also  of  comparatively  low 
virulence.  These  observations  are  interesting  as  bearing  on  the  spon- 
taneous decline  in  virulence  and  the  cessation  of  plague  epidemics. 


922  SYSTEM   OF  MEDICINE 

Ectogenic  Existence  of  the  Bacillus.  —  Yersin  was  able  to  cultivate  and 
isolate  a  bacillus  from  earth  of  an  infected  house,  four  to  five  centimetres 
below  the  surface,  which  precisely  resembled  that  from  buboes,  but  was 
not  virulent.  Kitasato  found  in  one  instance  that  dust  from  an  infected 
house  communicated  plague  by  inoculation.  Yersin  found  that  flies  die 
from  the  disease,  their  bodies  containing  the  bacillus  ;  and  by  inoculation 
of  material  contaminated  with  a  dead  fly  he  conveyed  plague  to  animals. 
^  The  conclusion  is  that  a  bacillus  has  been  discovered  capable  of 
parasitic  existence  in  men  and  animals,  capable  of  ectogenic  life,  showing 
spontaneous  variability  in  virulence,  and  thus  fulfilling  all  the  conditions 
necessary  to  explain  the  observed  phenojnena  of  plague. 

Endemic  Plague.  — In  discussing  the  existence  of  plague  as  an  endemic 
disease,  it  is  necessary  to  take  into  account  its  geographical  distribution, 
and  to  some  extent  its  history,  together  with  the  associated  physical  and 
social  conditions.  The  localities  where  it  is  now  known  to  occur,  or  to 
have  occurred  within  the  last  twenty  years,  are  as  follows :  — 

(1)  In  the  district  of  Benghazi  (the  ancient  Cyrenaica),  in  the  prov- 
ince of  Tripoli,  ISTorthern  Africa,  the  most  westerly  station  now  known; 
last  definitely  recorded  in  1874. 

(2)  The  district  of  Azir  or  Assyr,  in  South-western  Arabia,  bordering 
on  the  Red  Sea,  as  lately  as  1889. 

(3)  A  large  area  in  Asia,  comprising  Persian  Kurdistan  and  adjacent 
parts  of  Persia,  Turkish  Kurdistan,  and  parts  of  Irak  or  Mesopotamia  on 
the  banks  of  the  Tigris  and  Euphrates,  including  Baghdad.  From  this 
area  it  has  extended  to  Northern  Persia  on  the  shores  of  the  Caspian 
(Resht)  in  1877,  to  Baku  on  the  western,  and  Astrakhan  on  the 
northern  shore  of  that  sea;  and  up  the  Volga  to  the  village  of  Vetlanka 
and  its  neighbourhood  in  1877-79. 

(4)  The  districts  of  Kumaon  and  Gurwhal  in  the  north-west  of  India, 
on  the  slopes  of  the  Himalayas,  as  lately  as  1888. 

(5)  In  Southern  China,  the  mountain  district  of  Yunnan  and  the  sea- 
port Pakhoi  on  the  Tonkin  Gulf.  Apparently  by  extension  from  Pakhoi, 
plague  has  in  the  last  two  years  invaded  Canton  and  Hong-Kong  in 
Eastern  China. 

The  five  localities  above  named  appear  to  be  independent  centres  of 
the  disease,  since  no  communication  can  be  traced  between  them ;  and 
plague  is  not  known  to  exist  in  any  other  part  of  the  world. 

These  localities  are  all  in  the  temperature  zone,  with  the  exception  of 
the  Azir  district  and  Pakhoi,  Avhich  lie  just  within  the  tropics ;  but  they 
have  hardly  another  physical  feature  in  common.  Plague  prevails  in 
Benghazi  on  a  rocky  plateau  overlooking  a  marshy  district  liable  to 
inundation ;  on  the  banks  of  the  Tigris  and  Euphrates,  and  on  part  of  the 
shores  of  the  Caspian  in  low  and  marshy  situations.  But  the  mountains 
of  Kurdistan  are  5000  to  6000  feet  high;  and  the  Himalayan  seat  of 
plague  approaches  7000  feet  above  the  sea ;  while  in  Yunnan 'the  disease 
is  said  to  occur  only  at  elevations  of  from  1200  to  7200  feet.  These 
facts  show  the  old   belief   that  plague  prevails   only  in  marshy  and 


PLAGUE  923 

malarious  districts  to  be  unfounded.  In  fact  mountain  districts  are 
perhaps  the  most  persistent  foci  of  plague  now  known. 

The  social  conditions  of  these  localities  are  important,  and  will  be 
referred  to  presently. 

Endemic  Plague  as  a  Soil  Disease.  —  In  all  the  places  where  plague 
is  endemic,  there  is  reason  to  believe  that  the  virus  resides  permanently 
in  the  soil,  and  that  human  beings  acquire  it  thence  by  certain  channels 
of  communication.  Plague  is  therefore  partially,  though  not  wholly,  a 
miasmatic  or  soil  disease.  It  differs  from  malarial  disease  in  that  it  exists 
only  in  the  soil  of  inhabited  places,  and  has  never  been  acquired  from 
mere  telluric  conditions.  Since  the  living  virus  is  a  bacillus  which  exists 
in  the  affected  subjects,  it  will  pass  from  them  back  into  the  soil,  and  a 
mutual  relation  be  thus  established.  The  soil  theory  of  plague  is  a  popular 
belief  in  some  parts  of  the  world.  It  was  dimly  perceived  by  many  older 
writers  (by  Boghurst  in  the  seventeenth  century) ;  but  was  obscured  by 
other  less  tenable  hypotheses  of  infection  of  the  air  and  epidemic  con- 
stitutions. It  was  clearly  recognised  by  Dr.  C.  R.  Francis  as  the  ex- 
planation of  the  Indian  plague  of  Kumaon  in  1853.  It  was  suggested  as 
possible  by  Liebermeister  in  the  article  on  Plague  in  Ziemssen's  Cydo- 
pmdia  of  Medicine,  and  adopted,  subject  to  further  evidence,  by  myself 
in  the  Encydopoedia  Britannica  and  elsewhere:  but  it  was  first  defi- 
nitely formulated,  with  the  aid  of  Pettenkofer's  theory  of  soil  water,  by 
Dr.  Creighton  in  his  History  of  Epidemic  Diseases.  It  is  apparently  not 
held  by  most  epidemiologists. 

The  arguments  in  favour  of  this  view  are  somewhat  as  folloAvs :  — 

(1)  The  remarkably  limited  geographical  distribution  of  plague,  so 
widely  different  from  that  of  diseases  caused  by  a  floating  or  purely 
personal  contagion,  is  hardly  consistent  with  any  other  hypothesis. 

(2)  In  localities  where  the  disease  is  permanently  established  ani- 
mals living  underground  are  often  affected  in  a  peculiar  way.  Usually 
before  the  outbreak  of  an  epidemic  such  animals,  especially  rats, 
perish  in  large  numbers.  They  come  out  of  their  holes  evidently  very 
ill,  and  die,  or  are  found  dead  under  ground ;  so  that  this  phenomenon  is 
considered  by  the  people  in  India  and  China,  where  it  has  been  chiefly 
observed,  as  the  sign  of  a  coming  epidemic.  Eecent  observation  in  China 
has  shown  that  the  rats  suffer  not  merely  from  poisoning,  but  from  true 
bubonic  jjlague.  They  have  buboes,  and  their  organs  contain  immense 
numbers  of  the  plague  bacilli.  It  cannot,  therefore,  be  doubted  that  the 
virus  exists  under  ground  before  it  affects  human  beings.  In  some 
countries  other  animals  are  said  to  be  affected,  but  this  is  less  certain.^ 

(3)  Within  an  endemic  area  of  plague  the  disease  often  occurs  year 
after  year,  or  in  successive  epidemics,  precisely  in  the  same  spots,  even  in 
the  same  houses  ;  and  springs  up  simultaneously  in  several  independent 

1  In  thf!  older  European  epirlemios  it  seems  doubtful  whether  this  death  of  rats  was 
actually  oV)S(;rved.  Tlie  old  books  contain  Kcneral  statements  of  the  same  kind  regarding 
nnimals  which  live  in  the  ground,  but  they  have  the  appearance  of  being  traditional,  and 
borrowed  from  the  Arabian  writers,  especially  from  Avicenna,  who  is  very  copious  on  this 
point. 


924  SYSTEM   OF  MEDICINE 

foci.     In  London  in  1G65  it  was  said  the  disease  "fell  upon  several 
spots  of  the  city  and  suburbs  like  rain." 

(4)  Of  places  apparently  under  the  same  conditions,  and  in  free 
communication  with  one  another,  one  is  repeatedly  affected,  the  other 
never.  Dr.  Francis  observed  in  India  two  villages  on  the  same  mountain, 
with  the  same  aspect,  scarcely  500  yards  apart,  of  which,  at  every  visita- 
tion of  plague,  one  always  escaped,  the  other  suffered.  In  old  days,  again, 
it  was  observed  in  Egypt  that  Alexandria  might  have  a  terrible  epidemic, 
while  Cairo  entirely  escaped :  in  another  epidemic  the  converse  relation 
might  obtain;  and  this  in  spite  of  unchecked  communication. 

(5)  In  cities,  Avhere  a  notable  part  of  the  population  lives  on  the 
water  in  boats  and  barges,  it  has  more  than  once  been  noted  that  such 
persons  have  entirely  escaped  the  plague.  It  was  so  in  London  in  1665 ; 
and  recently  in  Canton,  where  250,000  people  live  and  sleep  on  the 
water,  this  part  of  the  population  enjoyed  almost  complete  immunity. 

(6)  It  has  often  been  observed  that  while  those  who  live  on  the 
ground  floor  of  a  house  are  seized  with  plague,  the  inhabitants  of  the 
upper  stories  may  entirely  escape ;  so  that  it  used  to  be  said,  "  Plague 
does  not  go  upstairs."  This  has  been  signally  confirmed  in  the  late 
epidemic  of  Canton. 

(7)  In  a  general  way,  the  beneficial  effects  of  local  sanitary  meas- 
ures, as  compared  with  mere  prevention  of  contagion,  tell  in  the  same 
direction;  but  the  bearings  of  these  facts  can  only  be  thus  briefly 
indicated. 

It  would  appear  from  the  above  reasons  that  the  endemic  prevalence 
of  plague  is  comparable  to  that  of  cholera  or  typhoid,  and  governed  by 
somewhat  similar  laws ;  though  in  other  respects  it  differs  very  much 
from  those  diseases.  In  the  double  infection  of  the  soil  and  the  organism 
it  resembles  anthrax.  Along  with  infection  of  the  soil  there  appears  to 
be  a  passage  of  the  virus  in  some  form  into  the  air,  so  that  it  has  always 
been  believed  that  the  disease  may  be  acquired  by  inhalation,  like  typhus. 
Scientific  explanation  of  this  method  of  receiving  the  virus  is,  however, 
still  wanting. 

Production  of  Epidemics.  —  While  remaining  fixed  in  one  spot,  plague 
varies  very  much  in  prevalence  and  intensity.  When  confined  to  sporadic 
cases,  or  existing  only  in  the  mild  form,  it  is  spoken  of  as  endemic.  When 
affecting  larger  numbers,  and  in  a  severer  form,  it  is  called  epidemic. 
The  disease  is  particularly  liable  to  recur  in  periodical  outbreaks  ;  and  in 
the  countries  affected  popular  belief  has  soinetimes  assigned  a  definite 
number  of  years,  such  as  seven,  for  the  interval.  There  is,  however,  no 
such  regularity ;  sometimes  a  great  epidemic  is  followed  by  several  years 
of  apparent  immunity,  sometimes  the  disease  recurs  several  years  in 
succession.  The  interval  of  apparent  health  is  probably  often  filled,  not 
so  much  with  sporadic  cases  of  severe  plague,  as  with  minor  plague. 

The  causes  of  the  development  of  minor  into  severe  plague,  and  of 
the  production  of  an  epidemic,  are  very  obscure.  Por  various  reasons  it 
cannot  depend  upon  the  number  of  susceptible  persons  in  the  population ; 


PLAGUE  925 

the  causes  must  be  physical,  affecting  the  biology  of  the  plague  bacillus 
•  whether  in  or  out  of  the  body.  The  best  established,  fact  is  that  epi- 
demics have  often  (but  not  constantly)  been  preceded  by  a  long  drought. 
Epidemic  diseases  among  animals,  failure  of  crops,  great  abundance  of 
lower  forms  of  life  —  such  as  flies  —  and  numerous  other  physical  inci- 
dents, have  been  also  described  as  preceding  or  accompanying  plague, 
but  are  of  little  moment.  More  important  are  social  conditions.  Many 
epidemics  of  plague  have  followed  on  famines,  wars,  and  other  calami- 
ties, which  produce  destitution  and  lowered  state  of  health.  Other 
fevers  have  sometimes  been  observed  to  prevail  at  the  same  time. 

Epidemics  of  plague  always  seem  to  terminate  spontaneously,  usually 
in  from  three  to  six  months.  Generally  in  each  place  they  begin  about 
the  same  season :  this  in  northern  countries  is  spring  or  early  summer ; 
and  they  are  checked  by  the  cold  of  winter.  When  j)revalent  in  Egypt, 
plague  used  to  begin  in  the  autumn  and  end  at  the  summer  solstice, 
when  hot  south  winds  prevail.  In  Russia  plague  has  on  some  occasions 
prevailed  through  the  winter,  being  kept  alive  by  the  high  internal  tem- 
perature of  houses.  In  Mesopotamia  an  air  temperature  of  86°  F.  at  once 
checks  an  epidemic,  and  one  of  113°  absolutely  stops  it. 

Conditions  favouring  the  continued  Existence  of  Plague.  —  It  has  been 
seen  that  no  physical  conditions,  except  temperature,  have  much  effect 
on  the  prevalence  of  plague.  But  certain  social  conditions  have  a  great 
influence,  and  seem  almost  indispensable  to  an  endemic  seat  of  the 
disease.  The  first  of  these  is  uncleanliness.  All  the  localities  in  which 
plague  flourishes  are  conspicuously  filthy.  The  villages  in  Mesopo- 
tamia were  in  an  incredible  state  of  filth  (Colvill).  The  sufferers  from 
Indian  plague  were  filthy  beyond  conception  (Erancis) ;  the  habits  of 
the  poorer  classes  of  Chinese  in  Hong-Kong  and  Canton  are  notori- 
ously of  the  same  kind.  A  soil  contaminated  with  faecal  discharges 
and  decaying  animal  matter  of  all  kinds  appears  to  be  an  essential  con- 
dition for  the  vitality  of  the  virus.  Among  other  causes  of  contamina- 
tion must  be  placed  cadaveric  infection  from  bad  customs  of  burial. 
This  was  notably  observed  in  the  Indian  seats  of  plague,  where  the 
rocky  nature  of  the  soil  offers  obstacles  to  efficient  burial ;  in  Yunnan 
also,  and  formerly  in  Egypt.  Dr.  Creighton  regards  this  as  the  domi- 
nant cause,  but  the  general  bearing  of  testimony  hardly  confirms  his 
opinion.  The  burial  among  or  within  dwelling-houses  of  those  who  die 
of  the  plague  has  otten,  however,  been  a  potent  means  of  continuing  the 
infection ;  such  bodies  contain  bacilli  in  enormous  numbers,  and  con- 
tagion from  dead  bodies  is  undoubtedly  possible.  Overcrowding  of 
dwelling-houses  ("not  necessarily  correlative  with  density  of  population) 
and  absence  of  ventilation  are  also  powerful  contributory  causes.  But 
of  all  social  conditions  poverty  and  general  social  misery  seem  to  be  the 
most  influential.  The  poor  are  always  the  chief,  sometimes  almost 
tlie  only  sufferers,  as  shown  by  such  epithets  as  miserim  morbus,  or 
''the  yjoor's  yjlague,"  often  given  to  the  disease. 

But  since  destitution  and  uncleauliuess  are  prevalent  in  so  many 


926  SYSTEM   OF  MEDICINE 

parts  of  the  world  where  plague  has  never  been  heard  of,  these  must  be 
regarded  as  favouring,  or  perhaps  essential,  conditions  for  the  disease, 
rather  than  as  accounting  for  its  origin.  A  very  moderate  improvement 
in  sanitary  matters  at  once  limits  or  eradicates  the  disease. 

Plague  as  a  communicable  Disease.  —  Unlike  true  miasmatic  diseases 
—  such  as  ague  —  there  can  be  no  doubt  that  plague  is  communicable, 
both  from  the  sick  to  the  healthy,  and  from  an  infected  place  to  one 
previously  uninfected;  but  the  extent  and  nature  of  this  communi- 
cability  have  been  the  subject  of  active  controversy. 

Communication  from  the  sick  to  the  healthy  does  not  take  place 
especially  by  contact,  as  was  formerly  believed  (and  hence  the  word 
contagion,  with  its  false  connotations,  is  better  avoided),  but  by  the 
atmosphere  of  the  sick-room,  or  of  the  house  itself ;  and  this  may  be 
largely,  if  not  completely,  obviated  by  abundant  ventilation.  It  may  be 
difficult  to  sa}'-  in  some  cases  whether  the  infection  is  acquired  from  the 
patient  or  from  the  house ;  but  it  is  pretty  clear  that  communication 
from  one  person  to  another  in  the  open  air,  or  by  casual  meeting,  is 
very  rare,  if  it  ever  occurs.  The  transmission  of  infection  by  clothing, 
bedding,  or  other  objects,  that  is,  in  the  old  phrase,  hy  fomites,  can  hardly 
be  questioned,  though  many  exaggerated  statements  have  been  made  on 
the  subject. 

Those  who,  like  the  French  physicians  in  Egypt,  denied  contagion 
altogether,  did  so  chiefly  on  the  ground  of  their  own  personal  immunity, 
though  they  attended  thousands  of  patients,  and  performed  many  post- 
mortem examinations.  One  of  them,  Bulard,  even  wore  the  clothes  of  a 
patient  who  had  died  of  plague,  and  Clot  Bey  tried  in  vain  to  inoculate 
himself  with  matter  from  a  pestilent  bubo.  Many  similar  negative  in- 
stances are  on  record ;  but  much  negative  evidence  is  not  so  conclusive 
with  regard  to  infection  as  a  few  positive  cases.  On  the  whole,  the  truth 
appears  to  be  that  during  different  epidemics  and  at  different  stages  of 
an  epidemic,  plague  differs  immensely  in  its  contagious  property,  as  it 
does  in  its  viridence ;  so  that,  broadly  speaking,  it  is  highly  communi- 
cable at  some  times,  and  very  slightly  so,  if  at  all,  at  others. 

In  explanation  of  cases  where  communication  cannot  be  traced,  it 
should  be  noted  that,  besides  rats  and  the  like,  domestic  animals  may 
convey  germs  of  disease,  and  Yersin  has  lately  shown  that  the  same  is 
true  of  house  flies. 

Transmission  of  plague  from  one  place  to  another  not  previously  in- 
fected must  also  be  regarded  as  well  established ;  though,  doubtless,  this 
has  often  been  wrongly  assigned  as  the  cause  of  purely  local  outbreaks. 
That  this  is  possible  by  means  of  infected  ships  is  clearly  proved  by  the 
records  of  the  Quarantine  at  Marseilles  (quoted  by  Prus),  when  in  several 
instances  the  infection  was,  so  to  speak,  caught  on  the  sieve  —  that  is  to 
say,  the  infected  ships  gave  rise  to  cases  of  plague  within  the  quarantine 
station,  of  which  some  were  fatal.  The  like  possibility  on  land  has  often 
been  established,  though  doubted  by  the  extreme  school  of  anti-con- 
tagionists.     For  instance,  in  the  London  Plague  of  1665,  towns  and 


PLAGUE  927 

villages  in  communication  with  London  became  affected,  though  they 
wei'e  previously  healthy,  and  had  not  suffered  from  plague  for  many 
years,  if  ever.  The  infection  is  doubtless  generally  conveyed  by  persons 
either  affected  with  the  disease  or  in  the  stage  of  incubation.  Such 
persons  convert  the  house  they  occupy  into  a  focus  of  infection,  till 
possibly  the  virus  passes  into  the  soil,  and  a  severe  epidemic  may  result. 
Conveyance  by  means  of  infected  objects  is  doubtless  possible,  but  prob- 
ably much  rarer.^ 

With  regard,  however,  to  this  mode  of  transmission,  it  should  be 
observed  that,  according  to  bid  and  sound  tradition,  the  plague  does  not 
spread  when  it  is  sporadic,  but  only  when  it  is  in  an  epidemic  form. 
Furthermore,  its  diffusibility  varies  as  much  as  its  contagiosity  in  the 
narrower  sense,  being  very  marked  in  great  epidemics,  very  slight  or 
self-limited  in  others.  Many  epidemics  have  burnt  themselves  out  on 
the  spot,  or  travelled  but  a  few  miles ;  others  have  spread  over  whole 
continents.  Generally  successive  epidemics,  if  unchecked,  cover  each 
time  a  somewhat  wider  area. 

The  rate  of  extension  is  also  variable,  but  is  generally  slow.  Plague 
has  taken  weeks  or  months  to  pass  from  one  side  of  a  city  to  another ; 
it  creeps  along  from  point  to  point,  so  as  to  be  compared  by  some  to  a 
drop  of  oil  on  paper. 

Such  gradual  extension  suggests  the  slow  progress  of  a  virus  in  the 
soil  itself,  and  probably  that  is  in  some  places  the  explanation;  but, 
obviously,  only  transmission  through  short  distances  can  be  thus  ac- 
counted for. 

Transmission  by  the  air  cannot  be  said  to  be  impossible,  and  was 
once  much  dreaded;  but  while  this  may  be  possible  through  distances 
measured  by  yards,  it  can  hardly  be  so  through  distances  measured  by 
miles. 

Plague  as  an  Epidemic  Communicable  Disease.  —  Clinical  Forms  of 
Plague.  —  It  is  now  pretty  clearly  established  that  plague  may  occur  in 
two  distinct  forms,  each  of  which  may  prevail  separately  to  the  exclusion 
of  the  other:  —  1.  Pestis  minor,  abortive  or  larval  plague.  2.  Pestis 
major,  severe  or  ordinary  plague.     Very  fatal  cases  of  the  latter  are 

1  The  instance  of  Eyam  in  Derbyshire  (whither  the  infection  was  carried  in  a  package 
from  London)  is  well  known ;  less  well  known  is  that  of  an  isolated  house  (Oakhow)  in 
Langdale,  in  which,  as  it  is  believed,  every  occupant  died.  A  son  of  the  house  died  of  the 
plague  in  London  in  1598  or  lG6r),  and  it  is  said  that  the  infection  was  carried  in  his  clothes, 
etc.,  which  were  sent  home.  Food  was  brought  near  the  house  by  the  neighbours,  who, 
however,  never  entered  it;  the  bodies  were  left  where  they  fell,  and  it  seems  probable 
that  the  house  was  burned  after  the  last  death.  A  mound  only  remains,  the  site  never 
having  boen  occupied  since.  No  cases  occurred  elsewhere  in  the  immediate  neighbour- 
hood, lint  the  pest  fell  heavily  upon  the  towns  of  Cumberland  and  Westmoreland.  Upon 
the  wall  of  Penrith  Chnrcli  is  the  following  insr-ription  :  "  a.d.  mdxcviii.  Ex  gravi  peste 
qufT!  regir>nil)us  hisne  incubuit  obierunt  apnd  Penrith  22fi0,  Kendal  2.^00,  Richmond  2200, 
Carlisle  llOfl.  Posteri,  Avertito  vos  et  Vivile,  Ezek.  18th,  ?>2.^'  Vide  Layt^  and  Ijcrjp.nds 
of  EiKjVinh.  Lnkti  Country,  by  J.  Ka<ren  Whitf!,  F'.R.C.S.,  Carlisle,  187.'?;  and  Dr.  Barnes' 
paper  in  vol.  xi.  '/'rnri.t.  Cumh.  ond  WfMd.  Arch,  and  Antiq.  Soc.  p.  l.'S.  In  those  days 
the  fresh  rushes  were  commonly  biirl  upon  thfise  of  previous  years  which  were  already 
charged  and  saturated  with  filth  and  refuse.  —  Ed. 


928  SYSTEM  OF  MEDICINE 

sometimes  called  '^  fulminant,"  or  Pestis  siderans  ;  but  as  they  do  not 
constitute  an  epidemic  by  themselves  this  is  hardly  a  distinct  form. 

1.  Pestis  minor  is  characterised  by  the  production  of  glandular  swell- 
ings, with  little  fever  and  no  severe  general  symptoms,  lasting  perhaps 
about  fourteen  days.  It  has  been  observed  in  Mesopotamia  preceding 
severe  epidemics  of  ordinary  plague ;  in  the  city  of  Astrakhan  in  1877 
(the  year  before  the  severe  outbreak  in  that  province),  and  elsewhere. 
A  similar  type  was  observed  in  London  in  1664,  the  year  before  the 
great  plague,  though  its  existence  was  concealed.  This  form  is  rarely 
or  never  fatal,  and  hence  has  often  been  ^-erlooked  or  misunderstood. 
It  does  not  appear  to  be  contagious,  and  is  not  certainly  known  to  be 
transmitted  from  one  place  to  another.  It  has  therefore  the  characters 
of  aii  endemic  miasmatic  disease. 

2.  Pestis  major  may  be  developed  out  of  the  milder  form.  In 
endemic  seats  of  plagues  the  mild  form  appears  sometimes,  probably 
from  some  change  in  the  soil  poison,  to  be  rapidly  transmuted  into  the 
severer  form,  which  then  appears  as  the  epidemic  form.  Strange  to  say, 
gradations  between  the  two  forms  do  not  seem  to  be  generally  observed, 
as  tire  earliest  cases  of  the  true  plague  are  usually  the  most  severe. 
When  the  severe  form  is  prevalent  as  an  epidemic  the  disease  is  cer- 
tainly transmissible.  The  extent  and  conditions  of  this  transmission 
will  be  discussed  later.  The  following  clinical  account  is  that  of  ordi- 
nary or  severe  plague  :  — 

The  Attack  of  Plague.^  —  Incubation.  —  The  latent  period  between  the 
reception  of  infection  and  the  commencement  of  symptoms  is  imperfectly 
known,  but  appears  to  be  generally  from  three  to  five  days,  or  at  most 
one  week.  Observation  for  about  eight  days  may  therefore  be  taken  as 
sufficient  to  show  Avhether  a  suspected  person  is  or  is  not  infected. 

The  symptoms  of  plague  vary  much  in  their  intensity  and  rela- 
tive frequency  in  different  epidemics ;  but  the  order  in  which  they  pre- 
sent themselves  and  the  general  course  of  the  attack  are  tolerably 
uniform. 

Prodromal  Stage.  —  Often  the  onset  is  quite  sudden ;  but  when  pre- 
liminary symptoms  (prior  to  the  coming  on  of  fever)  are  observed  they 
are  as  follows  :  —  The  nervous  system  is  chiefly  affected.  There  is  severe 
headache,  vertigo,  staggering  gait,  and  appearance  suggestive  of  drunken- 
ness passing  into  lethargy.  Colvill  says  —  "  The  patient  appears  absent- 
minded,  moves  along  speaking  to  no  one,  enters  his  house  mechanically, 
shutting  the  door,  and  drops  on  to  his  bed,  as  if  in  despair  or  wandering 
in  his  mind."  The  pallid  face,  the  injected  eyes,  the  vacant  or  stupefied 
expression  of  countenance,  with  inability  or  refusal  to  answer  questions, 
often  suffice  for  an  experienced  eye  to  make  the  diagnosis.  With  these 
are  associated  the  usual  symptoms  of  acute  febrile  disease,  pains  in  the 
limbs,  extreme  muscular  weakness,  and  intense  malaise.     The  tongue  at 

1  In  this  summary  I  have  followed  chiefly  the  accounts  given  by  Dr.  Cahiadis  and  Mr. 
Colvill  of  plague  in  Irak.  I  have  referred  also  to  Dr.  Cantlie's  observations  in  Hong- 
Kong,  and,  for  special  symptoms,  to  those  of  other  observers. 


PLAGUE  ,  929 

the  beginning  is  thickly  coated  on  the  dorsum,  the  edges  being  red; 
later  it  becomes  extremely  dry  and  of  a  mahogany  colour.  Bilious 
vomiting  or  hyematemesis  are  occasionally  the  initial  symptoms.  The 
prodromal  stage,  when  present,  may  last  a  few  hours  or  a  day,  rarely 
longer. 

Febrile,  Stage.  —  Immediately  after  the  above  symptoms,  concur- 
rently with  them,  or  sometimes  from  the  beginning,  high  fever  comes 
on,  ushered  in  by  a  prolonged  rigor  or  repeated  shiverings.  The  tem- 
perature may  rise  rapidly  to  102°,  104°,  or  even  to  107°  F.  and  higher. 
The  pulse  is  always  rapid,  from  90  to  120  or  130.  It  is  described  as 
sometimes  very  small  and  thread-like,  at  other  times  not  especially  weak. 
Dr.  Cantlie  speaks  of  it  as  very  variable  in  force,  frequency  and  character. 
The  skin  is  at  first  extremely  dry,  not  always  very  hot  to  the  touch. 
There  is  excessive  thirst,  with  a  sense  of  burning  in  the  throat  and 
stomach.  Constipation  is  the  rule  during  this  stage.  From  the  extreme 
weakness  the  decubitus  is  dorsal.  The  nervous  disturbances  are  mainly 
those  already  described ;  sometimes  they  pass  into  active  delirium,  more 
often  into  lethargy  and  coma.  The  duration  of  the  febrile  stage 
would  appear  usually  to  be  from  two  to  five  days,  but  sometimes  it  is 
much  longer.  The  fall  of  temperature  is  generally  described  as  sudden, 
and  it  may  not  rise  again ;  but  Dr.  Cantlie  observed  in  some  cases  a 
recurrence  of  high  temperature  after  three  or  four  days.  In  some  fatal 
cases  the  rectal  temperature  after  death  was  found  to  be  high.  In  cases 
which  do  well  there  is  a  gradual  but  irregular  fall,  and  after  fourteen 
days  the  temperature  is  often  subnormal.^ 

Buboes  or  inflammations  of  lymph-glands  constitute  the  most  impor- 
tant and  characteristic  feature  of  plague.  They  are  rarely  wanting,  and 
then  only  in  cases  which  are  very  rapidly  fatal ;  though  it  is  difficult 
to  say  in  what  proportion  of  cases  they  are  absent,  since  in  the  panic  of 
an  epidemic  they  may  be  overlooked.^  The  term  "  bubonic  plague  "  is 
therefore  in  the  main  accurate. 

Buboes  are  in  some  instances  the  first  symptoms  to  attract  the 
attention  of  the  patient,  perhaps  by  a  sudden  lancinating  pain.  More 
usually  they  occur  after  the  onset  of  fever,  on  the  second,  third,  fourth, 
or  even  the  fifth  day  of  the  disease.  With  the  appearance  of  buboes 
there  is  often  some  abatement  of  the  fever  and  general  symptoms. 
The  affected  glands  are  generally  extremely  painful,  but  sometimes  the 
enlargement  is  insidious,  and  only  detected  on  examination.  They  may 
enlarge  rapidly,  more  often  gradually.  G-lands  are  usually  affected  in 
groups,  but  generally  one  is  much  larger  than  the  rest.  At  first  the 
glands  are  extremely  hard,  and  in  fatal  or  very  severe  crises  may  retain 

1  The  temperature  charts  on  pp.  orso  and  031  are  copied  by  permission  from  Dr. 
Cantlie's  article,  Brit.  Med.  Journal,  18!)4,  vol.  ii.  p.  424. 

2  At  Vellanka  in  Russia,  after  the  epidemic,  I  was  informed  by  the  relatives  of  those 
who  had  died  of  plajjuc  tliat  there  were  no  swellings,  thongh  there  is  reason  to  believe 
that  such  had  occurred  ;  the  bodies  were  probal)ly  buried  hastily  in  ordinary  clothes  and 
not  carefully  examined.  In  Mohammedan  countries  this  would  be  less  likely  to  happen 
in  consequence  of  the  ritual  observances  carried  out  after  death. 

VOL.    I  3  O 


93° 


SYSTEM  OF  MEDICINE 


this  character  to  the  last ;  in  other  cases  suppuration  occurs,  which  is 
regarded  as  a  favourable  sign,  and  is  often  more  prevalent  during  the 
decline  of  an  epidemic.  On  the  other  hand,  rapid  softening,  flattening, 
or  even  disappearance  of  a  bubo  during  the  height  of  the  attack  is  some- 
times observed,  and  is  a  symptom  of  the  worst  omen,  being  speedily 
followed   by   death.     It   was    so   in   London   in   1665,   and   in   recent 


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Chart  10.  — Temperature  chart  of  an  acute  case,  with  temperature  in  rectum  after  death. 

epidemics  in  Irak.  Sometimes  the  skin  over  the  bubo  becomes  gan- 
grenous, forming  a  carbuncle.  According  to  Dr.  Cantlie  great  oedema 
surrounds  the  glands,  converting  the  group  into  an  elevated  doughy 
mass,  sometimes  five  or  six  inches  in  diameter.  A  bubo  once  formed 
usually  lasts  during  the  whole  of  the  attack.  In  suppurative  cases  Avhich 
recover  the  process  may  be  prolonged  for  several  days,  or  even  for  some 
weeks,  and  leave  formidable  scars,  the  diagnostic  marks  of  a  past  attack 
of  plague. 


PLAGUE 


931 


The  size  of  a  bubo  does  not  generally  exceed  that  of  an  almond  or  a 
walnut,  but  may  attain  that  of  an  e§^  or  small  orange.  In  the  majority 
of  cases  (three-fourths  or  more  according  to  some  observers)  only  a  single 
prominent  swelling  occurs  :  but  Dr.  Cantlie  remarks  that  swollen  glands 
are  to  be  found  in  other  regions  if  sought  for.  With  regard  to  situation 
all  observers  agree  that  the  inguinal  group  of  glands  is  most  frequently 


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Chart  11.  — Temperature  chart  of  a  less  rapid  case. 

affected,  such  cases,  according  to  Cabiadis  and  Colvill  (if  with  these  be 
included  those  of  the  femoral  triangle),  making  40-50  per  cent  of  the 
total  number ;  but  where  the  femoral  glands  have  been  distinguished 
from  the  inguinal,  the  former  appeared  to  be  most  frequently  attacked. 
Next  in  frequency  of  attack  come  the  axillary  glands  — in  25  or  30  per 
cent  of  cases,  and  in  a  larger  proportion  of  female  patients  ;  the  cervical 
and  submaxillary  or  other  glands  are  only  attacked  occasionally.  Some 
internal  glands,  especially  the  various  abdominal  groups,  are  always 
found  inflamed  on  post-mortem  examination. 


932  SYSTEM  OF  MEDICINE 

Of  secreting  glands  the  parotid  is  sometimes  though,  rarely  inflamed. 

Carbuncles.  —  Gangrenous  patches  of  skin,  called  carbuncles,  though 
evidently  not  anatomically  the  same  as  the  ordinary  carbuncles  pro- 
ceeding from  sebaceous  glands,  form  another  characteristic  feature  of 
plague.  According  to  Cabiadis  and  Colvill,  they  occur,  however,  only 
in  2  or  2J  per  cent  of  the  cases.  Red  patches  appear  on  the  skin,  and 
become  indurated  and  sometimes  vesicular ;  then  necrosis  occurs,  which 
spreads  till  the  patch  may  attain  a  width  of  some  inches.  They  may 
occur  on  any  part  of  the  surface  of  the  body,  and  have  sometimes  been 
attributed  to  direct  introduction  of  the  virus  of  plague  into  the  skin. 

Petechim.  —  Purpuric  patches,  due  to  ecchymosis,  sometimes  of  small 
size  (petechise),  sometimes  larger,  are  often  seen  in  severe  cases.  In  the 
seventeenth  century  they  were  known  as.  the  "Tokens,"  and  regarded 
as  invariably  indicating  the  approach  of  death. 

General  pustular  or  vesicular  eruptions  have  rarely  been  observed. 

Sweating  is  an  extremely  variable  symptom.  In  certain  epidemics 
very  profuse  sweats  have  been  observed,  in  others  this  feature  has  been 
entirely  wanting. 

Hcemorrhage  from  various  organs  is  sometimes  observed  in  severe 
cases,  and  is  much  more  frequent  in  some  epidemics  than  in  others. 
Epistaxis  is  a  common  form  of  it,  but  pulmonary  htemorrhage,  usually 
associated  with  congestion  or  inflammation,  is  regarded  as  of  specially 
serious  import.  It  was  observed  in  the  first  epidemic  of  the  Black  Death 
in  Europe  (1348),  in  the  epidemic  on  the  Volga  in  1879,  and  on  many 
other  occasions.  The  theory  of  Hirsch,  that  this  symptom  distinguishes 
a  special  Indian  variety  of  plague,  comprising  the  Black  Death  of  the 
fourteenth  century  and  the  Indian  epidemics,  is  virtually  abandoned  by 
its  author,  and  may  be  entirely  discarded. 

Hsematcmesis  is  sometimes  so  noticeable  as  to  have  been  called 
"black  vomit";  and  intestinal  haemorrhage  produces  black  dejections. 
Urinary  haemorrhage  and  metrorrhagia  occur,  and  are  generally  or 
always  fatal.  The  heemorrhagic  form  of  plague,  though  not  constitut- 
ing a  distinct  type,  may  be  compared  to  the  haemorrhagic  forms  of 
small-pox,  scarlet  fever,  and  so  forth. 

The  remaining  symptoms  will  be  best  considered  in  relation  to  the 
various  systems  of  the  body. 

Nervous  System.  —  The  general  features  have  been  already  described. 
There  is  profound  poisoning,  affecting  especially  the  cerebrum,  but  with 
little  disturbance  of  motor  functions,  except  occasional  convulsions,  and 
the  contraction  of  tendons  seen  in  the  last  stages  of  many  febrile  dis- 
eases. Paralysis  does  not  appear  in  the  descriptions.  The  violent 
or  maniacal  delirium  of  older  records  has  not  often  been  observed  in 
recent  epidemics. 

Respiratory  System. — The  respiration  is  accelerated  in  the  febrile 
state  in  proportion  to  the  fever,  perhaps  more  so.  In  some  epidemics 
marked  symptoms  of  engorgement  of  the  lungs  and  pneumonia  with  pro- 
fuse haemoptysis  are  described,  but  no  precise  accounts  of  physical  signs 


PLAGUE  933 

are  forthcoming.  These  cases  have  in  some  instances  given  occasion  for 
the  false  diagnosis  of  an  epidemic  pneumonia.  In  Hong-Kong  pulmo- 
nary symptoms  were  absent.  These  variations  are  probably  connected 
with  differences  of  climate  3.nd  season. 

Digestive  System. —  Beside  the  condition  of  the  tongue  already  noticed, 
some  cases  give  evidence  of  grave  gastric  disturbance,  in  the  form  of 
severe  bilious  vomiting ;  this  is  sometimes  an  early  symptom,  but  it  may 
occur  at  any  stage.  The  bowels  as  a  rule  are  constipated,  but  profuse 
diarrhoea  sometimes  occurs,  and  has  been  regarded  (by  Colvill  and  also 
by  Cantlie)  as  a  favourable  symptom.  The  occurrence  of  gastro-intestinal 
haemorrhage  has  already  been  noted. 

Blood  and  Circulation. — Ko  recent  observations  on  the  condition  of 
the  blood  are  recorded,  but  the  French  physicians  in  Egypt  in  1835-36, 
a  time  when  bleeding  was  customary,  made  some  analyses,  from  which 
it  appears  that  the  blood  coagulated  imperfectly,  and  never  formed  a 
buft'y  coat.  Its  surface  presented  fatty  globules,  the  serum  was  deeply 
coloured,  and  in  some  instances  the  reaction  of  free  sulphuretted  hydro- 
gen was  obtained.  The  water  was  in  excess.  These  results  are  evidence 
of  profound  decomposition  and  destruction  of  red  corpuscles.  Eecently 
in  China  the  characteristic  bacillus  has  been  occasionally  found  in  the 
blood,  but  never  abundantly. 

The  Circulatory  disturbances  have  been  described. 

The  Urinary  System  presents  nothing  very  notable.  The  urine  is 
generally  diminished,  sometimes  suppressed;  but  in  the  Hong-Kong 
epidemic  it  was  normal.     Hseniaturia  has  already  been  mentioned. 

Duration  of  Attack.  —  Cases  are  sometimes  fatal  within  a  day,  but  in 
general  the  duration  of  fatal  attacks  is  three  to  five  days.  Colvill,  in 
Baghdad,  found  nearly  one-fourth  of  his  fatal  cases  died  on  the  first 
day,  about  three-fifths  within  three  days,  and  five-sixths  within  five ;  a 
very  small  number  of  such  cases  lived  over  a  week.  Hence  if  a  patient 
lived  as  long  as  this,  he  was  thought  pretty  certain  to  recover.  On  the 
other  hand,  cases  in  which  suppuration  of  buboes  occurs,  and  which 
recover,  may  be  protracted  to  three  weeks  or  a  month. 

Mortality.  —  Plague  is  the  most  fatal  of  all  known  epidemic  diseases 
affecting  large  numbers.  At  the  beginning  of  an  epidemic  the  mortality 
is  often  80  to  90  per  cent  or  more  of  those  attacked,  and  this  rate  is 
maintained  or  increased  at  the  height  of  the  epidemic.  In  the  epidemic 
on  the  Volga  in  1879,  in  one  group  of  villages  visited  by  myself,  every 
person  attacked  by  plague  had  died.  Towards  the  end  of  every  epi- 
demic recoveries  predominate  over  death,  so  that  the  average  mortality 
falls  :  but  in  some  limited  epidemics  in  Irak  three-fourths  or  more  of  those 
attacked  have  died.  In  the  larger  epidemics  of  Baghdad  in  1876,  the 
proportion  of  deaths  was  officially  stated  as  55-7  per  cent;  and  at  Hillah 
in  the  same  country  it  was  given  by  Cabiadis  at  52-6  per  cent.  In  other 
epidemics  the  percentage  of  fatal  cases  has  not  been  more  than  40  per 
cent,  and  in  Egypt  in  1834-35  abeut  one-third. 

The  total  mortality  has  notoriously  been  in  many  instances  very 


934  SYSTEM   OF  MEDICINE 

great  both  absolutely  and  in  proportion  to  the  population,  though  older 
accounts  may  have  been  exaggerated.  The  Black  Death  is  calculated  to 
have  carried  off  one-third  of  the  inhabitants  of  Europe,  and  in  some 
countries  more  than  one-half,  but  these  estimates  must  be  uncertain. 
In  modern  times  it  is  said  that  the  plague  of  1830-31  killed  60,000  of 
the  150,000  inhabitants  of  Baghdad.  The  epidemic  of  1876  in  Irak  is 
stated  to  have  destroyed  one-eighth  of  the  whole  population.  In  1881 
most  of  the  villages  affected  lost  a  moiety  or  more  of  their  inhabitants. 
As  in  such  times  a  large  part  of  the  surviving  population  seeks  safety  in 
flight,  it  is  easy  to  understand  how  villages  may  be  entirely  ruined  and 
depopulated  by  the  ravages  of  plague,  as  was  the  case  also  in  our  own 
country  in  the  fourteenth  century. 

Prognosis.  —  The  most  unfavourable  symptoms  are  haemorrhage,  in 
whatever  form,  and  petechial  eruptions  or  "  tokens " ;  both  affections 
are  generally  lethal  prognostics.  Profound  affection  of  the  nervous 
system  is  also  an  unfavourable  sign.  Suppuration  of  buboes  is  always 
of  good  omen.  Sex  and  age  appear  to  have  little  or  no  influence  on  the 
result.  All  observers  agree  that  prognosis  is  generally  very  uncertain, 
and  that  cases  apparently  mild  often  terminate  fatally. 

Diagnosis.  —  No  acute  febrile  disease  presents  the  peculiar  affection 
of  the  lymph-glands.  Nevertheless  a  casual  lymphatic  inflammation  or 
an  inflamed  parotid  gland  may  occur  in  rare  cases  of  other  diseases, 
especially  in  typhus,  which  was  at  one  time  thought  to  show  in  some 
cases  a  transition  to  j^lague.  Modern  observers,  however,  have  found 
no  difiiculty  in  making  the  diagnosis ;  the  longer  duration  of  typhus 
C  the  fourteen  days'  fever  ")  and  the  collective  symptoms  making  a  well- 
marked  distinction.  Malignant  forms  of  malaria  have  sometimes  been 
confounded  with  plague ;  but  the  absence  of  intermissions,  or  even  of 
definite  remission  of  the  fever,  and  the  inefficacy  of  quinine,  are  obvious 
distinctions.  The  aspect  or  facies  of  a  malarious  patient  is  also  very 
different. 

Morbid  Anatomy.  —  There  is  little  satisfactory  information  on  this 
head;  the  fullest  accounts  are  still  those  which  Avere  made  up  by  the 
French  physicians  in  Egypt  in  1834-35  ;  but  some  valuable  observations 
were  made  also  in  the  recent  epidemic  at  Hong-Kong.  The  bodies  of 
plague  patients  undergo  rapid  decomposition,  and  this  change,  especially 
affecting  the  blood,  must  have  been  the  cause  of  some  of  the  appear- 
ances described  in  older  accounts,  such  as  red  or  black  staining  of  the 
serous  membranes,  of  the  surfaces  of  internal  organs,  of  the  mucous 
membranes,  and  so  forth.  The  central  nervous  system,  especially  the 
brain,  is  deeply  congested;  the  brain  substance  in  some  instances  is 
softened,  and  the  blood-vessels,  especially  the  veins,  much  engorged. 
The  lungs  are  much  congested,  especially  in  their  posterior  parts,  but 
evidently  this  was  partly  clue  to  hypostasis  before  or  after  death.  The 
pericardium  contains  an  excess  of  fluid,  frequently  blood  stained.  The 
right  side  of  the  heart  is  dilated  with  black,  imperfectly  coagulated 
blood,  and  the  whole  venous  system  is  engorged.    The  heart  substance  is 


PLAGUE  935 

pale,  and  sometimes  softened.  The  stomach  and  small  intestines  may 
contain  blood-stained  fluid,  sometimes  actual  blood,  the  surface  showing 
intense  venous  congestion;  but  Dr.  Cantlie,  in  Hong-Kong,  found  no 
congestion  of  these  parts.  In  a  few  cases  superficial  ulcerations  have 
been  noted;  but  the  Peyer's  patches  are  not  specially  affected.  The 
large  intestine  is  comparatively  normal.  The  peritoneum  is  described  as 
showing  great  vascular  congestion,  chiefly  venous.  The  liver  was  found 
enlarged  by  the  French  pathologists,  sometimes  considerably  ;  but  Dr. 
Cantlie  found  no  notable  enlargement :  its  substance  is  pale  and  anaemic, 
and  presents  the  appearance  of  cloudy  swelling.  Haemorrhage,  intersti- 
tial or  superficial,  is  found  occasionally.  The  spleen,  according  to  all 
observers,  is  greatly  enlarged.  The  kidneys  are  sometimes  enlarged,  and 
occasionally  present  haemorrhagic  patches ;  Dr.  Cantlie  describes  their 
histological  appearance  as  being  that  of  cloudy  swelling. 

The  one  characteristic  sign  is  inflammation  and  swelling  of  the  in- 
ternal lymphatic  glands,  a  condition  always  present  even  when  the 
external  glands  are  not  notably  enlarged.  All  groups  of  lymph-glands 
may  be  affected  so  as  to  form  continuous  chains,  the  cervical  being 
united  with  the  mediastinal  and  bronchial;  the  inguinal  with  the  groups 
surrounding  the  iliac  vessels  and  aorta,  and  with  the  pelvic  glantls,  and 
so  on.  The  mesenteric  glands  are  least  frequently  affected.  Agglom- 
erated glands  may  form  masses  weighing  as  much  as  two  pounds.  In 
substance  they  are  sometimes  red,  congested  and  hard,  sometimes  soft 
and  discoloured,  sometimes  breaking  down  into  a  pulp.  The  surround- 
ing tissue  is  infiltrated  with  serous  fluid. 

It  is  evident  that,  apart  from  the  condition  of  the  lymph-glands,  there 
is  nothing  distinctive  in  the  morbid  anatomy  of  plague. 

Treatment. — ISTothing  is  less  satisfactory  than  the  treatment  of 
plague.  In  old  days  opinions  were  divided  as  to  the  value  of  bleeding, 
but  the  balance  of  experience  was  decidedly  against  it.  The  violent 
sudorifics  used  in  the  seventeenth  century  appear  to  have  been  useless. 

In  modern  times  quinine  has  naturally  been  largely  administered,  but 
the  general  testimony  is  that  it  is  quite  useless.  Antiseptics  (such  as 
carbolic  acid,  salicylic  acid,  etc.),  antipyretics  and  cardiac  stimulants  have 
all  been  tried  with  no  better  results  ;  purging  with  calomel  and  magnesia 
was  largely  used  in  Hong-Kong,  but  with  little  benefit.  In  fact,  nothing 
approaching  to  a  specific  or  antidote  in  the  way  of  drugs  has  ever  been 
discovered.  The  general  principles  of  treatment  would  seem  to  be,  as  in 
other  asthenic  fevers,  to  give  the  patient  an  abundant  supply  of  fresh  air, 
to  avoid  overcrowding,  to  use  cold  affusions  or  baths  in  the  height  of  the 
fever,  and  to  administer  such  cooling  or  other  drinks  as  may  promote  his 
comfort.  When  the  strength  is  failing,  stimulants  are  of  course  indi- 
cated, but  alcoholic  stimulation  appears  to  be  of  less  value  than  in  typhus. 
En  the  seventeenth  century  some  good  observers  denounced  the  use  of 
"  strong  waters  "  as  positively  pernicious.  In  a  malady  of  such  short 
duration  the  utility  of  abundant  nutrition  would  appear  to  be  of  less 
importance  than  in  more  protracted  illnesses. 


936  SYSTEM  OF  MEDICINE 

The  local  treatment  of  the  buboes  has  received  much  attention.  The 
general  result  of  experience  is  that  energetic  treatment  by  caustics, 
mercurial  inunction,  or  early  surgical  interference,  is  painful  and  fruitless. 
In  earl}^  stages  only  soothing  applications,  such  as  poultices  and  anodynes, 
should  be  used.  When  softening  or  suppuration  occurs,  surgical  treat- 
ment by  incision  and  drainage  is  called  for.  There  is  no  evidence  of  the 
value  of  thorough  antiseptic  surgical  methods  ;  but  in  the  epidemic  of 
Hong-Kong  the  injection  into  the  glands  of  solutions  of  perchloride  of 
mercury  and  carbolic  acid  seemed  to  be  of  temporary  benefit. 

Finally,  it  should  be  noted  that  Yersin,  Calmette  and  Borel  in  the 
Institut  Pasteur,  claim  to  have  worked  out  a  system  of  serum  therapeutics 
for  plague  like  that  used  in  diphtheria  and  other  diseases.  Repeated 
injections  of  virulent  bacilli  were  made  into  a  horse,  and,  after  six  weeks' 
preparation,  its  blood  serum,  when  injected  into  rabbits,  was  found  to  be 
capable  of  producing,  not  only  immunity  against  a  subsequent  virulent 
injection  of  plague  bacilli,  but  also  in  larger  dose  the  cure  of  animals 
previously  submitted  to  a  virulent  injection. 

Prophylaxis  and  Prevention. — For  individual  prophylaxis  against 
contagion  a  number  of  elaborate  precautions  were  formerly  recommended, 
wliich  need  not  now  be  taken  into  account.  The  important  rules  seem  to 
be  that  any  person,  medical  or  other,  who  is  brought  into  contact  with 
infected  patients  or  dwellings,  should,  in  the  first  place,  keep  himself  in 
as  good  a  state  of  general  health  as  possible ;  and,  in  the  next,  remain 
in  the  sick-room  or  house  no  longer  than  duty  requires.  The  risk  of 
touching  and  handling  plague  patients  is  apparently  very  slight,  and 
nurses  and  attendants  in  well-managed  and  airy  hospitals  incur  no  special 
danger.  Doctors  on  the  whole  have  rarely  been  affected ;  and  in  most 
instances  have  conspicuously  escaped.  When  they  have  suffered  (as  was 
grievously  the  case  in  the  short  epidemic  of  Vetlanka)  it  has  generally 
been  because  they  lived  in  the  same  dwellings,  and  under  the  same  con- 
ditions as  the  affected  population;  or,  as  in  Hong-Kong,  they  have  been 
engaged  in  investigations  on  the  material  of  the  disease. 

The  prophylaxis  of  communities  is  a  difficult  matter,  as  it  involves 
the  question  of  quarantine,  a  system  of  regulations  which  has  been 
elaborated  chiefly  to  guard  against  this  very  disease ;  but  the  subject  is 
too  large  to  be  fully  discussed  here. 

Since  there  is  no  doubt  that  plague,  when  in  an  epidemic  form,  does 
tend  to  spread  to  other  places  and  countries  by  means  of  infected  persons 
or  objects,  we  have  to  consider  the  possibility  of  its  being  brought  to  an 
uninfected  place.  The  first  precaution,  and  probably  the  best,  consists  in 
making  the  place  unfit  to  be  the  nidus  of  the  disease.  This  precaution 
concerns  the  purity  of  the  soil  itself,  the  cleanliness  and  ventilation 
of  dwellings,  the  prevention  of  overcrowding,  of  extreme  poverty,  of 
personal  uncleanliness  and  other  insanitary  conditions.  It  is  improbable 
that  any  healthy  European  city  or  population  in  good  sanitary  condition 
could  be  the  seat  of  a  serious  epidemic  of  plague.  Since,  however,  san- 
itary perfection  is  not  universal,  and  a  very  intense  plague  infection 


PLAGUE  937 

seems  sometimes  to  spread  even  under  good  sanitary  conditions,  the 
question  of  exclusion  cannot  be  disregarded. 

Total  exclusion  of  persons  and  objects  coming  from  an  infected 
place,  as  common-sense  shows,  would  be  sufficient;  but  this  is  rarely- 
practicable.  The  epidemic  at  Noja,  in  Italy,  in  1815,  was  thus  isolated 
by  absolutely  cutting  off  communication  with  other  parts;  and  other 
instances  might  be  quoted.  But  for  general  application,  modified  exclu- 
sion or  "  quarantine  "  is  the  only  possible  method.  Quarantine  consists 
in  subjecting  all  persons  and  objects  coming  from  an  infected  country  to 
a  period  of  observation  measured  by  the  known  period  of  incubation 
of  the  disease,  and  in  requiring  certain  measures  of  disinfection  before 
they  are  permitted  to  proceed.  In  marine  quarantine  all  ports  in 
communication  with  an  infected  port,  unless  they  adopt  the  same 
regulations,  are  themselves  regarded  as  infected ;  arrivals  from  such 
ports  are  therefore  put  under  the  same  restrictions  —  a  serious  matter 
for  the  commercial  relations  even  of  countries  which  do  not  adopt 
the  principle  of  quarantine.  In  quarantine  on  land  these  arrangements 
are  complicated  with  a  so-called  "  cordon  sanitaire  "  along  the  frontier  to 
prevent  entrance  by  irregular  channels.  In  recent  times  infected  dis- 
tricts have  been  surrounded  by  double  or  triple  cordons  to  prevent  exit 
except  under  quarantine  regulations.  These  are  necessarily  military 
arrangements.  On  the  efficacy  of  quarantine  opinions  have  differed, 
though  notwithstanding  modern  scepticism,  it  wyuld  be  unreasonable  to 
doubt  that  this  system,  as  applied  in  former  times  in  the  Mediterranean 
ports,  was  of  great  service,  especially  as  against  infected  ships.  But 
early  in  this  century  the  system  became  out  of  date,  and  even  injurious 
through  mal-administration.  At  the  present  time  a  modified  system  of 
quarantine  against  plague  is  still  legally  in  force,  and  may  be  put  in 
operation  by  an  Order  in  Council ;  it  is  not,  like  other  sanitary  arrange- 
ments, subject  to  the  Local  Government  Board. 

The  land  quarantines  established  in  Asiatic  Turkey  and  Persia  are 
considered  by  most  unbiassed  observers  to  be  so  defective  as  to  be  use- 
less even  if  well  designed.  Some  authorities,  like  Tholozan,  deny  their 
efficacy  altogether,  and  regard  the  limitation  of  epidemics  attributed  to 
them  as  due  to  seasonal  decline.^ 

Dismissing  quarantine  in  the  old  sense,  attention  should  be  directed 
to  ships  arriving  from  an  infected  country  with  cases  of  plague  on  board, 
an  element  of  the  gravest  danger  which  no  sanitary  authority  could 

^  I  can  say  from  personal  knowledge,  that  the  limitations  of  the  epidemic  on  the  Volga 
in  ]S7!l  to  a  small  distri<;t  vonXd  not  have  been  due  to  the  elaborate  cordons  establislied  by- 
General  I^oi'is  Melikoff,  which  in  every  newspaper  were  credited  with  the  result.  For  two 
months  tlie  disease  was  cDnfined  to  a  single  village,  though  communications  on  the  main 
high  road  w(;n!  op(!ii  nearly  the  whole  time.  It  then  began  to  spread,  but  when  the  cordons 
were  estaldislied  it  was  already  confined  to  a  very  few  (tases  in  another  village.  It  is  right 
to  say  that  tlio  villagers  in  their  alarm  established  a  sort  of  quarantine,  or  rather  system  of 
exclusion  between  one  place  and  another.  Much  more  credit  is  due  to  the  radical  measures 
of  destruclion  carried  out  by  tlie  authorities.  All  infected  houses  (mostly  of  wood)  and  all 
suspcf'tcfl  objectts  were  burned;  and  it  is  highly  probable  that  the  disease  was  thus  pre- 
vented from  recurring  in  the  next  season  or  becoming  endemic. 


938  SYSTEM  OF  MEDICINE 


meet  other  wise  til  an  by  absolute  isolation,  followed  by  radical  disinfection, 
or  even  destruction  Avliere  practicable.  The  persons  on  board  should  be 
removed  to  an  isolation  hospital,  and  observed  for  a  period  corresponding 
to  tlie  known  incubation  of  the  disease.  Supposing  plague  to  be  intro- 
duced into  or  to  break  out  in  any  place,  its  restriction  must  depend  upon 
the  measures  usually  applied  to  infectious  diseases,  with  special  reference 
to  the  dwellings  which  may  retain  the  virus.  The  infected  house  should 
be  emptied,  patients  should  be  removed  to  a  hospital,  and  the  other 
inmates  isolated  under  observation.  Under  some  circumstances  the 
patient  might  be  better  isolated  in  his  own  house,  the  chief  thing  to  be 
avoided  being  concentration  of  the  virus.  The  dwelling  should  in  the 
meantime  be  thoroughly  disinfected,  and  all  clothing  or  infected  objects 
subjected  to  disinfecting  agents,  of  which  heat  appears  the  most 
efficacious.  On  account  of  its  usually  low  degree  of  contagiosity,  plague 
would  probably  in  a  clean  city  be  more  easily  controlled  than  small-pox 
or  typhus.  As  contagion  from  the  dead  body  is  possible,  interment 
should  be  carried  out  under  special  precautions. 

The  only  remaining  question  is  whether  the  infection  may  be  carried 
from  an  infected  country  to  a  distance  by  any  kind  of  infected  objects. 
As  regards  ordinary  articles  of  merchandise,  experience  shows  that  the  risk 
is  slight  or  none ;  but  the  importation  of  rags  or  worn  clothing  might,  as 
in  the  case  of  small-pox,  be  made  subject  to  special  restrictions. 

J.  F.  Payne. 

REFERENCES 

General  History. 

1.  HiRSCH.  Handbook  of  Geographical  and  Historical  Pathology,  translated  by 
C.  Creighton,  vol.  i.  New  Syd.  Soc,  London,  1883. — 2.  Haeser.  Geschichte  der 
Medizia  und  der  epldemischen  Krankheiten,  3te  Autiage,  Band  iii.  Jena,  1882.  — 
3.  Mahe.  Article  '' Feste,"  Dictionnaire  Eucyclopediqae  des  sciences  medicates,  vol. 
xxiii.  p.  611.  Paris,  1887  (with  a  very  complete  bibliography). — 4.  Creighton. 
History  of  Epidemics  in  Britain,  2  vols.  Cambridge,  18SH.  —  5.  Prus.  Rapoort  a 
VAcademie  Royale  de  Medecin?  sur  la  Peste  et  les  Qnarantaines.  Paris,  1840  (abridged 
translation  by  Galvin  Milroy.  London,  18-K)).  — G.  Payne.  Article  "  Plague,"  Ency- 
clopedia Britannica,  Dtb  ed.  (historical  summary). 

History  of  Special  Periods. 

In  Antiquity:  — 7.  Orieasius.  Collectanea,  lib.  xliv.  cap.  17  (CEuvres  de  Onba.ie, 
ed.  Bussemaker  and  Daremberg,  Paris,  1851,  vol.  iii.  p.  607).— 8.  Procopius.  De 
Hello  Persico,  ii.  22,  23,  and  other  authorities  referred  to  by  Gibbon,  Decline  and  Fall, 
chapter  xliii.  Fourteenth  Century  (The  Black  Death):  — 9.  Hecker.  Eoid^mii-s  of 
the  Middle  Ages.  Trans,  by  Babington.  Syd.  Soc,  London,  1844.-10.  Guy  de 
Chauliac.  La  Grande  CMrurgi",  ed.  Nicaise,  Paris,  18!I0,  p.  in7.  — 11.  F.  A. 
Gasquet.  The  G7-eat  Pestilenr.e  1^8-9.  London,  1893. —12.  J.  F.  Payne.  "Plagues, 
Ancient  and  Modern,"  St.  Thomas's  Hospital  Reports,  vol.  x^ii.  p.  10.3.  1889. 
Seventeenth  Century:— 13.  Thomas  Lodgie.  Treatis"  of  the  Plague.  London,  1603. 
—  14.  JosEPHUs  RiPAMONTius.  De  Peste  anui  My^^O.  Milan,  1641,  4to.  — 15.  Isbrand 
Diemerbroeck.  Tractatus  d"  Peste.  Arnheim,  1646,  4to ;  2nd  ed.,  Amsterdam, 
16(;5,  4to.  On  the  Great  Plague  of  London  in  1605  we  have:  — 16.  Nath.  Hodges. 
Loimologia,  sive  Pestis  nuperse  narrntio.  LoikIdh,  1672,  8vo.  English  ))y  Qninoy. 
London,  1720.  — 17.  Thomas  Sydenham.  In  Ohservationes  3Tedicse  circa  morhoram 
acutorum  historiam,  etc.     London,  1676.     English  edition  (Sydenham  Society).  — 18. 


PLAGUE  939 

William  Boghurst.  Loimographia :  an  Account  of  the  Great  Plague  of  London  in 
l(i65.  Published  from  the  MS.  by  the  Epidemiological  Society  of  London,  iy'.i4  (by 
far  tlie  best  account  of  this  epidemic,  containing  minute  clinical  records,  and  showing 
great  independence  of  judgmenl).  —  lU.  Defoe.  Journal  of  I  lie  Plague  Year,  an  often 
reprinted  tiction  founded  on  facts,  which  will  never  lose  its  interest.  The  Journals  of 
Evelyn  and  Pepys,  witli  the  Calendar  of  State  Papers  (Domestic  Series),  ltJG5-tJ, 
contain  many  important  facts.  Eighteenth  Century:— 20.  Relation  historique  de  la 
Peste  de  Marseille.  Cologne,  1721.  Translated  into  English:  Journal  of  the  Plague  at 
Marseilles.  London,  1721.  —  21.  Chicuyneau,  Verney,  etc.  Observations  de  la  Feste. 
Marseilles,  1721.  Also  English,  London,  1721. — 22.  Chicoyneau.  Trait6  de  la  Peste. 
Paris,  1744. — 23.  D'Antrechaus.  Relation  de  la  Pesle  de  Toidon  en  1721.  Paris, 
175(). — 24.  Sa.moilowitz.  Menioire  sur  la  Peste  en  Russie  1771.  Paris,  1783. — 25. 
Patricic  Russell.  Treatise  of  the  Plague  (Aleppo,  17(10-2,  etc.).  London.  17'.)1,  4to. 
Nineteenth  Century : — 2L).  Faulkner.  On  the  Plague  in  Malta.  London,  1820. — 27. 
TuLLY.  History  of  the  Plague  in  Malta,  Gozo,  Corfu,  etc.  London,  1821.  —  28. 
White.  Treatise  on  the  Plague  (at  Corfu).  London,  1847.  — 29.  Gosse.  Rlutlonde 
la  Peste  en  Grece  1827-8.  Paris,  1838. —  30.  Clot-Bey.  De  la  Peste  en  Egypte.  Paris, 
1840.— 31.  BuLARD.  De  la  Peste  Orientale.  Paris,  1839. —.32.  Tholozan.  La  Peste 
en  Turqule  dans  les  Temps  Modernes,  Paris,  1880;  Histoire  de  la  Peste  huhordque  en 
Perse,  Paris,  1874,  (and  other  works). —  33.  Reports  addressed  to  the  Constantinople 
Board  of  Health  on  Plague  in  Asiatic  Turkey,  by  Drs.  Castaldi,  Cabiadjs,  Bastoletti, 
and  others.  These  are  not  easily  accessible,  but  summarised  in  articles  by  Dr. 
Dickson  in    Trans.  Epkleiniolog.  Society,  London,  vol.  iv.  p.  140,  and  in  following: 

—  34.  J.  Netten  Radcliffe.  Report  of  Local  Government  Board  1875  to  1879-80; 
and  Supplement  1881 ;  also  Papers  on  Levantine  Plague  presented  to  Parliament  1879. 

—  35.  W.  H.  Colvill.  "Plague  in  the  Province  of  Baghdad,"  Trans.  Epidem.  Soc, 
vol.  iv.  p.  9;  also  Reports  quoted  by  Netten  Radcliffe,  op.  cit.    On  Indian  Plague: 

—  36.  Francis  and  Pearson.  Indian  Annals  of  Medical  Science,  vol.  i.  1854.  —  37. 
C.  R.  Francis.  Trans.  Epidem.  Soc.  London,  vol.  iv.  p.  391.-38.  John  Murray. 
Trans.  Epidem.  Soc.  London,  vol.  iv.  p.  12.). —39.  F.  Forbes.  On  Plague  in  N.  W. 
Provinces  of  India.  Edinburgh,  1840.-40.  Webb.  Pathologia  Indica.  2nd  ed. 
Calcutta,  1848.  On  the  Epidemic  of  Vetlanka:— 41.  Hirsch  and  Sommerbrodt. 
Pest-Epidemie  1878-9  in  Astrachan.  Berlin,  1880.-42.  Caeiadis.  See  Dickson, 
Trans.  Epidem..  Soc.  London,  vol.  iv.  p.  446.-43.  J.  F.  Payne.  "On  the  Epidemic 
of  Plague  in  Astrakhan,  1878-9,"  Trans.  Epidem.  Soc.  London,  vol.  iv.  p.  362. 
On  Plague  in  China:— 44.  Reports  of  Imperial  Chinese  Customs:  Manson,  Series  2 
for  1878,  15th  issue;  Lowry,  Ihid.  24th  and  28th  issue;  also  47th  and  48th  issues,  1895. 

—  45.  Netten  Radcliffe.  Op.  cit.  1881.-46.  United  Service  Magazine,  April  1895,  p. 
60,  and  Reports  quoted  in  the  text. —  47.  Rennie.  British  Medical  Journal,  1894,  ii. 
615.-48.  Yersin.  Annates  de  rinsVtut  Pasteur,  1894,  p.  662;  Ih.  18t:5,  p.  589.— 
49.  Kitasato.  Lancet,  1894,  ii.  428.  — 50.  "Report  by  James  A.  Lowson  on 
Plague  at  Hong-Kong,  1894,"  Hong-Kong  Government  Gazette,  13th  April  1895. 
On  Contagion,  Prevention,  Quarantine,  etc. : —51.    Fracastorius.     De  Contagionibus ; 

—  Opera,  Venice,  15.55,  4to.  —  52.  Cardinal  Gastaldi.  De  avertenda  et  Profliganda 
Peste. —Bologna.,  1681,  folio.  — .53.  Muratori.  Trattato  del  Govtrno  delta  Peste. 
Modena,  1714.  —  54.  Mead.  Disaours?  concernirig  Pestilential  Contagion.  London, 
1720,  8vo.— 55.  John  Hovtard.  An  Account  of  Lazarettoes  in  Europe,  etc. 
London,  1789,  4to.— 56.  Report  of  Committee  of  House  of  Commons  on  Quarantine, 
1819.  — 57.  A.B.Granville.  Letter  on  the  Plague  and  Contagion.  London,  1819.— 
58.  .John  Bowring.  Observations  on  the  Oriental  Plague.  Edinburgh,  1838.  —  59. 
Lorinser.  Der  Pest  des  Orients.  Berlin,  1837.-60.  Charles  Maclean.  Evils  of 
Quarantine  Laios,  etc.  London,  1824  (and  other  works). — 61.  Make.  Op.  cit. — 
62.   Peus.     Op.  cit. 

J.  F.  P. 


94°  SYSTEM   OF  MEDICINE 


EELAPSmG  FEVER,  OR  FAMINE  FEVER 

SYNO^fYMS.  — Five  or  seven  days'  fever ;  Five  days'  fever  with  relapses ; 
Remittent  fever;  Typhus  recurrens;  FiP.vre  ct  recliute;  Epidemic  fever 
of  Edinburgh,  of  Ireland;  Epidemic  remittent  fever;  Relapsing  synocha; 
Bilions  relapsing  fever ;  Bilious  typhoid;  Remitting  icteric  fever  ;  Fam- 
ine fever;  Die  Hangerpest ;  Miliary  fever ;   Typhinia. 

This  fever,  with  enteric  or  typhoid  fever,  formerly  confused  with  the 
larger  group  of  typhous  continued  fevers,  was  separated  and  distinguished 
by  a  long  series  of  researches  and  of  more  accurate  observations  in  the 
first  half  of  the  present  century.  The  essential  character  which  distin- 
guishes it  from  typhus  is  the  occurrence  of  the  relapse ;  while  from 
enteric  fever  it  is  distinguished  by  the  absence  of  intestinal  lesions. 
The  following  brief  description  has  been  given  of  it  by  Dr.  Murchison : 
—  "A  contagious  disease  which  is  chiefly  met  with  in  the  form  of  an 
epidemic  during  seasons  of  scarcity  and  famine.  Its  symptoms  are : 
A  very  abrupt  invasion  marked  by  rigors  or  chilliness;  quick,  full, 
and  often  bounding  pulse  ;  white,  moist  tongue,  sometimes  becoming  dry 
and  brownish;  tenderness  at  the  epigastrium  ;  vomiting  and  often  j  ami- 
dice  ;  enlarged  liver  and  spleen  ;  constipation  ;  skin  very  hot  and  dry  ; 
no  characteristic  eruption ;  high-coloured  urine  ;  severe  headache,  and 
pains  in  the  back  and  limbs ;  restlessness  and  occasionally  acute  delirium ; 
an  abrupt  cessation  of  all  these  symptoms,  with  free  perspiration  about 
the  fifth  or  seventh  day  ;  after  a  complete  apyretic  interval  (during  which 
the  patient  may  get  up  and  walk  about),  an  abrupt  relapse  on  the  four- 
teenth day  from  the  first  commencement,  running  a  similar  course  to  the 
first  attack,  and  terminating  on  or  about  the  third  day  of  the  relapse ; 
sometimes  a  second  or  even  a  third  relapse ;  mortality  small,  but  occasion- 
ally death  from  sudden  syncope,  or  from  suppression  of  urine  and  coma  ; 
after  death  no  specific  lesion,  but  usually  enlargement  of  liver  and  spleen." 
With  this  description  before  us  it  is  easy  to  see  how  relapsing  fever  might' 
be  confused  with  typhus,  especially  if  cases  of  it  were  few ;  as  the  relapse 
might  be  either  overlooked  or  attributed  to  some  accidental  or  unex- 
plained conditions.  But  when  cases  became  more  numerous  the  points  of 
difference  would,  as  happens  during  epidemics,  be  forced  into  prominence, 
and  the  more  so  that  during  certain  epidemics  sometimes  cases  of  typhus 
proper  would  predominate,  and  sometimes  cases  of  the  fever  Avith  relapse. 
When  also  it  appeared,  by  and  by,  that  patients  who  had  been  affected  by 
the  one  form  of  fever  contracted  and  went  through  a  well-marked  course 
of  another,  there  could  no  longer  be  any  doubt  that  two  different  kinds 
of  fever  were  under  observation.  Dr.  Henderson,  of  Edinburgh,  was 
enabled  in  1843  to  advance  arguments  leading  to  the  general  acceptance 
of  the  view  that  relapsing  fever  must  be  distinguished  as  a  separate 
disease  from  typhus  fever.  It  appears  now,  in  the  light  of  further 
information,  that  relapsing  fever  is  by  no  means  a  new  disease.  Dr. 
Spittal,  of  Edinburgh,  stated  in  1844  that  Hippocrates  described  an 


RELAPSING  FEVER,    OR  FAMINE  FEVER  941 

epidemic  of  relapsing  fever  as  occurring  under  his  own  observation  in 
the  island  of  Thasos.  The  observations  of  Hippocrates  are  somewhat 
confused,  some  cases  of  doubtful  character  being  described  among  many 
which  may  well  have  been  instances  of  relapsing  fever.  Neither  then 
nor  now  did  cases  run  a  perfectly  definite  course  ;  but  the  accounts 
would  lead  us  to  believe  that  in  most  cases  the  disorder  ran  its 
course  in  seventeen  days  {De  Morhis  vulgar,  lib.  i.).  Thus  in  two 
brothers  who  were  attacked  in  the  very  same  hour  (the  invasion  having 
been  therefore  sudden),  the  phenomena  were  as  follows:  —  In  one  the 
initial  fever  lasted  seven  days,  in  the  other  six ;  the  intermission  in 
one  five  days,  in  the  other  six ;  and  the  relapse  in  both  five  days,  so 
that  they  recovered  together  (Z)e  Morhis  vulgar,  p.  956,  see  also 
pp.  953-956).  In  other  cases  the  initial  fever,  intermission,  and 
relapse  lasted  respectively  five,  seven,  and  five  days ;  seven,  seven,  and 
three  days  ;  six,  six,  and  five  days  ;  and  again,,  six,  seven,  and  four  days. 
It  will  be  seen  that  the  addition  of  the  three  numbers  in  all  these  cases 
gives  a  total  of  seventeen  days,  which  corresponds  very  well  with  the 
duration  observed  in  modern  epidemics.  In  Bradford,  for  example, 
during  the  course  of  the  epidemic  which  I  witnessed  in  1869-70,  the 
duration  of  the  initial  fever,  intermission,  and  relapse  respectively  were 
seven,  seven,  and  three  days ;  eight,  six,  and  five  ;  five,  eight,  and  four ; 
five,  eight,  and  five  ;  six,  seven,  and  four ;  six,  eight,  and  three  days,  and 
so  on.  Out  of  sixteen  successive  and  regular  cases,  omitting  those  in 
which  a  second  relapse  occurred,  the  whole  duration  of  the  disease  was 
seventeen  days  in  eight  or  one-half  of  the  cases  ;  in  three  cases  the  dura- 
tion was  eighteen  days ;  in  three,  nineteen  days  ;  and  in  two,  twenty 
days.  Hippocrates  dwelt  on  four  important  phenomena,  whose  occur- 
rence at  the  period  of  crisis  might  be  looked  upon,  separately  or  together, 
as  of  good  prognostic  omen.  These  were  epistaxis,  enuresis,  diarrhoea, 
and  dysentery.  Sweating  he  also  considered  a  favourable  sign.  That  is 
to  say,  as  we  should  put  it,  when  secretion  and  excretion  were  free  and 
abundant  the  cases  did  well ;  when  otherwise,  the  reverse.  The  symp- 
toms in  his  description  are  very  characteristic.  He  mentions  the  splenic 
enlargement,  the  jaundice,  the  tendency  of  pregnant  women  to  abort,  as 
well  as  the  frequent  appearance  of  menstruation  during  the  disoi'der. 
Iftie  first  mention  of  the  relapse  is  in  these  words  :  — ''  And  about 
Arcturus  "  (the  beginning  of  September)  "  many  had  the  crisis  on  the 
eleventh  day,  and  such  had  relapse  without  apparent  cause."  Some  of 
the  severe  cases  (many  of  which  seem  to  have  been  fatal)  appear,  from 
the  mention  of  the  swellings,  to  have  partaken  of  the  character  of  plague. 
When  suppuration  occurred,  such  cases  were  always  fatal. 

It  is  a  re}narkable  fact  that,  so  far  as  I  am  aware,  no  reference  to  re- 
lapsing fever  seems  to  be  known  between  these  highly  interesting  records 
of  Hippocrates,  and  the  time  when  Rutty  wrote  in  1770  describing  the 
weather,  seasons,  and  diseases  in  Dublin  from  1725  to  1765.  It  seems 
incredible  that  relapsing  fever  was  absent  during  the  long  centuries  that 
elapsed  between  these  two  dates,  yet  no  references  to  its  occurrence 
appear  to  be  extant. 


942  SYSTEM  OF  MEDICINE 

Symptoms.  —  Tlie  invasion  of  relapsing  fever  is  generally  sudden. 
The  patient  is  seized  with  rigors,  headache,  backache,  and  loss  of 
strength ;  though  the  muscular  weakness  does  not  hinder  patients  from 
walking  long  distances  to  hospital,  especially  during  the  first  day  or  two 
of  the  disease.  In  Bradford  they  would  walk  into  the  workhouse  as  late 
as  the  third  or  fourth  day.  I  saw  many  cases,  however,  in  which  the 
symptoms  appeared  to  set  in  gradually  rather  than  suddenly.  On  the 
other  hand,  cases  did  occur  very  suddenly,  like  one  I  remember  in  a 
man,  not  himself  a  smoker,  who  was  suddenly  attacked  while  sitting 
among  a  number  of  smoking  companions  —  the  attack  commencing  with 
rigors,  vomiting,  and  purging ;  but  such  suddenness  as  this  was,  so  far 
as  my  recollection  goes,  comparatively  rare.  More  commonly  the  patient 
had  been  ailing  for  some  time  before  giving  in  to  the  attack,  and  would 
present  himself  with  a  white,  moist  tongue,  and  complaining  of  general 
malaise,  rheumatic  pains  in  the  limbs  and  joints,  and  headache. 

The  invasion  was  not  so  gradual  as  to  make  it  difficult  to  date  the 
commencement,  but  it  was  rarely  so  sudden  as,  for  instance.  Dr.  Murchi- 
son  describes  it  to  be  —  by  no  means  so  sudden  as  the  onset  of  typhus  or 
pneumonia.  Still,  on  the  whole,  the  writers  who  have  recounted  the 
symptoms  seen  in  the  various  epidemics  which  have  appeared  in  this 
country,  especially  those  of  1819,  1826,  1828,  and  in  the  great  epidemic 
of  1843,  unite  in  the  statement  that  the  onset  of  the  disease  was  sudden. 

The  period  of  incMhation  has  varied  in  different  epidemics.  Some- 
times the  disease  has  broken  out  immediately  after  exposure  to  contar 
gion ;  sometimes  not  till  as  many  as  fourteen  days  had  elapsed.  In 
Silesia  in  1857  it  was  said  to  be  longer  —  from  a  fortnight  to  three  weeks. 

But  whether  the  attack  come  on  suddenly,  or  be  preceded  by  a  period 
of  anorexia  or  malaise,  it  is  generally  ushered  in  by  rigors  which  may  be 
slight  or  more  severe,  though  they  are  generally  severe.  After  being  put 
to  bed  the  patients  complain  of  headache,  generally  referred  to  the  occiput 
and  vertex,  and  not,  as  a  rule,  accompanied  by  delirium.  Pains  are  also 
complained  of  in  the  back  and  limbs.  The  skin  is  hot  and  burning,  and 
the  patient  is  restless  with  a  flushed  face,  although  the  rest  of  the  skin 
generally  shows  a  characteristically  yellow  hue.  The  temperature,  dur- 
ing the  first  few  days  of  the  attack,  is  high,  ranging  from  102°  to  105°  F. 
or  even  higher.  The  pulse  also  is  quick,  and  is  said  sometimes  to 
reach  even  140  on  the  second  day.  In  my  cases  it  usually  rose  at  that 
period  to  110-120,  and  it  appeared  to  me  to  be  higher  during  the  re- 
lapse—  when  it  might  rise  to  130,  or  140,  or  even  160 — than  during 
the  initial  fever.  These  very  high  rates  did  not,  however,  seem  to 
indicate  any  particular  danger  in  the  case.  I  saw  very  few  deaths ; 
but  most  of  my  patients  were  young  adults,  and,  as  will  subsequently 
appear,  they  did  not  seem  to  have  been  much  debilitated  by  hardship  or 
starvation,  and  so  Avere  no  doubt  better  fitted  to  struggle  successfully 
with  incidental  illness.  Although  I  did  not  observe  any  instance  in  which 
the  pulse  rose  so  high  as  160  on  the  second  or  third  day,  I  often  saw 
a  temperature  of  104°  F.,  and  soifietimes  observed  it  as  high  as  105°. 


RELAPSING  FEVER,    OR  FAMINE  FEVER  943 


Generally  there  was  no  rash,  but  in  a  considerable  minority  of  my  cases 
a  rose  coloured  rash  was  observed,  not  unlike  the  spots  of  typhoid  fever, 
but  individually  smaller.  This  rash  was  never  petechial.  It  appeared 
on  the  thorax,  abdomen,  and  limbs.  In  one  case  a  rash  was  seen  twice 
during  the  attack ;  the  spot  was  from  one  to  two  lines  in  diameter,  was 
rose  coloured,  and  scarcely  distinguishable  from  that  of  typhoid  fever. 
All  these  rashes  disappeared  in  a  day  or  two.  The  second  appearance  of 
the  rash  occurred  just  before  the  defervescence  at  the  end  of  the  relapse. 

Some  interest  attaches  to  the  question  of  rasli  in  relapsing  fever. 
Dr.  Murchison,  who  met  with  it  in  8  out  of  about  600  cases,  says  it 
consisted  of  small  s^^ots,  or  of  a  reddish  mottling  :  sometimes  it  resembled 
measles,  but  more  often  it  was  undistinguishable  from  that  of  typhus  at 
an  early  stage ;  yet  it  always  disappeared  luider  pressure,  and  faded 
after  a  few  hours,  or  within  three  or  four  days  at  the  latest.  It  came 
out  sometimes  during  the  first  attack,  sometimes  in  the  relapse,  and 
either  as  early  as  the  third  day  or  immediately  before  the  crisis.  Pete- 
chiae  were  not  uncommonly  present.  It  is  suggested  by  Dr.  Murchison 
that  the  rash  in  some  -cases  was  urticarial.  What  I  saw,  and  not  in  one 
case  only,  but  in  many,  was  neither  petechial  nor  urticarial.  In  the 
epidemic  of  relapsing  fever  in  Silesia  in  1857  a  rose  rash  on  the  second 
or  third  day  Avas  the  rule ;  and  a  considerable  number  of  the  cases  seen 
in  Bradford  in  1869-70  showed  the  same  feature,  approximating,  there- 
fore, in  character  to  those  seen  in  Silesia  rather  than  to  those  seen  in 
other  epidemics  in  this  country. 

The  respiration  is  hurried,  and  varies  from  twenty-eight  to  forty  a 
minute.  A  distressing  cough  is  usually  present,  with  rhonchus,  sibilus, 
and  harsh  breathing  on  auscultation.  I  seldom  saw  expectoration, 
and  in  none  of  my  cases  did  true  pneumonia  supervene ;  the  symptoms 
indicated  rather  congestion  of  the  tracheo-bronchial  mucous  membrane 
than  congestion  or  inflammation  of  the  king  itself. 

These  symptoms  continue  for  several  days,  five  to  seven  as  a  rule, 
but  in  some  cases  I  have  known  them  persist  for  as  many  as  nine,  the 
patient  complaining  most  of  the  nausea  and  sickness,  and  of  pains  in 
the  limbs  and  joints.  The  skin  remains  persistently  yellow,  and  it  is 
found  in  nearly  all  cases  that  the  area  of  hepatic  dulness  is  increased, 
while  that  of  the  splenic  is  always  so.  In  some  of  my  cases  the  area 
of  splenic  dulness  seemed  to  be  actually  continuous  with  that  of  the 
heart,  the  spleen  appearing  almost  as  large  as  another  liver.  Patients 
then  complained  of  weight  and  tenderness  at  the  part.  Tenderness 
was  also  well  marked  over  the  liver  in  many  cases,  corresponding  with 
the  occurrence  of  jaundice,  which  was  present  in  nearly  every  case. 
As  the  latter  was  so  common,  occurring  as  well  in  slight  as  in  severe 
cases,  I  cannot  agree  with  those  observers  who  look  on  it  as  a  formid- 
able symptom ;  but  it  is  possible  that  different  epidemics  have  shown 
widely  different  characters  in  this  as  in  other  respects.  The  jaundice 
has  no  necessary  connection  with  head  svmptoms,  and  probably  depends, 
as  Dr.  Murchison  suggested,  on  functional   interference  by  the  fever 


944  SYSTEM  OF  MEDICINE 

poison  with  the  proper  metamorphosis  of  the  biliary  products,  which  are 
retained  in  the  blood  instead  of  being  eliminated  by  the  liver. 

The  rest  of  the  digestive  apparatus  also  shows  signs  of  disturbance. 
Generally  speaking  the  tongue  remains  moist,  and  covered  with  a 
yellowish  white  fur.  It  is  frequently  red  at  the  tip,  and  occasionally 
the  whole  organ  may  be  seen  brown  and  dry  as  in  typhus.  Frequent 
and  persisting  vomiting  of  greenish  yellow  matter  is  often  observed. 
This  symptom  is  in  some  cases  most  distressing,  and  may  remain  con- 
stant during  the  whole  of  the  primary  fever,  disappearing  during  the 
intermission  and  reappearing  during  the  relapse.  Thirst  is  also  a  com- 
mon symptom.  The  bowels  are  constipated  as  a  rule,  but  in  some  cases 
diarrhoea  occurs,  and  in  others  the  bowels  act  every  other  day  or  so. 
Pregnant  loomen  almost  always  abort,  but  often  not  till  the  relapse 
occurs. 

After  these  symptoms  have  contiiiued  for  five,  seven,  or  nine  days, 
the  severity  pursuing  an  increasing  or  climacteric  course,  and  the  patient 
complaining  much  of  the  nausea  and  sickness,  and  of  the  pains  in  the 
limbs  and  joints,  a  crisis  suddenly  occurs.  A  copious  perspiration 
appears,  or  diarrhcea  or  epistaxis,  or  two  or  more  of  these  phenomena 
concur,  often  ushered  in  by  a  rigor  (during  which  I  have  known  the 
thermometer  to  register  a  temperature  as  high  as  105°  F.),  and  im- 
mediately the  patient  feels  quite  well.  The  temperature  may  then  fall 
from  7°  to  10°  F.,  and  the  pulse  from  136  to  70  or  so ;  and  the  patient 
who,  a  few  hours  before,  was  tossing  helplessly  in  the  height  of  the  fever, 
perhaps  even  with  paralysis  of  the  sphincters  and  pharynx,  suddenly 
declares  himself  quite  well,  and  is  with  difficulty  prevented  from  get- 
ting up.  The  rheumatic  pains,  vomiting,  headache,  and  all  the  febrile 
symptoms  having  disappeared,  he  will  profess  great  surprise  if  he  is 
told  that  there  is  another  period  of  illness  in  store  for  him.  The  crisis 
occurred  almost  always  during  the  night. 

Although  I  might  succeed  in  keeping  my  patients  in  bed  for  a  few 
days,  yet  they  generally  got  up  towards  the  close  of  the  interval,  and 
before  the  relap)se,  which  often  therefore  came  upon  them  with  all  the 
force  of  the  onset  of  a  new  disease.  As,  however,  by  no  kind  of  treat- 
ment did  it  appear  possible  to  prevent  the  occurrence  of  the  relapse, 
and  as  therefore  no  hope  could  be  held  out  that  rest  in  bed  might  save 
the  patient  from  its  onset,  it  appeared  the  less  desirable  to  interfere 
with  the  patient's  OAvn  inclinations. 

One  of  my  patients  had  been  out  in  India  as  a  soldier,  and  had  there 
suffered  repeatedly  from  attacks  of  intermittent  fever.  He  was  quite 
certain  that  the  illness  from  which  he  was  suffering  in  1870  was  of  the 
same  character  as  the  attacks  with  which  he  had  been  so  familiar  in 
India,  and  consequently  felt  quite  incredulous  when  I  told  him  he 
would  have  a  relapse.  After  the  manner  of  people  of  his  class,  he 
offered  to  lay  a  wager  that  I  was  mistaken,  and  that  he  would  have  no 
relapse.     The  relapse  came,  nevertheless,  as  predicted. 

This  incident  is  quite  in  keeping  with  what  has  been  observed  in 


RELAPSING  FEVER,    OR   FAMINE  FEVER  945 


other  epidemics,  and  reminds  us  of  the  classic  case  of  Dr.  Hughes 
Bennett,  who  had  relapsing  fever  in  the  epidemic  of  1843,  when  he  was 
attended  by  Dr.,  afterwards  Sir  Robert  Christison.  When  the  patient 
was  told  by  his  medical  attendant  that  "  he  was  suffering  from  an  attack 
of  an  old  acquaintance  "  of  Christison's,  "  whose  face  had  not  been  seen 
for  a  good  many  years ;  that  he  had  not  yet  done  with  it,  and  that  he 
would  have  another  attack,  commencing  with  rigor,  on  the  fourteenth 
day.  Dr.  Bennett  expressed  great  astonishment."  "Surprised,"  says 
Christison,  "  I  will  not  say  incredulous,  Dr.  Bennett  replied  that  the 
relapse  had  no  time  to  lose,  as  there  were  only  two  or  three  hours  of  the 
fourteenth  day  to  run.  It  did,  indeed,  lose  no  time,  for  I  must  have 
scarcely  reached  home  from  his  house  before  the  rigor  set  in  with 
violence." 

The  period  of  exemption  from  febrile  symptoms  —  the  intermission  — 
is  of  variable  duration.  In  my  cases  it  usually  seemed  to  last  longer 
in  those  who  defervesced  early  after  the  primary  fever,  and  a  shorter 
time  when  the  primary  fever  had  lasted  longer.  Thus  the  intermission 
extended  to  between  nine  and  ten  days  in  a  case  where  the  primary 
fever  endured  only  six  days  ;  and  only  six  days  when  the  primary  fever 
lasted  between  eight  and  nine.  In  the  former  case,  therefore,  the  re- 
lapse took  place  on  the  fifteenth  day,  or  between  the  fifteenth  and  six- 
teenth; in  the  latter  between  the  fourteenth  and  fifteenth.  But  this 
rule  is  not  invariable.  The  authorities  state  that  the  relapse  generally 
occurs  abruptly  on  the  fourteenth  day.  It  is  ushered  in  by  rigor. 
The  duration  of  the  relapse  was  from  three  to  five  days  in  the  cases  I 
saw.     The  usual  duration  appears  to  be  three  days. 

A  relapse  occurred,  so  far  as  my  observation  extended,  in  every  case 
without  exception.  The  symptoms,  similar  to  those  of  the  primary 
fever,  were  often  more  severe  ;  and  one  sometimes  saw  the  tongue  com- 
pletely brown  and  dry  as  in  typhus,  and  observed  the  pulse  ranging  at 
what,  in  other  circumstances,  would  be  considered  the  perilously  high  rate 
of  160.  At  the  end  of  three  or  four  days  this  set  of  symptoms  usually 
came  to  a  termination  nearly,  if  not  quite,  as  abrupt  as  that  of  the  pri- 
mary fever,  the  thermometer  indicating  a  fall  of  6°  or  7°  F.,  rarely  of 
10°  F.,  and  the  pulse  a  corresponding  diminution.  The  second  crisis 
generally  led  to  the  establishment  of  complete  convalescence,  though 
sometimes  a  second  relapse  occurred.  In  such  a  case  the  symptoms  were 
not  so  severe,  nor  the  defervescence  so  sudden  as  before. 

In  none  of  the  cases  which  I  saw  did  a  third,  fourth,  or  fifth  relapse 
occur. 

It  is  worthy  of  remark  that  during  convalescence,  as  well  during  the 
intermission  as  after  the  relapse,  the  temperature  and  pulse  both  invariably 
sank  considerably  below  the  normal  standard,  and  gradually  rose  as  con- 
valescence became  more  coTnpletely  established  until  the  normal  was  again 
reached.  This  sequence  is  observed  no  doubt  inmost  of  the  acute  diseases, 
being  in  accordance  with  the  general  law  of  action  and  reaction ;  but  it  seems 
to  me  that  the  temperature  ranges  lower  after  the  elevation  of  the  febrile 

VOL.  I  3  P 


946 


SYSTEM  OF  MEDICINE 


stage  of  relapsing  fever  than  in  most  other  diseases.  Thus  a  temperature 
of  96''  F.  was  common  at  the  commencement  of  the  intermission ;  while 
in  one  of  my  cases,  in  which  a  second  relapse  occurred,  the  temperature 
during  the  second  intermission  was  observed  to  be  94:-5°  P.,  95-6°,  and 
93^  on  successive  days.     Even  lower  temperatures  may  be  registered. 

Two  temperature  charts  are  reproduced  here.     The  first,  that  of  E,.  D., 
set.  30  years,  is  more  or  less  typical  of  the  records  of  temperature  (and 


Name 

.R.D. 

Agre 

.  3 

9  f/ea/-^ 

Disease.  Relapsing  Feuer 

Yi.esv.\tRecouerg 

Day   of 
Disease 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

uJ 
-1 
< 
O 
CO 

w 

UJ 

X 

z 

UJ 
UJ 

a: 

D 
1- 
< 

u 

Q. 

S 

UJ 

H 

/  106" 
105 

104 

103 

102 

101° 

100 

03 

9C 

97" 
^    96 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

M  E 

ME 

M  E 

M  E 

ME 

ME 

M  E 

M  E 

ME 

ME 

ME 

M  E 

M  E 

-41°  ^^ 

LU 

< 

CO 
UJ 
Q 

< 

0: 
0 

hi 
tlJ 

tc 

H 
< 
q: 

UJ 
CL 

UJ 

1- 

/ 

\ 

1 

\ 

/ 

y 

^/ 

\ 

\ 

-39° 
-38° 
-37° 

-36° 

J 

^ 

^N 

^ 

\ 

f 

\ 

/ 

^ 

\ 

w 

/■^ 

y 

Pulse     ^ 

IOC 

118 

120 
IIS 

112 

IIS 
112 

02 
68 

68 

64 
72 

64 
70 

64 
72 

70 

118 
106 

IIS 
126 

118 
126 

103 
64 

S4 
64 

56 
64 

56 
64 

SI 
64 

68 
1 

^      /'(//se 

Resp.     ^ 

^     /?e.;,. 

Motions 

Motions 

Urine    ozs. 

Urine    ozs. 

Sp.Gr. 

Sp.Gr. 

Reaction 

Reaction 

Chlorides 

Chlorides 

Albumen 

Albumen 

Nov.   1869 

17 

18 

19 

20 

21  22 

23 

24 

25 

26 

27 

28 

29 

30 

Dec. 
1 

2 

3 

4 

5 

6 

7 

CuART  12.  —  Case  of  relapsing  fever  (Rabagliati). 

pulse)  found  in  relapsing  fever.  These  ranges  may  be  defined  as  two  or 
more  sets  of  high  readings  in  temperature,  alternating  with  periods  of 
complete  apyrexia.  I  have,  unfortunately,  no  observations  on  the  tem- 
perature at  the  very  beginning  of  the  fever  (though  I  have  one  observa- 
tion of  103-5°  F.  on  the  second  day),  but  the  authorities  state  that  it  is 
very  high,  agreeing  in  this  respect  with  the  early  stage  of  typhus,  but 
differing  from  that  of  typhoid  fever.  In  the  two  charts  depicted,  the 
temperature  was  103-5°  F.  on  the  third  day  in  one,  and  104°  and  105° 
on  the  fourth  day  in  the  other.  The  second  chart,  that  of  J.  O'H.,  is 
introduced  to  show  the  very  great  fall  of  temperature  Avhicli  is  sometimes 
observed  during  the  intermission.  There  is  no  fallacy  in  the  observations 
which  record  temperatures  so  low  as  95°  F.  and  92-2°  F.,  for  I  took  much 


RELAPSING  FEVER,    OR  FAMINE  FEVER 


947 


care  to  satisfy  myself  by  repeated  observations  that  these  sublingual 
readings  were  correct.  Between  the  highest  and  lowest  recorded  tem- 
peratures in  the  case  of  J.  O'H.  there  is  a  difference  of  no  less  than  13° 
F.,  —  a  state  of  things  which,  if  not  unique  in  medical  thermometry,  is 
at  any  rate  extremely  rare.  Chart  No.  1  (and  indeed  No.  2  also,  except 
that  the  fall  in  the  intermission  is  greater  than  usual)  shows  so  well  the 


Name.  J.O.H. 

Age.  20  Years 

Disease.  Relapsin 

7  fewer 

Result. /?ecoyec(;. 

Day  of 
Disease 

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93 

92 

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M  E 

M  E 

M  E 

M  C 

M  E 

M  E 

M  E 

M  E 

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25 

26 

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28 

29 

30 

Dec. 
1 

2 

3 

4 

5 

6 

7 

8 

9 

CnAKT  13.  —  Case  of  relapsing  fever  (Rabagliati). 


course  of  the  temperature  in  relapsing  fever,  that  the  reader  may  be 
spared  a  verbal  description. 

The  pulse  rate  is  also  characteristic  of  the  cases  seen  in  the  Bradford 
epidemic.  The  usual  accounts,  however,  state  the  pulse  rate  as  higher 
than  is  shown  in  the  chart.  Thus  140  is  said  to  be  not  uncommon, 
while  IGO  is  said  to  be  occasionally  reached.  An  interesting  point  is 
that,  as  I  have  said,  these  rates  do  not  seem  to  imply  danger  to  the 
patient,  much  less  do  they  prove  the  forerunners  of  a  fatal  termination. 
As  with  the  temperature,  so  with  the  pulse,  a  sudden  and  extensive  fall 
oc(;urs  at  the  end  of  the  primary  attack,  and  also  at  the  termination  of 
the  relapse.  One  of  my  observations  records  a  fall  from  148  to  80,  or  of 
no  fewer  than  G8  beats  a  minute  in  the  course  of  a  few  hours.     A  fall 


948  SYSTEM  OF  MEDICINE 

from  120  to  60  in  a  night  was  quite  a  common  occurrence.  Like  tlie  tem- 
perature, the  pulse  also  usually  falls  below  normal  before  returning  to 
its  natural  rate.  Thus  it  remained  for  about  a  week  at  60  a  minute  in  a 
young  fellow  of  eighteen,  whose  normal  pulse  rate  was  much  higher  than 
that.  The  pulse  and  temperature,  as  might  be  anticipated,  usually  rise 
and  fall  together,  though  this  is  not  always  the  case.  Sometimes  the 
rise  of  one  precedes  that  of  the  other,  and  may  be  symptomatic  of  the 
general  fever  about  to  supervene.  Both  temperature  and  pulse  gradually 
reach  normal  as  convalescence  becomes  established. 

The  only  fatal  case  Avhich  occurred  in  my  practice  was  of  an  old 
woman  of  seventy.  She  died,  like  one  of  Hippocrates'  cases,  on  the 
sixth  day.  As  she  did  not  live  long  enough  to  have  the  relapse,  there 
was  just  that  amount  of  doubt  as  to  the  diagnosis  which  must  attach  to 
every  such  case  ;  but  I  had  no  doubt  that  the  malady  was  relapsing 
fever. 

This  course  of  the  general  symptomatology  of  relapsing  fever  is  then 
very  characteristic,  and  no  one  looking  at  these  temperature  charts  could 
possibly  mistake  them,  or  confuse  them  with  those  of  any  other  disease. 
No  doubt  anomalous  cases  occur.  This  is  so  in  all  epidemics,  and  not 
of  relapsing  fever  only.  In  one  case  of  mine  the  disease  ran  on  for 
thirty-six  days,  and  seemed  to  be  a  case  in  which  typhoid  and  relapsing 
fevers  were  mixed  together ;  although  perhaps  other  explanations  of  it 
were  possible.  Yet  the  characters  of  the  disease,  as  it  was  generally 
met  with,  were  so  striking  and  peculiar  as  to  be  readily  separable  from 
those  of  any  other  disease,  and  to  leave  no  doubt  on  the  mind  of  the 
observer  as  to  their  ti'ue  character. 

Etiology.  —  Remoter  Causes.  —  So  far  as  I  saw,  the  male  sex  was 
much  more  liable  to  relapsing  fever  than  the  female.  Dr.  Miirchison 
gives  the  proportion  as  116  to  104,  but  inclines  to  the  opinion  that  sex 
has  very  little  influence  in  the  matter.  If  the  male  sex  suffer  more  than 
the  female,  it  is  probably  because  men  are  more  exposed  to  the  exciting 
causes  of  the  disease.  As  to  age,  relapsing  fever  (like  other  fevers)  is 
especially  a  disease  of  early  life.  Most  of  my  cases  occurred  in  young 
male  adults.  Dr.  Murchison  gives  the  mean  age  as  244  years.  As  to 
occupation,  almost  all  the  cases  were  either  among  paupers  or  very  poor 
persons.  This  has  been  the  general  rule  in  epidemics  of  the  disease,  a 
fact  which  is  so  notorious  as  to  have  given  a  name  to  the  disease.  At 
the  same  time,  it  must  be  said  that  careful  inquiry  in  Bradford  often 
failed  to  elicit  the  fact  that  the  sick  had  had  to  undergo  any  special  hard- 
ships, or  to  endure  any  special  privations  in  food.  Trade  was  then  moder- 
ately good  in  the  town,  and  the  consequent  demand  for  labour  w§,s  pretty 
active.  In  Liverpool  at  the  time  of  the  epidemic  of  1870,  according  to  the 
Lancet  report,  "  there  was  full  employment  for  every  able-bodied  and  in- 
dustrious man."  The  patients  themselves  did  not  show  any  signs  of  hav- 
ing been  deprived  of  food.  Of  522  patients  of  whom  the  inquiry  was  made, 
only  91  had  been  in  the  workhouse  before,  which  shows  at  least  that  they 
did  not  belong  to  the  habitual  pauper  class.    Besides  this,  at  the  time  of  the 


RELAPSING  FEVER,    OR  FAMINE  FEVER  949 

Liverpool  epidemic,  there  were  (1st)  considerably  fewer  inmates  resident 
in  the  workhouse,  (2)  considerably  fewer  families  in  receipt  of  outdoor 
relief ;  (3)  considerably  fewer  patients  suffering  from  zymotic  diseases 
than  in  the  corresponding  period  of  the  year  preceding.  From  all  these 
circumstances  it  appears  as  if  the  name  of  "  famine  fever  "  is  not  always 
an  appropriate  one.  Other  circumstances  appear  to  enter  into  the 
causation  of  the  disease.  Mere  overcrowding  is  not  a  sufficient  cause, 
as  some  very  overcrowded  populations  have  suffered  even  less  from  it 
than  others  less  densely  packed.  The  Lancet  report  on  the  Liverpool 
epidemic  in  1870  showed  that  there  were  at  least  three  principal  causes, 
namely,  (a)  the  sites  of  the  houses,  which  were  frequently  placed  on 
decaying  vegetable  and  animal  matter  and  midden  refuse ;  (6)  insuffi- 
cient and  imperfect  drainage ;  and  (c)  the  extensive  prevalency  of  cellar 
dwellings  in  darkened  and  filthy  courts. 

On  the  other  hand,  much  evidence  exists  to  show  that  there  is  as 
a  rule  some  connection  between  the  occurrence  of  rel?.psing  fever  and 
the  existence  of  destitution  among  the  population  attacked.  Contagion 
cannot  explain  the  whole  of  the  cases  or  the  spread  of  epidemics.  Kot 
to  mention  the  fact  that  in  Bradford  and  Liverpool  in  1869-70  the  mass  of 
the  cases  of  the  disease  occurred  among  the  pauper  class,  Dr.  Murchison 
showed  that  in  London  97*5  per  cent  of  the  cases  investigated  by  him- 
self were  paid  for  by  the  parochial  authorities,  and  were  totally  destitute. 
Nine  of  the  remaining  cases  (430  in  all  were  investigated)  were  admitted 
free,  and  were  also  destitute.  Not  a  single  patient  had  been  a  servant 
in  a  private  family,  and  in  one  instance  only  was  a  fee  for  admission  paid 
by  the  patient's  friends.  It  is  probably,  also,  not  without  significance  that 
the  epidemics  of  1817,  1818,  and  1819  raged  during  a  period  notorious 
in  British  history  for  low  wages,  high  prices  of  food,  and  general  depres- 
sion due  to  the  fall  of  the  inflation  of  the  markets  caused  by  the  great 
continental  war ;  while  the  epidemics  of  1843-4  and  of  1847-8  occurred 
about  the  time  of  the  great  Irish  famine,  and  during  the  general  destitu- 
tion which  played  so  great  a  part  in  causing  the  abolition  of  the  corn 
laws,  and  in  preventing  their  re-enactment.  In  1826  Stokes  described 
relapsing  fever  as  famine  fever,  and  in  1847  Corrigan's  pamphlet  bore 
the  title,  On  Famine  and  Fever,  as  Cause  and  Effect  in  Ireland.  When 
the  epidemic  occurred  in  Silesia,  in  1847,  the  inhabitants,  in  consequence 
of  a  succession  of  bad  harvests,  had  been  reduced  to  subsist  on  clover, 
grass,  i.iushrooms,  and  the  roots  of  trees.  The  synonym  "  Hungerpest" 
points  unmistakably  to  the  connection,  in  German  opinion,  between 
relapsing  fever  and  the  existence  of  destitution.  "  Carter  states  that  it 
was  brought  to  Bombay  in  1877  by  the  peasantry  flocking  into  the  citj 
from  famine-stricken  districts  "  (Fagge).  Dr.  Murchison's  view,  as  is 
well  known,  was  that  relapsing  fever  is  due  to  destitution,  while  typhus 
is  produced,  he  thought,  by  overcrowding  and  destitution  combined. 

Immediate  Causes  —  Contagion.  —  The  question  of  the  contagiousness 
of  relapsing  fever  was  very  fully  gone  into  by  Dr.  Murchison,  who  proved 
his  position  that  it  was  an  exceedingly  contagious  disorder  in  the  same 


950  SYSTEM    OF  MEDICINE 

way  that  he  did  for  typhus  fever.  Several  facts  in  corroboration  of  his 
opinion  came  under  my  notice.  Thus  several  cases  were  admitted  to 
hospital  from  the  same  house  or  street  imder  circumstances  which  left 
little  or  no  doubt  that  some  patients  had  been  infected  by  others.  In 
one  case,  again,  early  in  the  epidemic,  and  before  I  was  accustomed  to 
recognise  and  diagnose  the  fever,  I  ordered  a  patient  suffering  from  it 
into  the  general  ward,  thinking  he  had  rheumatism.  It  was  not  long 
before  I  had  to  order  the  removal  both  of  him  and  of  another  patient, 
who  lay  beside  him,  to  the  fever  hospital.  Both  had  relapsing  fever,  and 
the  other  patient  had  been  some  time  in  the  general  ward.  However,  no 
nurses  or  attendants  on  the  sick  in  Bradford  took  the  disease  from 
patients.  I  suppose  this  good  fortune  was  diie  to  the  fact  that  our  cases 
were  not  very  numerous,  and  perhaps  also  to  the  further  fact,  that  our 
fever  hospital  was  roomy  and  airy,  rather  than  that  our  cases  were  not  so 
infectious  as  they  have  been  in  other  epidemics.  At  any  rate  both  in  1818 
and  in  1843  relapsing  fever  appeared  as  a  very  infectious  disorder.  Thus 
Dr.  Welsh  says  of  the  epidemic  of  1818,  that  in  the  course  of  four  months 
his  three  colleagues,  two  of  the  young  men  in  the  apothecary's  shop, 
two  housemaids,  and  thirteen  or  fourteen  nurses,  caught  the  disease ;  and 
the  matron  and  one  of  the  dressers  died  of  it.  In  Queensberry  House  in 
1818  two  medical  men,  the  matron,  two  apothecaries  in  succession,  the 
shop  boy,  washerwoman,  and  thirty-eight  nurses  were  infected,  and  four 
of  the  nurses  died.  Of  the  epidemic  of  1843—4  Dr.  Wardell  wrote: 
"  Most  of  the  medical  officers  connected  with  the  Edinburgh  Royal 
Infirmary,  and  additional  fever  hospital,  were  seized  with  it;  eight  of 
the  resident  and  clinical  clerks  in  quick  succession  became  affected."  .  .  . 
"The  majority  of  the  nurses  and  domestics  took  the  disease,  and  of  the 
former,  at  one  time,  no  less  than  nineteen  were  labouring  under  it." 
And  more  to  the  like  effect.  The  late  Dr.  Begbie,  from  his  experience  of 
the  epidemic  of  1847,  arrived  at  the  conclusion  that  relapsing  fever,  like 
typhus,  was  communicable  from  "  the  sick  to  the  healthy  ;  that  for  this 
purpose  actual  contact  with  the  sick  was  not  necessary,  the  subtle  poison 
of  this  form  of  continued  fever,  equally  with  that  of  typhus,  being  readily 
conveyed  through  the  air  surrounding  the  latter ;  and,  lastly,  that  by 
means  of  fomites  or  clothes  the  disease  may  readily  be  propagated." 

A.  R. 

Bacteriology.  —  Although  Henderson  of  Edinburgh,  in  1843,  had  dis- 
tinguished relapsing  fever  from  other  diseases  with  which  it  had  been 
classed  under  the  general  term  "typhus,"  it  was  not  until  1873  that 
Obermeier,  assistant  to  Professor  Virchow  in  Berlin,  demonstrated  the 
presence  of  lively  spirilla  in  the  blood  of  patients  suffering  from  the  dis- 
ease.  This  observation  has  been  generally  corroborated  by  later  observers. 

The  micro-organism  of  relapsing  fever  is  a  long  and  slender  spirillum, 
of  varying  length  (16  to  40  /x),  sinuous,  or  twisted  spirally  in  10-20  turns. 
In  fresh  blood  the  spirillum  is  seen  to  be  flexible  and  very  active.  Its 
movements  are  progressive,  with  undulations  passing  wave-like  along 


RELAPSING   FEVER,    OR   FAMINE   FEVER  951 

from  OKe  extremity  to  the  other.  It  is  so  fine  that  under  a  low  power 
its  presence  is  revealed  only  by  the  commotion  among  the  blood  cor- 
puscles, which  by  the  rapid  movements  of  the  spirilla  are  thrust  violently 
aside.  The  spirilla  are  much  thinner  than  a  cholera  vibrio,  and  their 
ends  are  tapering  and  sharp.  These  thin  tapering  ends  were  formerly 
considered  by  some  to  take  the  place  of  flagella,  but  Koch  has  since 
demonstrated  true  flagella,  which  account  for  their  rapid  motion.  The 
rapidity  and  intensity  of  the  movements  depend,  according  to  Dr.  Van- 
dyke Carter,  directly  on  the  number  of  the  spirilla. 

Activity  persists  after  the  death  of  the  diseased  person,  and  can  be 
studied  for  a  long  time  in  preparations  in  one-half  per  cent  salt  solution, 
or  in  blood  serum. 

Heydenreich  found  that  the  vitality  of  the  spirilla,  as  evidenced  by 
mobility,  could  be  preserved  for  a  time  varying  from  two  and  a  half 
hours  to  fourteen  days,  according  to  the  temperature  at  which  they  were 
kept ;  at  a  higher  temperature  the  movements  ceased  sooner. 

The  presence  of  the  spirilla  in  the  blood  has  been  taken  as  evidence 
of  their  aerobic  nature. 

Although  it  has  been  found  impossible  to  cultivate  the  bacteria  of 
relapsing  fever  in  or  on  artificial  media,  Koch  has  observed  the  forma- 
tion of  tangled  masses,  and  an  increase  in  the  length  of  spirilla  which 
had  been  placed  in  tubes  of  blood  serum. 

The  total  disappearance  of  the  spirilla  from  the  blood  after  the 
XDyrexial  attack,  together  with  their  reappearance  in  the  next  paroxysm, 
led  some  bacteriologists  to  the  probably  erroneous  conclusion  that  they 
produce  spores,  in  which  form  they  were  assumed  to  remain  dormant 
until  the  next  relapse. 

Metschnikoff  has  shown,  however,  that,  after  the  parasites  have  dis- 
appeared from  the  blood,  masses  of  them  may  still  be  present  in 
the  spleen,  where  they  are  mostly  enclosed  in  cells.  Many  of  these 
cells  seem  to  be  undergoing  degeneration,  and  it  is  possible  that  the 
contained  bacilli  may  then  escape  in  a  condition  capable  of  causing  the 
relapse.  On  the  other  hand,  those  microbes  which  had  not  been  en- 
gulfed, and  had  remained  extracellular,  may  be  responsible  for  the 
second  febrile  attack. 

The  low  temperature  by  which  the  infective  nature  of  the  blood  of 
a  patient  is  destroyed  seems  to  point  to  the  absence  of  spores,  although 
Soudakewitch  has  described  spirilla  which  showed  distinct  terminal 
swellings.  Free  globular  bodies  are  also  observed,  which,  from  their  size 
and  appearance,  may  be  these  swellings  detached  from  the  spirilla. 
Carter  had  some  years  previously  called  attention  to  the  irregular  dotted, 
beaded,  or  clubbed  appearance  chiefly  to  be  observed  in  dried  specimens. 
From  the  spirillar  nature  of  the  organism  it  is  highly  improbable  that 
it  forms  ordinary  endospores;  it  is  more  likely  that  reproduction  takes 
place  by  fission,  the  spirillum  dividing  into  two  equal  parts. 

The  organism  stains  readily  with  the  ordinary  basic  aniline  dyes, 
such  as  gentian  violet,  bismarck  brown,  and  fuchsin. 


952  SYSTEM  OF  MEDICINE 

The  spirilla  are  to  be  found  in  the  blood  for  some  hours,  or  even  one 
or  two  days  before  the  crisis,  but  after  the  crisis  they  generally  dis- 
appear quickly. 

The  micro-organisms  persist  throughout  a  pseudo-crisis,  and  are  not 
to  be  found  in  the  non-febrile  intervals  between  the  true  attacks. 

At  the  beginning  of  the  pyrexia  the  spirilla  are  seen  to  increase  in 
number  until  at  the  crisis,  according  to  Carter,  they  may  be  in  the  pro- 
portion of  one-twentieth  to  one-tenth  the  total  number  of  red  blood  cells. 
There  is  then  a  diminution,  until  in  a  short  time  none  is  to  be  observed 
in  the  blood. 

The  constant  occurrence  of  this  micro-organism  in  all  of  Obermeier's 
cases,  and  its  invariable  absence  in  other  diseases  similarly  examined, 
point  to  its  causative  relation  to  the  symptoms.  That  it  has  been  found 
impossible  to  cultivate  the  spirilla  in  artificial  media  can  hardly  be  con- 
sidered a  serious  objection  when  we  consider  the  following  facts:  — 

Carter,  working  in  India  in  1879,  Avhile  verifying  the  observation 
already  made  in  Europe,  gave  the  following  as  reasons  for  connecting 
the  presence  of  the  spirilla  Avith  the  fever  symptoms  in  the  disease :  — 

1.  The  blood  infection  is  always  followed  by  the  characteristic  fever, 

although  an  interval  of  some  hours  or  even  one  or  two  days 
may  intervene. 

2.  With  the  advent  and  progress  of  pyrexia  the  spirilla  increase  in 

number,  but  there  is  no  fixed  relation  between  the  type  and 
intensity  of  the  fever  and  the  number  of  organisms  present  in 
the  blood. 

3.  They  disappear  with  the  cessation  of  fever,  persisting,  however, 

occasionally  for  a  day  or  two,  especially  during  pseudo-crises 
and  slow  defervescence. 

4.  By  inoculation  of  dehbrinated  blood  removed  during  the  period 

of  pyrexia — and  therefore  containing  the  spirillar  organisms  — 
from  a  patient  suffering  from  relapsing  fever  into  a  healthy 
person,  the  disease  may  be  conveyed  to  new  subjects. 

The  disappearance  of  the  spirilla  from  the  blood  in  man  during  the 
apyrexial  periods  is  as  yet  unexplained  ;  though  Metschnikoff 's  observa- 
tions have  been  taken  as  evidence  that  they  are  largely,  if  not  altogether, 
destroyed  by  the  phagocytes,  which  engulf  them  and  carry  them  to  the 
spleen.  This  organ  is  enlarged,  and  is  the  seat  of  the  chief  pathological 
changes  in  those  cases  in  which  death  from  the  disease  occurs ;  it  is  then 
seen  to  be  filled  with  white  cells  containing  the  parasites.  The  liver 
and  marrow  of  the  bones  contain  foci  of  necrosis. 

Koch,  Carter,  Metschnikoff,  and  Soudakewitch,  by  inoculation  experi- 
ments on  monkeys,  have  produced  symptoms  which  correspond  to  the 
disease  in  man ;  by  this  means  they  have  thrown  much  valuable  light 
on  the  pathology  and  bacteriology  of  the  disease,  and  have  established  its 
specific  nature.  In  these  animals  inoculation  was  followed  by  a  sharp 
febrile  attack,  beginning  usually  in  about  three  days.     The  disease  ter- 


RELAPSING   FEVER,    OR  FAMINE  FEVER  953 

minated,  witliout  relapse  in  recovery.  Spirilla  were  observed  during  the 
pyrexia,  but  disappeared  soon  after  the  temperature  had  fallen ;  and  in 
animals  which  had  been  killed  ten  hours  after  the  crisis  the  parasites  were 
found  only  in  the  form  of  debris,  chiefly  contained  in  the  microphage 
cells  in  the  spleen. 

An  emulsion  of  spleen-pulp,  containing  the  spirilla,  produces,  when 
injected  into  a  second  monkey,  the  same  symptoms  and  fever.  A  monkey 
that  had  passed  through  an  attack  remained  susceptible  to  a  second  in- 
oculation ;  recovery  is  not  followed  by  immunity. 

Although  under  ordinary  conditions  the  monkeys  invariably  survived, 
Soudakewitch  showed  that  on  removal  of  the  spleen  the  disease  proved 
fatal  to  some  of  the  monkeys.  The  temperature  gradually  subsided  until 
death  occurred.  On  examining  such  animals  after  death  the  blood  was 
found  to  be  swarming  with  spirilla ;  in  one  instance  the  inferior  vena  cava 
was  nearly  blocked  by  tangled  skeinlike  masses  of  these  organisms. 

F.  F.  Wesbrook. 


Relation  between  Relapsing  and  Typhus  Fevers.  —  Some  interest  at- 
taches to  this  subject.  We  have  seen  that  Dr.  Murchison  thought  that, 
in  the  matter  of  causation,  there  was  some  relation  between  these  two 
diseases ;  he  believed  that  relapsing  fever  was  caused  by  destitu- 
tion, while  typhus  fever  was  due  to  destitution  and  overcrowding. 
In  the  matter  of  the  bacteriology  of  the  two  diseases  no  such 
relationship,  appears  to  have  been  as  yet  determined.  While  the 
bacteriological  cause  of  relapsing  fever  seems  to  have  been  made  out,  that 
of  typhus  fever  has  not.  If  ever  the  latter  is  discovered,  it  will  be 
interesting  to  notice  whether  in  genus  or  species  it  is  related  to  the 
former.  At  any  rate  as  regards  the  progress  of  the  two  disorders  in 
different  epidemics  a  well-marked  relationship  has  been  seen.  The 
sequence  has  generally  been  that  in  epidemics  of  relapsing  fever 
well-marked  cases  have  been  most  numerous  in  the  commencement  of  the 
epidemic,  while  cases  of  typhus  were  comparatively  rare.  As  the  epi- 
demic advanced  the  cases  of  relapsing  fever  have  become  comparatively 
fewer,  while  those  of  typhus  have  become  comparatively  more  numerous. 
Towards  the  close  of  the  epidemic,  on  the  other  hand,  the  cases  of  typhus 
have  become  much  the  more  numerous,  while  those  of  relapsing  fever 
have  been  comparatively  rare.  Even  as  early  as  1826  the  distinction 
between  the  two  fevers  had  been  observed,  but  in  1843  it  was  more 
particularly  insisted  on,  especially  by  Dr.  Henderson.  In  Glasgow 
Infirmary,  for  instance,  there  were  admitted  2871  cases  of  relapsing  fever 
in  1843,  and  only  142  of  typhus.  In  1844,  432  cases  of  relapsing  fever 
were  admitted,  and  711  of  typhus  ;  Avhile  in  1845,  only  37  cases  of 
relapsing  fever  were  received,  and  2GG  cases  of  typhus,  the  mortality 
being,  as  inight  have  been  expected,  much  higher  in  the  typhus  than  in 
the  relapsing  fever  cases.  In  1869-70  I  saw  a  good  many  patients  who 
first  contracted  relapsing  fever,  and  in  the  course  of  a  few  weeks  there- 


954  SVSr£M   OF  MEDICINE 

after  took  typhus.  I  did  not  see  any  who  took  typhus  first  and  had 
relapsing  fever  afterwards ;  and  I  doubt  if  there  were  any  patients  in 
Bradford  in  whom  this  sequence  was  observed.  Such  a  sequence  luay,  of 
course,  have  occurred  in.  other  epidemics. 

In  those  cases  in  which  typhus  fever  folloAved  relajpsing  fever  in  the 
same  patient  within  a  short  interval  of  time,  it  seemed  to  me  that  the 
typhus  pursued  a  milder  course  than  it  might  have  been  expected  to  do 
had  the  patient  suffered  primarily  from  typhus.  This  is  not  altogether 
what  might  have  been  anticipated.  We  might  rather  have  anticipated 
that  the  patient,  debilitated  by  the  previous  occurrence  of  relapsing 
fever,  would  thus  have  been  brought  into  greater  danger  on  the  sub- 
sequent occurrence  of  typhus.  My  observations  were  not  perhaps 
numerous  enough  to  allow  me  to  generalise  from  them ;  but  I  confess 
that,  such  as  they  were,  they  did  raise  the  question  in  my  mind  whether 
the  two  fevers  might  not  have  some  causal  relationship.  May  not  the 
causes  of  relapsing  fever  and  typhus  fever  be  so  closely  connected,  that 
the  occurrence  of  one  of  them  in  a  patient  may  modify  the  subsequent 
course  of  the  other  ?  In  vaccination  and  small-pox,  for  example,  we 
have  such  a  sequence  of  events,  and  without  laying  too  much  stress  on  it, 
it  seemed  to  me  that  the  facts  of  the  Bradford  epidemic  might  justify 
some  such  reflections. 

Be  this  as  it  may,  a  relationship  between  the  numbers  of  cases  of 
relapsing  and  typhus  fevers  has  been  observed  as  a  rule  in  epidemics 
since  the  time  when  the  two  fevers  were  first  distinguished.  And 
even  before  this  time  an  investigation  into  the  mortality  at  the  be- 
ginning, middle,  and  end  of  epidemics  has  rendered  it  almost  certain 
that  a  similar  incidence  of  cases  of  relapsing  fever  and  of  typhus  fever 
has  occurred. 

Daring  the  continuance  of  the  visitation  of  epidemic  diseases  the 
mortality,  as  a  rule,  is  highest  at  the  onset  of  the  epidemic,  diminishing 
gradually  as  the  epidemic  advances.  This  may  be  because  the  most 
susceptible  are  first  attacked,  and  take  the  disease  in  its  most  virulent 
form.  "  Increase  of  susceptibility  "  may  be  mistaken  for  "  increased  viru- 
lence "  of  disease,  the  former  expression  referring  rather  to  the  nature  of 
the  soil,  so  to  speak,  in  which  the  disease  finds  a  lodgment ;  while  the  lat- 
ter refers  rather  to  the  nature  of  the  seed  than  to  the  characters  of  the  soil. 
Another  reason  for  the  diminishing  mortality  observed  as  epidemics  ad- 
vance in  time  may  simply  be  that  the  disease  assumes  a  milder  form  which 
we  are  unable  to  account  for.  In  epidemics  of  relapsing  fever,  on  the  other 
hand,  even  before  it  was  properly  distinguished  from  typhus  fever,  we 
find  records  of  a  low  mortality  at  the  beginning  of  the  epidemic,  of  an 
increasing  mortality  as  the  epidemic  advanced,  and  of  a  mortality  which 
was  highest  towards  the  close  of  the  epidemic.  This  was  particularly 
noticed  in  the  epidemics  of  1817-18,  and  in  1819;  the  most  prob- 
able inference  seems,  therefore,  to  be  that  there  was  a  mixture  of  cases 
of  relapsing  and  of  typhus  fever,  and  that  their  relative  frequency  at 
different  periods  of  the  epidemic  determined  the  observed  mortality. 


RELAPSING  FEVER,    OR  FAMINE   FEVER  955 

If  that  were  so,  as  it  appears  to  have  been  in  1817-19,  as  it  certainly 
was  in  1826-28,  when  the  distinction  between  relapsing  and  typhus 
fevers  was  first  made,  and  in  184.3  and  onwards,  when  it  was  generally 
accepted  by  the  profession  through  the  labours  mainly  of  Dr.  Hender- 
son, it  seems  reasonable  to  suppose  that,  as  a  rule,  relapsing  fever  and 
typhus  fever  have  at  other  times  borne  to  one  another  the  relationship 
which  has  been  shown  to  exist  in  those  epidemics. 

Diagnosis.  —  The  relationship  already  dealt  with  is  to  some  extent 
helpful  in  the  diagnosis  of  relapsing  fever.  As  a  rule,  the  severity  of 
the  onset  is  greater  than  in  typhoid  fever,  and  the  absence  of  abdominal 
symptoms  serves  still  further  to  distinguish  it;  although,  of  course,  in 
some  cases  of  typhoid,  abdominal  symptoms  may  be  in  abeyance,  and  on 
the  other  hand,  in  a  few  cases  of  typhoid  the  onset  of  symptoms  may  be 
both  sudden  and  severe.  As  the  cases  progress  the  differences  become 
more  marked.  Before  the  eruption  of  typhoid  fever  is  due,  a  sudden 
defervescence  will  have  revealed  that  the  attack  is  one  of  relapsing 
fever.  From  typhus,  again,  the  absence  of  rash  in  the  majority  of  the 
cases  of  relapsing  fever  (though  we  have  seen  that  in  some  cases  a  less 
characteristic  rash  has  appeared  both  in  this  country  and  abroad)  will 
serve  to  distinguish  it.  In  both  typhus  and  relapsing  fever  the  onset 
may,  of  course,  be  sudden.  But  as  between  typhus  and  relapsing  fevers 
the  great  and  obvious  difference  is  the  sudden  defervescence  that  char- 
acterises the  latter  at  about  the  end  of  the  first  week ;  and  this  short 
convalescence  will  also  serve  to  distinguish  relapsing  fever  from  pneu- 
monia, in  which  the  onset  is  likewise  often  sudden. 

From  small-pox  the  diagnosis  is  comparatively  easy  after  the  third  or 
fourth  day,  the  shotty  eruption  under  the  skin  of  the  wrists  and  on  the 
face  in  variola  being  never  present  in  relapsing  fever.  In  influenza  —  the 
epidemic  which  played  such  havoc  with  our  people  in  1891,  and  which 
has  reappeared  to  greater  or  less  extent  every  year  since  —  the  symptoms 
are  as  sudden  as  in  relapsing  fever ;  but  they  persist  for  a  shorter  time  in 
mild  cases,  while  in  severe  cases  of  influenza,  broncho-pneumonia  almost 
always  occurs.  In  influenza  there  is  no  sudden  recovery  and  no  subsequent 
relapse,  the  symptoms  in  influenza  progressing  pretty  steadily  to  death 
or  to  some  degree  of  convalescence. 

All  these  points  of  difference  which  serve  to  distinguish  relapsing 
fever  from  other  diseases,  such  as  typhoid  and  typhus  fevers,  small-pox, 
and  pneumonia,  are  open  to  the  objection  that  time  is  necessary  for  their 
appreciation.  Is  there  no  character,  it  may  be  asked,  which  will  enable 
us  at  an  earlier  j)eriod  to  say  positively  —  this  is  or  is  not  relapsing  fever  ? 
The  demonstration  of  the  microbe  proper  to  the  disease  would  do  this ; 
and  Dr.  Carter,  of  Bombay,  says  that  no  less  than  25  per  cent  of  his  cases 
were  irregular.  In  1809  I  Avas  not  aware  of  the  existence  of  the  microbe 
of  relapsing  fever,  so  that  I  was  not  able  to  use  it  for  diagnostic  purposes. 
If,  however,  a  new  epidemic  were  to  attack  us,  I  think  it  would  be  found 
that  the  chief  means  of  diagnosis  would  be  time,  as  it  has  been  in  previous 
epidemics ;  especially  as  an  observer  might  or  might  not  think  of  relapsing 


956  SYSTEM   OF  MEDICINE 


fever  if  he  had  not  had  to  treat  it  before.  The  discovery  of  the  spirocliceta 
would  make  the  diagnosis  sure. 

Sequelae.  —  These  are  not  common  in  relapsing  fever ;  with  the  ter- 
mination of  the  attack  itself  the  patient  nearly  always  recovers,  unless 
the  illness  occur  in  a  very  debilitated  subject.  In  such  persons  as  these 
the  consequences,  chiefly  pulmonary,  with  which  we  are  familiar  in  other 
fevers,  may  follow  relapsing  fever.  Parotitis  must  be  especially  men- 
tioned, not  because  of  its  frequency  in  Great  Britain,  where  on  the  con- 
trary it  is  very  rare,  but  because  in  some  epidemics  —  as  in  that  which 
occurred  in  Russia  about  twenty-live  years  ago  —  its  comparative  fre- 
quency has  led  to  the  rumour  of  plague.  Parotitis  is  occasionally  seen 
in  typhus,  and  enteric  fever  likewise. 

Prognosis  is  greatly  determined  by  diagnosis.  In  relapsing  fever  we 
know  that  the  mortality  is  not  more  than  5  per  cent,  while  in  typhus  it 
may  approach  20.  The  cautious  physician  will  judge  of  each  case  on 
its  merits,  and  after  he  has  diagnosed  relapsing  fever,  as  he  will  no 
doubt  be  on  the  lookout  for  cases  of  typhus  fever  in  the  later  phases  of 
the  epidemic,  he  will  remember  that  a  much  higher  mortality  may  then 
be  looked  for,  although  of  course  it  will  still  remain  true  that  relapsing 
fever  has  a  low  mortality.  The  higher  mortality  will  probably  be  due 
to  intercurrent  typhus  fever,  and  not  to  relapsing. 

Morbid  Anatomy.  —  Although  the  cases  which  I  saw  exhibited  a 
very  small  mortality,  and  although,  therefore,  my  opportunities  for 
inquiry  into  the  morbid  anatomy  of  relapsing  fever  were  almost  nil,  it 
has  not  been  so  in  all  epidemics.  In  Berlin,  for  instance,  in  1872-73, 
not  fewer  than  100  fatal  cases  occurred  in  the  Charite  Hospital  alone; 
and  there  were  therefore  numerous  opportunities  of  making  careful 
inquiry  into  the  morbid  anatomy.  The  organs  in  which  the  most 
marked  changes  were  found  were  the  spleen  and  blood,  the  liver,  the 
heart,  the  kidneys,  the  bones,  and  the  muscular  tissues.  The  most 
important  changes  of  all,  both  as  regards  structure  and  gravity  of 
import  to  life,  were  those  found  in  the  spleen  and  heart. 

An  alteration  was  commonly  observed  in  the  muscular  tissue  of  the 
heart,  so  grave  as  frequently  to  account  for  the  fatal  issue.  The  organ 
was  flabby,  the  muscular  tissue  throughout  pale,  of  a  dirty  gray-yellow 
colour,  and  friable.  The  primitive  muscular  flbrils  were  in  many  cases 
found  to  be  fatty.  The  fattiness  and  general  degeneration  found  in 
the  heart  in  relapsing  fever  equalled  that  seen  in  the  most  malignant 
septicaemic  and  puerperal  fevers,  and  in  diphtheria. 

The  spleen,  was  very  much  enlarged,  and  at  the  same  time  softened 
and  fatty.  In  different  observations  it  is  described  as  weighing  (as  com- 
pared with  its  normal  4  ozs.)  in  one  case  as  much  as  4.1-  lbs.  avoirdupois, 
in  another'  over  2  lbs.  (920  grammes),  in  another  about  11  lb.  (070 
grammes),  in  another  15  ozs.,  and  again  about  |  lb.  (330  grammes).  The 
enlargement  of  the  organ  was  greater  than  occurs  in  any  other  affection 
except  leukaemia,  and  consisted  of  two  sets  of  changes,  a  diffuse  gen- 
eral enlargement,  usually  accompanied  with  noticeable  softening,  on  the 


RELAPSING  FEVER,    OR  FAMINE  FEVER  957 

one  hand;  and  on  the  other  the  appearance  of  small  yellow  softened 
patches  which  in  some  cases  reached  the  size  of  a  horse  bean.  Some 
observers  have  believed  these  patches  to  be  due  to  infarctions.  The 
enlargement  took  place  in  all  directions,  the  capsule  being  tightly- 
stretched  and  shiny,  the  tissue  substance  softer  than  usual,  though  not 
exactly  diffluent;  the  spleen-pulp  dark  blue-red,  standing  out  strongly; 
the  follicles  considerably  enlarged  and  often  obliterated ;  their  colour 
for  the  most  part  gray,  though  sometimes  pure  white  or  yellowish. 
The  swelling  of  the  spleen-pulp  was  mainly  due  to  marked  congestion 
of  the  vessels,  and  an  abundant  increase  of  the  cell  elements. 

As  regards  the  morbid  anatomy  of  the  liver,  some  difficulty  occurred 
in  distinguishing  the  recent  effects  caused  by  relapsing  fever  from  those 
frequently  pre-existing  effects  caused  by  alcoholism  in  the  same  patients. 
But,  so  far  as  could  be  made  out,  the  increase  in  the  size  of  the  liver 
was  greater  than  has  been  observed  in  any  other  of  the  infectious 
diseases.  In  one  case  the  liver  weighed  3620  grammes  —  almost  8 
lbs.  avoirdupois  —  an  enormous  increase.  The  organ  was  enlarged 
throughout,  the  lobules  being  also  increased  in  size,  so  that  their 
boundaries  were  rendered  obscure ;  the  cut  surfaces  were  cloudy,  and 
of  a  striking  uniform  gray-red  colour.  On  microscopic  examination 
there  was  found  cloudy  swelling  of  the  hepatic  cells  with  fatty  in- 
filtration round  their  edges,  and  fine-celled  infiltration  along  the  portal 
vein.  Jaundice  did  not  seem  to  bear  any  relation  to  the  gravity  of 
the  cases,  being  well  marked  in  some  slight  cases.  On  the  other  hand, 
out  of  sixty-five  fatal  cases  only  sixteen  showed  the  presence  of  this 
symptom. 

The  Iddneys,  like  the  liver,  were  also  much  increased  in  size,  some- 
times weighing  even  twice  their  normal  weight.  The  parenchyma  was 
found  soft  and  flabby,  the  cortical  substance  widened  and  filled  with 
cloudy  swelling,  the  vessels  and  the  Malpighian  corpuscles  for  the  most 
part  pale.  In  other  cases  the  cloudy  swelling  was  found  for  the  most 
part  in  the  straight  tubules.  There  were  found,  besides,  more  or  less 
abundant  dark  red  spots  specially  numerous  near  the  surface  ;  and, 
converging  thence  in  a  radiating  manner  towards  the  papillae,  they 
could  be  traced,  as  red  or  brown  spots  or  stripes,  deeply  into  the  tissue 
of  the  pyramidal  substance.  On  microscopic  examination  it  was  found 
that  not  only  were  the  tubuli  more  or  less  fatty,  but  also  that  the  lumen 
of  the  urinary  tubuli  was  filled  partly  with  transparent  fibrinous  material, 
and  partly  with  haemorrhagic  clots  in  the  most  diverse  stages  of  colora- 
tion. For  the  most  part  these  were  met  with  in  the  under  parts  of  the 
tubuli  contorti  and  of  the  loops  of  Henle ;  the  haemorrhages  were  often 
found  also  between  the  capsule  of  Bowman  and  the  interlacings  of  the 
vessels  of  the  glomeruli.  And  as,  besides  these  conditions,  an  abundant 
infiltration  of  small  cells  was  found  in  the  interstitial  tissue,  all  the  ana- 
tomical conditions  were  evidently  present  for  the  subsequent  onset  of 
Bright's  disease. 

In  the   lungs  were  found  marks  of  hepatisation  and  pneumonic 


958  SYSTEM   OF  MEDICINE 

infiltration ;  also  in  some  cases  bronchiectasis  and  bronchitis.  In  others 
old  apical  cheesy  and  chalky  deposits  were  found  which  might  or  might 
not  have  been  caused  by  the  disease. 

The  condition  of  the  hJood  of  patients  suffering  from  relapsing  fever 
was  related  to  the  organism  found  to  be  present  in  the  disease,  and  has 
been  dealt  with  under  the  bacteriology. 

The  changes  in  the  hones  caused  by  relapsing  fever  were  mainly  a 
simple  fattiness  or  reddening  of  the  marrow.  In  some  cases  the  diaphy- 
ses  and  epiphyses  of  the  thigh-bones  or  humeri  showed  yellowish  white 
infarcts  of  irregular  spotty  character  and  varying  in  size  from  that  of  a 
hemp  seed  to  that  of  linseed.  Sometimes  they  were  discrete,  sometimes 
united  by  thin  bridges  to  coarser  infiltrations. 

Treatment.  —  I  think  it  may  be  taken  as  pretty  certain  that  no  remedy 
essentially  modifies  the  course  of  the  disease.  E-elapsing  fever,  appar- 
ently, has  its  invasion,  its  primary  five,  seven,  or  nine  days'  fever,  its 
intermission,  and  its  relapse,  in  spite  of  all  the  resources  of  art.  Some 
symptoms  may  be  modified,  but  not  apparently  the  great  features  of  the 
disease.  Thus  several  antiperiodics  were  used,  without  enabling  me  to 
prevent  the  occurrence  of  the  relapse.  The  headache  and  arthritic  pains 
were  very  severe,  and  though  both  were  sometimes  relieved  by  alkalies, 
it  was  often  necessary  to  have  recourse  to  opium.  Colchicum  seemed  to 
have  no  effect  on  the  pains.  The  persistent  and  distressing  vomiting  was 
very  difl&cult  of  alleviation.  Sometimes  the  effervescing  draught,  with  or 
without  hydrocyanic  acid,  was  of  service  ;  sometimes  relief  Avas  obtained 
by  the  administration  of  small  and  freqnent  doses  of  ipecacuanha,  some- 
times by  sinapisms  to  the  epigastrium ;  and  in  some  cases  all  these 
resources  were  unavailing  till  the  patient  found  relief  in  the  natural  issue 
of  the  disorder. 

A.  Rabagliati. 
REFERENCES 

1.  Rutty.  Chronoloqical  History  of  the  Weather,  Seasons,  and  Diseases  in  Dithlin 
from  1725  to  1705.  —  2.  "Review  on  Epidemic  Fever,"  Edinburgh  Medical  and  Surgical 
Journal,  xiv.  181S.  —  .3.  Clutterbuck.  Observations  on  the  Preventio7i  and  Treatment 
of  the  Epidemic  at  present  prevailing.  London,  1819.  —  4.  Hartz.  Historic  Sketch  of  the 
Causes,  Progress,  Extent  and  Mortality,  of  the  Contagions  Fever  in  Ireland  during  the 
years  1817-19.  Dublin,  1820. — 5.  Barker  and  Cheyne.  Account  of  the  Fever  lately 
Epidemical  In  Ireland.  London,  1821.  —  fi.  Graves  and  Stokes.  Description  of  the 
Yellow  Fever  at  Dublin  in  1826.— 7.  Alison,  W.  P.  "Observations  on  the  Epidemic 
Fever  now  prevalent  among  the  Lower  Orders  in  Edinburgh,"  Edinburgh  Medical  and 
Surgical  Journal,  xxviii.  1827.  —  8.  Reid,  John.  "Statistics  and  Pathology  of  the 
Continued  Fever  of  Edinburgh,"  Edinburgh  Monthly  Journal  of  Medical  Sciences, 
1842. — 9.  Henderson,  W.  "On  some  of  the  Characters  which  distinguish  the 
present  Epidemic  Fever  from  Tyjihus,"  Edinburgh  Medical  and  Surgical  Journal, 
1844:. — 10.  Various  articles  in  the  Edinburgh  Medical  and  Surgical  Journal  in  1843 
and  1841;  also  in  the  Scottish  and  North  of  England  Medical  Gazette  for  those  years 
by  H.  D.  S.  GooDSiR,  Craigie,  Alison,  Arnott,  W.  Henderson,  J.  Rose  Cormack, 
W.  Reid,  Gibson,  Kilgour,  Jackson,  Spittal,  Halliday  Douglas,  etc.,  etc. — 
11.  CoRRiGAN.  Famin"  and  Fever.  Duiblin,  1847.  — 12.  Bottomley.  Famine  Fever 
at  Croydon.  — 13.  Die  Hungerpest  in  0berschlesi°7i.  Mannheim,  1848.  — 15.  Jenner,  W. 
"  On  the  Identity  or  non-Identity  of  the  Specific  Cause  of  Typhoid,  Typhus  and 
Relapsing  Fever,"  Med.-Chir.  Transactions,  vol.  xxxiii.,  also  Edinburgh  Monthly 
Journal  of  Medical  Sciences,  1849-50. — 16.   Zuelzer,  W.     Der  Recurrirende  Typhus 


RELAPSING   FEVER,    OR   FAMINE   FEVER  959 

in  St.  Petersburg.  Berlin,  1867. — 17.  Virchow.  On  Famine  Fever.  London,  1868. 
English  Translation.  — 18.  Hallter,  E.  Parasitologische  Untersuchungen  bei  Masern, 
Hangertyphu.'i,  etc.  Leipzig,  18L)8.  — 19.  MtrECHisoN.  "The  Re-appearance  of  Relaps- 
ing Fever  in  England,"  iartcef,  ii.  503,  1S69. — 20.  Clark,  H.  "On  Relapsing  Fever 
in  India,"  Indian  Annals  of  Medical  Science,  January  1869.  —  21.  Wyss  and  Bock. 
Studien  liber  Febrls  I'ecnrrens.     Berlin,  1869.  —  Oberjieieb,   Pastau,  Pribram  and 

ROBITSCHEK,  also   EsTLANDLER,  HUPPERT,  SCHULTZEN   aud    RiESENFELD,  all  Wrote  OU 

Relapsing  Fever  in  18l>9.  In  1870,  Liecert,  Breslau ;  Frantzel,  C.  Muirhead, 
Edinburgh  ;  Clymer,  New  York  ;  Clark,  New  York  ;  Parry,  Philadelphia,  wrote  on 
this  Fever. — 22.  Murchison.  "The  Period  of  Incubation  of  Typhus,  Relapsing 
Fever,  and  Enteric,"  St.  Bartholomew's  Hospital  Reports,  vol.  ii.  —  23.  G.  P.  Tenxent 
on  "Relapsing  Fever,"  Glasgow  Medical  Journal,  May  1871.  —  24.  Lyons,  on  R'-dapis- 
ing  Fever.  London,  1872.  —  25.  Obermeier,  O.  "  Vorkonimen  feiuster,  eine  Eigen- 
hewegung  zeigende  Ftiden  im  Blute  von  Recurrens  Kranken,"  Centralhlatt  fiir  Med. 
Wis.nensch.  181)3,  No.  10.  Beside  the  above  authors,  various  German  writers  wrote  on 
Relapsing  Fever  in  Silesia,  Berlin,  Breslau,  etc.,  among  whom  may  be  mentioned  — 
26.  Dr.  PoNFiCK.  Anatomische  Studien  iiber  den  Typhus  Recia-rens ;  Virchow's 
Archiv,  Bd.  Ix.  Hft.  2,  and  Griesinger,  Azema,  Hermann  and  Kuttner,  St.  Peters- 
burg, 1865 ;  Kernig,  and  Dr.  Carter,  Lancet,  1879  and  1880. 

A.  E. 

1.  Obermeier.  Centralblattf.  d.  med.  Wissensch.  1873,1:^0.  10;  and  Berliner  klin. 
Wochenschr.  1873, 'No.  35.  — 2.  Koch.  Deutsche  med.  Wochenschr.  1879.  —  3.  Vandyke 
Carter.  Med.  Chir.  Trans.  London,  1880,  2nd  series,  xlv.  pp.  7,  148;  and  Trans. 
Internat.  Med.  Congress.  London,  1881,  p.  334. — 4.  Metschnikoff.  Virchow's  Archiv, 
cix.  1887,  p.  176.— 5.  Soudakewitch.  Ann.  de  I' Inst.  Pasteur,  v.  1891,  p.  545.  —  6. 
Heydenreich.    Der  Parasit.  des  R'dckfallstyphus.    Berlin,  1877. 

F.  F.  W. 

P.S.  — On  Dr.  Wesbrook's  departure  for  Minneapolis,  Dr.  Kanthack 
most  kindly  undertook  the  revision  and  correction  of  the  proof  of  the 
section  on  the  Bacteriology  of  Eelapsing  Fever,  and  of  the  corresponding 
references.  —  Ed. 


LIST    OF    AUTHORITIES 


Abel,  895 

Abelous,  168 

Ackerley,  R.,  209 

Adami,  511 

Addison,  T.,  168 

Addison,  W.,  104 

Aitken,  903 

Alessi,  548,  801 

Alison,  792 

Allbutt,  Clifford,  18,  688,  788 

Althaus,  687 

Anderson,  808 

Andrew,  264  {note) 

Araki,  187  (mite) 

Aretseus,  731,  747  {note),  917 

Arloing,  2-54 

Armstrong,  652 

Amino;,  5:^6 

Arnold,  100 

Arnott,  Neil,  307 

Aronsohn,  154,  754 

Avicenna,  923  {note) 

Babes,  563.  628 

Bake  well,  K.  H.,  261 

Ballard,  656 

Balzer,  175 

Bamberger,  627 

Barfarth,  118  {note) 

Barker,  Fordyce,  635,  662 

Barkley,  632 

Barlow,  H.  C,  791 

Barlow,  T.,  165,  371 

Barnes,  H.,  927  {note) 

Barr,  James,  851 

P.arry,  de,  70,  129,  509 

Barthez,  220 

IJassier,  402 

Baswell,  854 

Bauer,  180 

Baurngarten,  88,  554 

Baxt?;r,  27 

r.egbie,  950 

Heliring,  80,  563  et  seq.,  580  et  seq. 

754,  709  et  seq.,  885 
BelfantJ,  820 
IJcnnet,  Henry,  264 
Bennet,  Hughes,  945 

VOL.    I 


Bergeon,  .302  {note) 

Berkley,  H.  J.,  109 

Bernard,  Claude,  163, 223,  302  (note),  495 

Berry,  J.,  401 
Bert,  Paul,  273,  301 
Bertillon,  30 
Berton,  .303 
Beumer,  801 
Bishat,  222 
Biden,  262 
Biggs,  6.32 
Billroth,  156,  615 
Binet,  37 

Birch-Hirschfeld,  554,  628 
Bischoff,  323 

Blagove.stchewsky,  -544,  552 
Blake,  223 
Blakeney,  25  {note) 
Blanche,  382 
Blocqui,  829 
Blunt,  254 
Blyth,  Wynter,  657 
Bochefontaine,  892 
Boerhaave,  219,  601 
Boginsky,  755 
Bonom6,  603,  629,  675 
Booker,  723 
Bordet,  85,  886 
Bordier,  22,  32 
Bordene-Uffreduzzi,  675 
Borel,  81.  936 

Bouchard,  167,  562,  582,  793,  851 
Boudin,  22,  47,  492 
Bouillaud,  627 
Boulting,  690 
Bouveret,  821 
Bowditch,  24  {note),  255 
Bowles,  254 
Boxall,  637 

Bramwell,  Byrom,  628,  782 
Brand,  347,  845,  849 
Brandt,  383,  792 
Braun,  681 
717,       Brehmer,  276 

Bretonneau,  420,  701.  731,  791 
Brieccer,  521  et  seq.,  588,  723,  766,  796, 

893 
Bris.saud,  633 
961  3  Q 


962 


SYSTEM   OF  MEDICINE 


Bristowe,  627 

Broadbent,  W.,  852 

Broca,  29,  32 

Brodie,  Gregor,  212 

Brouardel,  845 

Broussais,  221 

Brown,  221 

Brown-S^quard,  168,  377 

Brunner,  770 

Briinton,  Lauder,  377,  466,495,  530,914 

Buchan,  A.,  258 

Buchanan,  G.,  24  (note),  255 

Buchner,  89,  254,  514  et  seq. 

Budd,  791 

Buhl,  807 

Bujwid,  552,  880 

Bulard,  926 

Bunge,  164,  377 

Burdon-Sanderson,  55,  314,  589,  662 

Burkart,  631 

Buschelt,  800 

Buschke,  769,  800 

Butlin,  215 

Buzzard,  688 

Cabiadis,  928  (note) 

Cahn,  821 

Caiger,  585 

Calraette,  5(54  et  seq.,  936 

Canal  is,  548 

Candolle,  de,  27 

Canney,  267 

Canon,  ()94 

Cantlie,  929  et  seq 

Card,  725 

Caretti,  782 

Carle,  759 

Carter,  949 

Castelnau,  601 

Caton,  846 

Cattani,  89,  551,  578,  760,  914 

Caylev,  628,  849 

Celli,  674 

Champneys,  751 

Chantemesse,  795  et  seq. 

Charcot,  37,  172,  627 

Charles,  283 

Charrin,  129,  158,  548 

Chauffaro,  S2  1 

Chauveau,  566 

Chervier,  32 

Chevers,  897 

Christison,  Hobert,  945 

Claussen,  895 

Clot  Bey,  926 

Clanny,  307 

Clarke,  Lockhart,  788 

Coats,  793 

Cobbett,  131 

Coen,  118 

Cohn,  523,  767 

Cohnheim,  65,  104,172,  205 


Coley,  216 

CoUignon,  29,  32 

Collins,  Treacher,  197 

Colvill,  925  et  seq. 

Cornil,  116,  620,  628,  638,  840 

Corrigan,  949 

Councilman,  70,  123 

Coupland,  631 

Coxwell,  552 

Creighton,  690,  701,  918 

Crombie,  904 

Crum-Brown,  225 

Cruveilhier,  601,  636 

Cullen,  220,  865 

Cunningham,  1).  D.,  612,  621,  881  et  seq 

Curling,  776 

Currie,  792,  849 

Curt  Braem,  795 

Cygnseus,  801 

Dalton,  301 

Damalix,  377 

Dance,  601 

D'Arcet,  602 

Darwin,  21,  555 

Davidson,  268,  876 

Dfijerine,  172,  728 

Dekpine,  805 

Demoor,  80  (note) 

Deneke,  879 

Denison,  274 

Denman,  635 

Denys,  90 

Desplats,  627 

Desportes,  776 

Dessy,  628 

Devignac,  821 

Dickinson,  W.  H.,  788 

Dietrich,  819 

Disselhorst,  106 

Donders,  377 

Downes,  254 

Drasche,  845 

Dreschfeld,  628 

Duchenne,  184 

Duclaux,  523 

Ducrest,  601 

Duenschmann,  81 

Dufourt,  824 

Dugues,  627 

Duguet,  821 

Dunbar,  808,  883  et  seq. 

Duncan,  Matthews,  486,  594 

Dunham,  880 

Durham,  H.  E.,  887 

Dutrochet,  104 

Eberth,  792  et  seq. 
Eccles,  S.,  377 
Edinger,  179  (note) 
Edwards,  VV.  F.,  253 
Egger,  273 


LIST   OF  AUTHORITIES 


963 


Ehrlich,  77,  564  at  seq..  Ill,  825 

Ehrenber2:,  249 

Eichhorst;  818 

Eischel,  689 

Eisenlohr,  829 

Eisner,  798  {note) 

Emmerich,  891 

Engelmann,  58 

Eppinger,  818 

Erb,  184 

Erichsen,  609 

Ernst,  800 

Eschericli,  789,  796 

Eulenberg,  382 

Everard,  80  {note) 

Ewald,  169 

Ewing,  729 

Faber,  K.,  760 

Fagge,  173,  811 

Farr,  William,  13,  47 

Faure-Miller,  H.,  348 

Fayrer,  251 

Fehleisen,  216,  615 

Fenwick,  Soltau,  782,  843 

Fermi,  549,  552 

Ferniteld,  631 

Ferrati,  798 

Ferult,  828 

Fiessinger,  631 

Fileliiie,  125,  155 

Finkler,  879 

Fiiilayson,  7 

Finsen,  N.,  254 

Fischer,  118 

Fitz,  175 

Flexner,  602,  665 

Flint,  823 

Flugge,  554,  807,  879 

Foa,  211,  551,  675 

Fodor,  von,  88,  563,  568,  711,  801 

Fonsangrives,  256 

Fosbroke,  713 

Fox,  Wilson,  292 

Francis,  C.  R.,  266,  923 

Frankel,  522,  570,  658,  723,  767 

Frankel,  A.,  801 

Frankel,  C,  886 

Frankel,  E.,  628,  801 

Frankland,  E.,  148,  249,  529 

Eraser,  225,  564,  583 

Freuiid,  579 

Freymuth,  892 

Friedlander,  629,  658,  673 

Friedrich,  627,  888 

Friis,  074 

Frosch,  723,  726 

Fuller,  738  (note) 

Gamritsciiewhki,  82,  729 
Gaffky, 793 
Galen,  635 


Galton,  Francis,  37 

Gainaleia,  626,  725,  880 

Gartner,  555 

Gaspard,  588 

Gaule,  186 

Gautier,  350 

Gee,  756 

Geigel,  153 

Gergens,  110 

Gerhardt,  814 

Gerst,  377,  380 

Gervis,  676 

Gesenius,  845 

Gilbert,  628,  801  ei  seq- 

Girode,  801  ( 

Giuffre,  674 

Glenard,  F^  347 

Gley,  167 

Glovetzky,  377  i 

Gluziuskd,  832 

Goldscheider,  770i 

Golgi,  181,  831 

Goltz,  169  (note) 

Gombaiilt,  728 

Gompertz,  13 

Godall,  725 

Godell,  3^4 

Goodhardt,  377,  628 

Gordon,  Samuel,  667 

Gottlieb,  R.,  155 

Gowers,  382,  687 

Graves,  681,  792,  823  . 

Grawitz,  70,  129 

Green,  George,  696 

Greenwood,  M.,  57 

Gressweli,  D.  A. ,  705 

Griesinger,  823,  903 

Griffiths,  Joseph,  118  (weie) 

Grimshaw,  671 

Grohmann,  568 

Gross,  759     • 

Grosz,  679 

Gruber,  884 

Gubler,  826 

Gueniot,  639 

Gulland,  80 

Gumprecht,  769 

Gunther,  601 

Haeckel,  61 

Haffkine,  659,  869  et  seq. 

Hahn,  166 

Hahnemann,  221 

Haller,  Albert  von,- 220,  588 

Halliburton,  89,  174,  212 

Hamilton,  185,  192  (Jigs.) 

Hammer,  254 

Hnnau,  207 

Handford,  840 

Hankin,  89,  522,  568,  676,  888 

Hanson,  Armauer,  555 

Hardy,  Ralph,  8 


964 


SYSTEM   OF  MEDICINE 


Hardy,  W.  B.,  60  ef  seg.,  132 

Harley,  John,  4G1 

Harvey,  636 

Hassall,  306 

Hasterlik,  891 

Havel,  90 

Haviland,  24  {'note),  210 

Hayeiii,  340,  627,  845 

Hayne,  Louis,  696 

Hayward,  756 

Hecker,  917 

Heiberg,  628 

Heidenhain,  96,  152 

Helmont,  von,  218i 

Henderson,  940,  950 

Hensch,  720 

Hergt,  875 

Hericourt,  582 

Herwerden,  675 

Heubner,  720 

Hewetson,  826 

Heydenreich,  951 

Higgens,  688 

Hiidebrandt,  577,  800 

Hildsbrandt,  von,  791 

Hippocrates,  46,  246,  635,  941 

Hirsch,  22,  658  et  seq.,  875,  918 

Hirschler,  628,  629  ' 

His,  109 

Hoelscher,  823 

Hoffinger,  379 

Hoffmann,  219       ■ 

Hofmann,  97  {note} 

Hobnfeldt,  70 

Holz,  798  {note) 

Hook,  van,  854 

Hooper,  50D 

Houz^,  31  {note) 

Hovell,  624 

Huchard,  121 

Hunter,  John,  122,  161,  601 

Huppe,  509,  562,  879,  888 

Huppert,  146 

Hiiter,  55,  129 

Hutinel,  830 

Huxham,  691 

ISSAEPF,  886 

Jaccoud, 631 

Jacob,  713 

Jacobs,  64 

Jackson,  304 

Jackson,  Keeves,  383 

Jacobson,  154 

Jaff^,  674 

Jaksch,  von,  852 

Janeway,  853 

Janowsky,  795 

Jenner,  William,  315,  559,  791,  849 

John  of  Gaddesden,  254 

Johne,  555 


Johnston,  Alex.  Keith,  47 
Johnstone,  J.,  745  {note) 
Jones,  Wharton,  77 
Josseraut,  628,  629 
Junod,  306 
Jurgensen,  851 

Kant,  36,  38 

Kanthack,  78,  132,  503  {note),  726,  756, 

773 
Karlinski,  800,  895 
Kaupp,  323 
Kernig,  6(i6  {note) 
Kircher,  Athanasius,  702  {note) 
Kirkes,  627 
Kirkland,  636 
Kitasato,  563,  694,  760,  797,  890,  920  et 

seq. 
Klebs,  110,  205,  566,  628,  702,  717,  808 
Kleen,  380 
Klein,  377,  507   et  seq.,  581,   655,  694, 

709  et  seq.,  797  et  seq.,  882 
Klemperer,  667,  831,  886  et  seq. 
Klemperer,  G.,  894 
Klipstein,  764 
Koch,  156,  212,  254,  510,  544,  589.  615, 

759,  793,  878  et  seq.,  951 
Koester,  628,  633 
Kolisko,  723 
Kolliker,  198 
Komelevsky,  P.  A.,  254 
Korczynski,  832 
Kossel,  90,  577 
Kowalewsky,  189 
Kraepelin,  37 
Krafft,  117 
Kraus,  192,  624,  854 
Kraus,  F.,  145 
Kronecker,  377 
Krukenberg,  57 
Kiibler,  770 
Kiihne,  157 

Lacassagne,  256 

Ladenberg,  227 
Laennec,  303 
Lancereaux,  167,  627 
Landgraf,  818 
Landouzy,  554,  817 
Lange,  314 
Langlois,  168 
Larat,  350 
Lassar,  377 
Latham,  A.  C,  795 
Latham,  P.  M.,  731  {note) 
Lavdowsky,  105 
Lave  ran,  844 
Lazarus,  798  {note) 
Leared,  260,  266 
Leber,  70  et  seq.,  521 
Leborius,  794 
Le  Dantec,  57 


LIST   OF  AUTHORITIES 


965 


Lee,  Henry,  304 

Lehman,  144 

Leichtenstern,  675 

Leitz,  800 

Leloir,  172,  196 

Lenhossek,  181  (note) 

Leopold,  6o8 

Lepp,  563 

Lesage,  888 

LetuUe,  97  {note) 

Leva,  631 

Lewin,  818 

Lewis,  879,  904 

Leyden,  825,  829 

Lickfelt,  892 

Liddon,  Edward,  35 

Liebermeister,  173,  816,  923 

Liebig,  324 

Limbeck,  von,  132 

Ling,  335 

Lingard,  821 

Lion,  628 

Lion,  G.,  628 

Lister,  Joseph,  103,  249,  592,  602 

Litteii,  187,  193,  628 

Lloyd,  E.  L.,  730 

Loeb,  60 

Loewy,  145 

Loffler,  509,  547,  702,  717,  880 

Lombard,  22,  377 

Longmore,  280 

Longstaff,  704 

Lotze,  38 

Low,  Bruce,  710 

Lubarsch,  89,  560 

Luff,  796 

Lukomsky,  615 

Lustig,  805 

Macaigne,  888 
Macalister,  D.,  159 
Macfadyen,  513,  530 
Maclean,  492 
Macnamara,  759,  871 
Mafucci,  555,  557 
Magendie,  223 
Maggiora,  377 
Makehani,  13 
Malibran,  631 
Mannaberg,  629 
Manson,  27,  503  {note) 
Maragliano,  152,  583 
Marcet,  260,  316 
Marcliand,  118 
Marches!,  761 
Marchiafava,  674 
Marie,  181 

Miiriotti,  Hiaiiclio,  802 
Marti  I  a,  631 
Martin,  Ranald,  251 

Martin,  Sidney,  121, 189,  521  at  seq.,  634, 
717  (it  seq. 


Mason,  826 

Massa,  601 

Massart,  80  (note) 

Masson,  166 

Mathieu,  631 

Matches,  158 

May,  147 

Mayer,  149 

M'Clintock,  577 

McDowell,  676 

M'Lean,  Russell,  657 

Mehu,  97  (note) 

Meier,  R.,  628 

Meigs,  V.  A.,  413  (note) 

Meisels,  800 

Melloni,  249 

Mering,  von,  167 

Merkel,  554 

Mesnil,  78  (note),  91 

Metschnikoff,  57  et  seq.,  82  et  seg.,  211, 

237,  562  et  seq.^  842,  887  et  scq.,  951 
Meyer,  728,  729 
Mezger,  377 
Michel,  L^vy,  256 
Miller,  879 
Minkowski,  166 
Mirto,  675 
Mitchell,  522 

Mitchell,  Weir,  294,  377,  397 
Moleschott,  253 

Montagu,  Lady  M.  Wortley,  559 
Moore,'  J.  W.,  822 
Moos,  668  (note) 
Morax,  797 
Morgagni,  222 
Moritz,  88 
Morpargo,  548 
Morris,  811 
Morse,  729 
Mosengeil,  von,  377 
Moser,  816 
Mosso,  152,  377 
Mott,  F.  W.,  178  (note) 
Moson,  171,  627 
Miiller,  J.,  140,  554 

Murehison,  166,627,  792  etseg.,  MO etseq. 
Murphy,  Shirley,  708 
Murray,  303,  307 

Nageli,  504 
Naunyn,  146,  187 
Nencki,  166,  527 
Netter,  628,  629,  631 
Nettez,  674 
Neuhans,  800 
Neumeister,  523 
Newman,  800 
Nicolaier,  760 
NicoUe,  797 
Nienieyer,  P.,  266 
Nissen,  89 
Nikiforoff,  118 


966 


SYSTEM  OF  MEDICINE 


Nissen,  5G3 
Noeggeratli,  211 
Nothnagel,  154 
Nunneley,  613 
Nuttall,  88,  563,  568 

Obermeier,  950 

Oemler,  551 

Oergel,  892 

Oertel,  805,  316,  334,  702 

Oesterlen,  22 

Ogle,  J.  W.,  627,  631 

Ogston,  677 

Oliver,  G.,  168 

Orth,  547,  680 

Osier,  348,  628  et  seq.,  813  {note) 

Page,  David,  713 

Pagenstecher,  377 

Paget,  James,  113 

Paitauf,  723 -'  • 

Panum,  313,  588,  792 

Par6,  Ambrose,  601 

Parkes,  E.  A.,  140,  251,  460,  492,  903 

Parry,  778 

Parsons,  H.  F.,  657,  692 

Pasquale,  884 

Pasteur,  125,  249,  549,  559,  566,  768 

Pawlow,  166 

Peiper,  801 

Pekelliaring,  85 

Peinbrey,  159 

Pepper,  661  {note} 

P6r^,  798 

Pernice,  548 

Perret,  629 

Perry,  791 

Peter,  631,  792 

Petruschky,  549,  798 

Pettenkofer,  248,  807,  881 

Pfeffer,  58 

Pfeiffer,  582,  694,  885  et  seq, 

Pfeiffer,  Ludwig,  211 

Pfeiffer,  R.,  92,  808 

Pfliiger,  250 

Pfuhl,  794 

Philippe,  738  {note) 

Phillips,  Sydney,  382,  81? 

Pisenti,802 

Pitcairn,  A.,  218 

Pitres,  172 

Platen,  von,  253 

Playfair,  377,  383 

Podwyssozki,  118 

Poehl,  880 

Port,  257  {note) 

Potain,  816 

Power,  d*Arcy,  208 

Power,  W.  H.,  705 

Prior,  879 

Profanter,  377,  383 

Prudden,  628.  795 


Prus,  926 
Purcer,  628 
Purjez,  813  {note) 
Puzos,  635 

QUEYRAT,  554 

Quincke,  H.,  253 

Rabot,  738  {note) 

Radcliffe,  Netten,  870 

Ramon  y  Cajal,  181  {note) 

Ramsay,  A.  C,  49 

Randolph,  666 

Ransome,  A.,  254 

Rasori,  221 

Rattone,  759 

Recklinghausen,  von,  615 

Regnard,  515 

Reibmayr,  379 

Reichert,  522 

Reinke,  57 

R6my,  797 

Rennie,  920 

Renzi,  de,  555 

Reuss,  97  {note) 

Ribbert,  90,  602,  628,  696 

Richard,  795 

Richards,  Percy,  189  {note) 

Richardson,  Benjamin,  672  {note) 

Richet,  582 

Richie,  819 

Richmond,  James,  793 

Richter,  155 

Rieder,  78 

Rindfleisch,  77,  101,  554 

Ringer,  146 

Roberts,  William,  632 

Robin,  826 

Rochard,  256 

Rockwell,  371 

Rodet,  548,  629,  792 

Roehrig,  342 

Roger,  106,  111,  544  et  seq. 

Rohden,  256 

Rolleston,  175 

Romberg,  109 

Rose,  782 

Rosenbach,  O.,  617,  628,  760 

Rossignol,  460 

Rotch,  416 

Rouget,  764 

Routh,  Amand,  639 

Roux,  82,  254,  522  et  seq.,  628,  717  et 

seq.,  766,  792,  886 
Roy,  123  ■  ■ 

Rubner,  149 
Ruffer,  80  {note),  211 
Rufus,  of  Ephesus,  917 
Rumpel,  887 
Rumpf,  854,  889 
Riitimeyer,  110 
Rutty,  941 


LIST   OF  AUTHORITIES 


967 


SabolotnYj  891 

Sacchi,  548 

Sachs,  154 

yaeiiger,  628 

Salkowski,  880 

Salmon,  560,  770 

Salsaiio,  549,  552 

Salu.s,  891 

Samuel,  110 

Saiiarelii,  88,  801,  886  et  seq. 

Sander,  546 

Sausom,  683,  690 

Saundby,  689 

Saunders,  279 

Saussure,  de,  248 

Sawtschenko,  551,  891 

Scabia,  551 

Schafer,  168 

Scharrenbroich,  283 

Scheuer,  340,  346 

Schiff,  140,  167 

Schild.  798 

Schmelz,  818 

Schmidt,  A.,  85,  157 

Schmiedeberg,  236 

Scholl,  526,  892 

Schott,  335 

Schroter,  819 

Schultze,  Max,  77 

Schulze,  829 

Schwann,  249 

Scudamore,  303 

Seitz,  795 

Sellers,  843 

St  Imi,  588 

Semmelweiss,  636 

Senator,  142 

Senftleben,  63 

Senger,  628 

Severini,  110 

Shattuck,  831 

Sherrington,  78,  130,  169,  178  {note) 

Siawcillo,  81 

Silvestrini,  815 

Simmonds,  801 

Simon,  J.,  460,  670 

Simon,  II.,  684 

Simpson,  James,  637,  759,  769 

Sinkler,  377 

Siredey,  817 

!-'irotinin,  801 

Sniellie,  035 

Smith,  Archibald,  275 

Smith,  F.,  560,  770,  797 

Smith,  R.,  Angus,  252,  301 

Snow,  870 

Sobernlieim,  890 

Soudake witch,  211,  951 

Spittal,  940 

Sprague,  4H3 

Springthorpf;,  391 

Stahl,  58,  219 


Steell,  631,  835 

Stembo,  315 

Stenhouse,  226 

Stephens,  J.  W.  W.,  723,  756 

Stern,  628,  808 

Stewart,  37,  791 

Stewart,  T.  Grainger,  689 

Stich,  732 

Stills,  661  (note),  665 

Stoerk,  223 

Stokes,  303,  792,  816,  949 

Stokvis,  20 

Stoll,  738 

Stott,  632 

Straus,  70,  129 

Stroganoff,  800 

Strpolansky,  800 

Strumpell,  623,  663  {note),  666 

Stutzer,  415 

Sugg,  797 

Sultan,  800 

Sutton,  Bland,  198 

Svensdeu,  254 

Swieten,  van,  636 

Sydenham,  218 

Sylvius,  218 

Symonds,  C.  J.,  401 

Taylor,  F.,  628,  826 

Teissier,  853 

Terray,  825  {note) 

Thayer,  W.  S.,  817 

Thiroloix,  633 

Thomas,  123,  259,  283 

Thompson,  681,  845 

Thompson,  Symes.  279 

Thomson,  A.  T.,  303 

Thomson,  Theophilus,  701 

Thorne,  Thorne,  807 

Thucydides,  917 

Thudichum,  905 

Tizzoni,  89,  551,  578,  700 

Todd,  792 

Tomkins,  851 

Toner,  J.  M.,  272 

Topinard,  29 

Toupet,  116 

Tourdes,  667 

Traube,  88 

Tripier,  845 

Trousseau,  613,  747  {note),  823 

Truchot,  352 

Tsuboi,  892 

Tubini,  253 

Tufnell,  400 

Tunnicliffe,  377 

Tyndall,  248 

UOIIETTI,  674 

Unna,  196,  254 
Uschinsky,  524 


SYSTEM  OF  MEDICINE 


Vaillakd,  172,  552,  570,  585,  629,  764 

.    et  seq.,  817 

Vauderkindere,  31  (note) 

Van  der  Velde,  90 

Vaquez,  817 

Vaughan,  89,  577 

Velpeau,  613 

Viault,  273 

Vincent,  552,  764,  802 

Virchow,  95,  161,  177,  202,  556,  601,  627 

905 
Vivenot,  von,  256,  313 
Voges,  52() 
Vogl,  845 

Voit,  186,  :;23,  392,  460 
Volkmann,  615 
Voltolini,  668  (note) 
Vulpian,  627 

Wagner,  821 

Waldsteiii,  730 

Wall,  899  et  seq. 

Waller,  104,  162 

Walshe,  256 

Walton,  320 

Ward.  Marshall,  254,  514 

Warden,  950 

Warington,  529 

Washbourn,  674,  695,  725 

Wassermaiin.  796 

Wassiljeff,  852 

Waters,  2(>9 

Watson,  T.,  698 

Watt,  F.  M.,  38T 

Webb,  Law,  209 

Weber,  103 

Weber,  E.  H.,  140 

Weber,  Otto,  156 

Wedel,  628 

Weibel,  891 

Weichselbaum,  628  et  seq.,  658,  891 

Weigert,  174 

Weil,  813  (note) 

Weintrand,  820 


Weir  Mitchell,  vide  Mitchell 

Weiss,  J.,  77  (note) 

Weissmann,  40,  558 

Welch,  530,  574,  721,  755 

Welsh,  950 

Wendland,  814 

Wernher,  613 

Wernicke,  563 

Wesbrook,  526,  893 

Weyl,  766 

White,  J.  Bagen,  927  (note) 

Whittle,  676 

Widal,  674,  795 

Wilks,  171,  591,  627,  685,  903 

Williams,  C.J.  B.,  315 

Williams,  C.  T.,  250 

M'illiams,  Roger,  35 

Willis,  218 

Winge,  627 

Winogi-adski,  529 

Winternitz,  340,  377 

Wood,  H.  C,  154,  495 

Woodhead,  793 

Wooldridge,  577 

Wratch,  800 

Wright,  J.  H.,  723 

Wunderlich,  812 

Wundt,  38 

Wurlz,  798 

Wyssokowitsch,  547,  628,  808 

Yeo,  B.,  853 

Yersin,  522,  717  et  seq.,  920  et  seq. 

Youatt,  21 

Zabludowskt, 377 

Zenker,  175 

Ziegler,  117,  192 

Ziemec,  831 

Ziemssen,  von,  257  (note),  347,  377,  662 

et  seq.,  856 
Ziilzer,  822 
Zuntz,  144 


INDEX 


Abscess,  experimental,  71 ;  metastatic, 
74 

Abscesses,  multiple,  587,  610 

Acetonaria  in  inanition  and  fever,  146 

Acne,  electric  treatment  of,  371  ;  diet 
in,  411 

Addison's  disease,  diet  in,  406 

Adipocere,  l!)2 

^soplui<;eal  obstruction,  feeding  in,  401 

Age  in  dosa2,e  of  drugs,  244, 

Agenesis,  178 

Ainhum,  27 

Air,  see  Atmosphere,  247 

Albuminuria  in  diphtheria,  736  ;  in  en- 
teric fever,  826  ;  in  phthisis  (climatic 
treatment  of).  287  ;  in  life  assurance, 
486 

Alcohol  in  diseases  of  children,  421  ;  in 
enteric  fever,  845  ;  in  puerperal  fever, 
649  ;  in  dietetics,  389 ;  indications  for, 
in  febrile  states,  390 

Alcoholism,  diet  in,  408 

Alexins,  5')9,  576 

Amenorrhoea,  compressed  air  bath  in, 
315 

Amphophile  cells,  79 

Ansemia,  balneo-therapeutic  treatment 
of,  334  ;  climates  for,  2!)4  ;  compressed 
air  bath  in,  315  ;  dietary  in,  405;  hy- 
dro-therapeutic treatment  of,  346  ; 
massage  in,  378 

Aneurysms,  dietary  in,  400 

Angina,  recurrent  pellicular,  743 

Anorexia  nervosa,  diet  in,  396 

Antliracosis,  197 

Anthropology  and  medicine,  21 

Anti-inim-obic  substances,  573 

Antitoxins,  565,  573  ;  specificity  of,  574 

Antipyretics,  155 

Aplasia,  178 

Apoplasmia,  132 

Apoplexy,  h^at,  see  Insolation,  491 

Argyria,  197 

Arin-i)li'thysmograph  in  fever,  156 

Artf'rial  degeneration,  dietary  in,  400 

Arthritis,  dietary  in,  409 


Arthritis,  traumatic,  massage  in,  379 

Arthrospores,  509 

Artificial  aero  therapeutics,  300  et  seq. 

Asthma,  climates  for,  293 ;  compressed 
air  bath  in,  316  ;  diet  in,  398 

Ataxia  \\i\X\  reference  to  life  assurance, 
486 

Atmosphere,  composition  of,  248  ;  diather- 
mancy of,  249  ;  humidity  of,  influence 
on  climate,  252  ;  qvialities  of,  247 

Atmospheres,  artificial,  300  ;  inlialation 
of,  301  ;  varying  in  barometric  press- 
ure, 306 

Atrophy,  dietary  in,  411;  from  disuse, 
178  ;  from  inherent  defect,  179 

Atrophy  of  cell  elements  of  glands,  184 

Bacilli,  507 

Bacteria,  506 

Bacterial  activity  in  disease,  533 

Bacterial  infection,  general,  534  ;  local, 
•534 

Bacterial  products,  517  ;  in  infective  proc- 
esses, 538 

Balneo-therapeutics,  338  ;  definition  of, 
318  ;  courses  of,  337  ;  seasons  for,  337 

Basophile  cells,  79 

Baths,  compressed  air,  310  ;  compressed 
air,  influence  of,  on  circulation,  313  ; 
influence  of,  on  respiration,  313  ;  elec- 
tric, 363,  368;  mercury,  304;  Roman, 
341  ;  sulphur,  304  ;  Turkish  and  Rus- 
sian, 341 ;  varieties  of,  340 

Bed- rests,  431 

Bed-sores,  432 

Bladder,  chronic  catarrh  of,  climates  for, 
294 

Blastomycetes,  505 

Bleeding  in  insolation,  499 

Blood  and  tissues,  acquired  properties 
of,  169  ;  inherited  properties  of,  169 

Blood,  anti-microbic  properties,  568  ;  the 
nutrient  fluid,  163 ;  proteids  essential 
to,  165 

Blood  serum,  bactericidal  action  of,  88  ; 
toxicidal 'action  of,  94 


909 


97° 


SYSTEM  OF  MEDICINE 


Blood-vessels,  their  part  in  inflammation, 

100 
Boils,  see  Furuncle,  G51 
Boils,  diet  in,  411 
Bronchitis,  climates  for,  293  ;  compressed 

air  bath  in,  315  ;  diet  in,  397 
Broussais,  his  theory  of  disease,  221 
Brown,  his  theory  of  disease,  221 
Buboes  in  plague,  929 

Calcareous  precipitation,  causes  of, 
194  ;  results  of,  195 

Cancer,  distribution  of,  22 

Cancer  of  the  stomach,  dietaiy  in,  403 

Cancrum  oris  in  enteric  fever,  820 

'Capillaries,  formation  of  new,  in  chronic 
inflammation,  lUl 

Carbuncles,  G54  ;  diet  in,  411 

Carcinoma,  auto-infection  of,  207  ;  chem- 
istry of.  212  ;  definition  of,  203  ;  Koch's 
postulates,  210  et  seq.;  transference 
of,  207  ;  treatment  of,  215 

Cardiac  failure  in  diphtlieria,  737 

Caseation,  175 

Catamenial  irregularities,  hydrothera- 
peutics  of,  340 

Cataphoresis,  351 

Catarrh,  conmion,  diet  in,  399  ;  hydro- 
therapeutics  of,  340 

Catheterisation,  437 

Cellulo-iiumoral  theory,  the,  89 

Cerebral  exhaustion,  climates  for,  294 

Cerebr.d  heat  centres,  153 

Cerebro-spinal  fever,  see  Meningitis, 
epidemic  cerebro-spinal,  G59 

Chemiotaxis,  58,  04;  "negative,"  86 

Chemiotropism,  04 

Chilblains,  electric  treatment  of,  371 

Children,  sleep  of,  470  ;  baths  for,  419  ; 
teeth  of,  465  ;  clothing  of,  4(i3  ;  diet 
and  therapeutics  of,  412  ;  diet  in  dis- 
ease, 418  ;  education  of,  physical,  467 
et  seq. ;  food  of,  404  ;  cubic  space  for, 
400 ;  habits  in,  400 ;  heights  and 
weights  of,  459,  465  ;  somnambulism 
in,  407  ;  country  air  for,  458  ;  athletic 
sports,  472  ;  work,  effects  of,  on  brain, 
468-470 ;  residence  for,  460,  402  ; 
physical  training  of,  461  ;  hereditary 
taint  in,  462 

Chlorosis,  dietary  in,  405 

Cholera  Asiatica,  aetiology  and  epidemi- 
ology, 869  ;  artificial  immunity  from, 
893  ;  laacterial  investigation  of  dejecta, 
890;  bacteriology,  878,  895;  bibliog- 
raphy, 915  ;  conditions  of  epidemics, 
875  ;  definition,  864  ;  diagnosis,  907  ; 
dietary  of,  395, 915  ;  history  and  geog- 
raphy of,  865  ;  hyperthermic  form  of, 
901  ;  individual  susceptibility  to,  871  ; 
:  mode  of  access,  809  ;  morbid  anatnuiy. 
902 ;     prognosis,     908 ;     prophylaxis. 


909  ;  sequelfe,  902  ;  spread  of  epidemic, 
873  ;  symptimis,  897  ;  theory  of,  9D6  ;. 
treatment,  908  et  seq.  ;  varieties  of,  900 

Cholera  nostras,  diet  in,  403 

Cholera  sicca,  900 

Cholerine,  900 

Chorea,  27  ;  dietary,  396 ;  massage,  382 

Chromatin,  165 

Cicatrices,  massage  for,  381 

Cilia,  509 

Cirrhosis  of  liver,  as  a  fibrosis,  180 

Cleanliness  of  hospital,  424  ;  surgical,  424 

Climacteric  changes,  climatic  treatment 
of,  295 

Climate,  home,  296  ;  influence  of  forests 
on,  255  ;  influence  of  mountain  chains 
on,  255;  in  treatment  of  disease,  247  ; 
principal  elements  of,  248  ;  treatment 
of  phthisis  by,  286 

Climates,  coast,  258,  269 ;  for  invalids, 
285  ;  inland,  271  ;  inland,  elevated  or 
mountain,  271  ;  inland,  lowland,  280  ; 
marine,  257  ;  marine,  humid,  259,  261 

Clinical  tliermometer,  428 

Closure  tetanus,  357 

Cloudy  swelling,  192 

Cold  bath  in  enteric  fever,  849  ;  in  inso- 
lation, 499 

Cold  douche  in  insolation,  498 

Cold  in  inflannnation,  125 

Colic,  hepatic,  hydrotherapeutics  of ,  345 

Colic,  nephritic,  hydrotherapeuticsof,345 

Colic,  renal,  diet  in,  407 

Colitis,  ulcerative,  diet  in,  403 

Coloboma  iridis,  inheritance  of,  46 

Compressed  air  baths,  311-313 

Complexion,  blonds,  inferiority  of,  27  ; 
relation  to  cancer,  35 ;  relation  to 
phthisis,  35 

Constipation,  dietary  in,  404 

Contagion,  539-547  ;  direct,  540 ;  indi- 
rect, 540 

Convalescence,  tardy,  balneo-therapeu- 
tics  of,  332  ;  climate  in,  295 

Convulsions,  infantile,  hydrotherapeutics 
of,  347 

Corpuscles,  diapedesis  of,  104 

Coryza,  diet  in,  399 

Cradle,  in  nursing,  431 

Death-rates  of  American  cities,  dia- 
gram, 6  ;  of  various  diseases,  tables, 
14-17  ;  in  Jewish  populations,  table,  19 

Degeneration,  atrophic,  of  nervous  sys- 
tem, 181,  182 

Degeneration,  calcareous,  193 

Degeneration,  fatty,  appearances  of, 
190;  experimental  pathology  of,  18(i; 
of  the  heart,  187  ;  of  muscle  fibres, 
changes  in,  191  ;  of  muscles,  from 
toxins,  189 ;  of  nervous  system,  181, 
188  ;  senile,  188 


INDEX 


971 


Degeneration,  parenchymatous  or  gran- 
ular, 1U2 

Degeneration,  pigmentary,  195 

Degeneration,  waxy,  of  muscle,  175 

Delirium,  liydrotherapeutics  of,  317  ;  in 
enteric  fever,  8^7 

Delirium  tremens,  diet  in,  408 

Dermatitis,  exfoliative,  diet  in,  411 

Deutero-albumose,  in  tuberculin,  157 

Diabetes,  baineo-tlierapeutics  of,  335 ; 
climatic  treatment  of,  295  ;  diet  in, 
407 ;  liydrotlierapeutic  treatment  of, 
346 

Diapedesis,  104,  108 

Diarrhoea,  tubercular,  climate  in,  287, 
291;  dietary  in,  403  ;  in  enteric  fever, 
810,  821,  854 

Diarrhoea,  clioleraic,  see  Cholerine,  900 

Diathesis,  hsemorrhagic,  inheritance  of, 
44 

Diazo  reaction  in  enteric  fever,  825 

Dietary  in  disease,  397  et  seq. 

Dietetics  in  disease,  general  principles 
of,  385 

Diphtheria,  701 ;  setiology  of,  703,  711  ; 
age  in,  705  ;  artificial  immunity  from, 
730;  bacteriology,  717;  bibliography, 
766  ;  dietary  in,  394  ;  fomites,  7(i8  ; 
history  of,  702  ;  in  low^er  animals,  710, 
721;  morbid  anatomy,  726  ;  pathology, 
722  ;  prophylaxis,  714  ;  season  in,  704  ; 
sex  in,  705  ;  spread  of,  705  ;  toijogra- 
phy,  704  ;  treatment,  744 

Diphtheria,  "chronic,"  728  ;  latent, 754  ; 
local  forms  of,  753;  milk,  708;  nasal, 
752 ;  simple  and  malignant,  731  ; 
tracheal,  749 

Diphtheria,  serum  treatment  of,  754 ; 
serum  treatment,  bibliography  of,  757 

Diphtheritic  croup,  745 ;  course  and 
symptoms,  747  ;  diagnosis,  746,  750 ; 
dysphonia  in,  746;  prognosis,  748; 
treatment,  751 

Diphtheritic  sore  throat,  731 ;  diagnosis, 
742  ;  prodroma,  732  ;  symptoms,  732  ; 
temperature  in,  736  ;  treatment,  744 

Diplococci,  506 

Disease,  "  change  of  type  "  in,  697  ;  dis- 
tribution of,  48 

Diseases,  race  in,  28 

Dosage  of  drugs  for  children,  422 

Douches,  340 

Drug  addiction,  massage  in,  384 

Drug  therapeutics,  bibliography  of,  247; 
principles  of,  217,  224  ;  sources  of  fal- 
lacy in,  246 

Drugs,  action  of,  on  inflammation,  237  ; 
analgesic,  242  ;  antitoxin,  237  ;  cumu- 
lative action  of,  2-16  ;  dosage  of,  244  ; 
hypnotic,  242  ;  idiosyncrasy  in,  245  ; 
limit  of  action  of,  236,  24(5  ;  modifica- 
tions of  influence  of,  245  ;   nature  of, 


224  ;  nature  of  action  of,  227  ;  object 
of,  224;  principles  of  admuiistration 
of,  243  ;  rational  therapeutics  of,  230, 
231;  "standardisation"  of,  226;  tol- 
eration of,  245  ;  vaso-dilators,  23-4 

Dry  cupping,  307 

Dysentery,  dietary  in,  394 

Dyspepsia,  climate  in,  294;  dietary  in, 
402,  404  ;  hydrotherapeutics  of,  345 

Eczema,  diet  in,  411 

Effusions,  hemorrhagic,  massage  in, 
378  ;  inflanunatory,  massage  in,  377 

Electric  bath,  363 

Electric  osmosis,  351,  364 

Electrical  reactions,  35t) 

Electrical  testing,  of  sensibility,  362  ;  of 
tinnitus  aurium,  371  ;  practical,  360 

Electricity,  medical,  apparatus,  351 ; 
applications  of,  349,  362  ;  bibliogra- 
phy, 373 ;  definition,  350 ;  physio- 
logical action  of,  350  ;  units  of  meas- 
urement in,  353 

Electrification,  general,  363 ;  localised, 
364 

Electrolysis,  351,  364 

Electrostatic  combined  battery,  353  ;  ma- 
chine, Wimshurst,  352  ;  treatment,  352 

Electrotonus,  350 

Embolism,  food  in,  395,  401 ;  in  pyaemia, 
591,  603 

Emphysema,  climates  for,  293 ;  com- 
pressed air  bath  in,  315  ;  food  in,  398  ; 
with  reference  to  life  assurance,  484 

Endocarditis  in  children,  treatment  of, 
420 

Endocarditis,  infective,  tetiology  and  his- 
tory of,  627  ;  age  in,  632  ;  bacteriology, 
630  ;  bibliography,  634  ;  causes  of,  gen- 
eral, 631  ;  chemical  pathology,  634  ;  in 
connection  with  pyaemia,  591  ;  paths  of 
infection  of,  632 ;  types  of  various,  630 

Endospores,  508 

Endothelial  cells,  enlargement  of,  in 
inflammation,  116 

Endothelium,  vascular,  in  inflammation, 
100 ;  action  of  diffusible  irritants  on, 
106 

Enemata,  nutrient,  437  ;  purgative,  436 

Enteric  fever,  791  ;  setiology  of,  793 ; 
bibliography,  863 ;  definition,  791 ; 
diagnosis,  834  ;  diet  in,  391,  845  ;  ery- 
sipelas in,  815  ;  geographical  distribu- 
tion of,  793  ;  history  of,  791  ;  infection, 
immunity  from,  807  ;  remoter  causes 
of,  806  ;  spread  of,  802  ;  mixed  infec- 
tion in,  832  ;  mortality  from,  814  ;  nu- 
trition of  body  in,  831  ;  pathoio.uy,  837- 
842  ;  prognosis,  843  ;  prophylaxis,  858  ; 
relapse  in,  831  ;  sequelae,  828  ;  stools, 
examination  of,  798  ;  sudden  death  in, 
844;    symptoms,    816-842;    tables   of 


972 


SYSTEM  OF  MEDICINE 


mortality,  860  ;  temperature  in,  812 
temperature     in     post-typhoid,     814 
treatment,  347,  84G-857  ;  treatment  of 
special  symptoms,  854;  varieties  of, 832 

Enteritis,  diet  in,  4U3,  404 

Enzymes,  519 

Eosinophile  cells,  78 ;  excretory  func- 
tions  of,  91 

Epilepsy,  dietary  in,  396 

Eruptions  in  enteric  fever,  814 

Erysipelas,  aetiology  of,  614  ;  bibliogra- 
phy, 626  ;  curative,  ()16  ;  bacteriology, 
616  ;  complications  in,  620  ;  diet  in, 
394;  definition,  613;  diagnosis,  621; 
history,  613;  minute  anatomy,  615; 
pathology,  ()17;  prognosis,  621  ;  result- 
ing from  wounds,  615;  sequelae,  620  ; 
symptoms,  618  ;  treatment,  622 

Erysipelas  in  enteric  fever,  815 

Erythemata,  diet  in,  411 

Erythro-proteid  reaction,  177 

Exanthemata,  diet  in,  393 

Family  diseases,  43 

Eaniine  fever,  see  Kelapsing  fever,  940 

Feeding-bottles,  457 

Feeding-cup,  387 

Fermentation,  519 

Ferments  in  inflammatory  exudate,  99 

Fever,  abnormal  action  of  the  skin  in, 
152  ;  aetiology,  156  ;  changes  of  volume 
of  tlie  skin  in,  152;  disorder  of  nutri- 
tion in,  144  ;  phtliisis  and  climate,  287, 
291;  surface  temperature  in,  153; 
thermotaxis  in,  150 

Fever,  the  doctrine  of,  139  ;  Cohnheim's 
theory,  143 ;  Lelimann  and  Zuntz  on, 
144;  Leyden's  theory,  142;  Lieber- 
meister's  theory,  140,  151 ;  rtluger's 
experiments,  143 ;  Senator's  theory, 
142  ;  Traube's  theory,  140,  151  ;  Vir- 
chovv's  researches,  140 

Fibrin  in  the  inflammatory  exudate,  97 

Fibroblasts  in  inflammation,  117 

Fibrosis,  178 

Fibrous  substitution,  121 

Fistula  in  life  assurance,  485 

Flagella,  509 

Fraenkel's  pneumatic  apparatus,  308 

Friction  in  diseases  of  children,  420 

Furuncle,  651  ;  aetiology  of,  652  ;  bac- 
teriology of,  652  ;  situation  of,  652 ;  suc- 
cessive crops  of,  652  ;  treatment  of,  653 

Gall-stones,  diet  in,  404 
Gangrene,  acute  spreading,  176 
Gangrene,  dry,  175 
Gangrene,  moist,  176 
Gangrene,  secondary,  174 
Gastritis,  dietary  in,  401 
Geigel  and  iVlayer's  pneumatic  apparatus, 
309 


Geography,  medical,  of  Great  Britain,  40 

Giant  cells,  nature  of,  81 

Gluge's  corpuscles,  as  result  of  inflam- 
mation, 81 

Glycogen  in  the  liver,  storage  function 
of,  163 

Glycosuria,  balneo-therapeutic  treatment 
of,  335  ;  dietary  in,  407  ;  in  life  assur- 
ance, 486 

Goitre,  exophthalmic,  electric  treatment 
of,  371 

Gonorrhoea  in  life  assurance,  480 

Gout  and  rheumatism,  climates  for,  293 

Gout,  balneo-therapeutic  treatment  of, 
335  ;  dietary  in,  409  ;  distribution  of, 
23  ;  liydrotUerapeutics  of,  345 ;  and 
life  assurance,  485 

Granulation  of  cells,  table,  78 

Gravel  and  stone,  balneo-therapeulics 
of,  335 

Gutta  rosacea,  diet  in,  411 

Gynaecology,  massage  in,  383 

ILT;:\rATOiDiN,  196 

llaemopliilia,  dieting  in,  405 ;  and  in- 
herited gout,  45 

Haemoptysis,  treatment  of,  by  climate, 
286  ;  and  life  assurance,  483 

Hfemorrhage,  cerebral,  feeding  in,  395 

Haemorrhage  in  enteric  fever,  822,  855 

Haemorrhages  in  diphtlieria,  737 

Haemosiderin,  196 

Hahnemann's  theory  of  disease,  221 

Handball  sprays,  305 

Harelip,  inheritance  of,  46 

Head,  retraction  of,  in  epidemic  c.-sp. 
meningitis,  665 

Headache  in  epidemic  c.-sp.  meningitis, 
665 ;  in  influenza,  684 

Health  resorts,  mountain,  274 ;  principal, 
256  ;  summer,  270,  292  ;  winter,  270, 
292 

Heart  disease,  climates  for,  293 ;  in 
phthisis,  climatic  treatment  of,  287  ; 
and  life  assurance,  484 

Heart,  diseases  of,  balneo-therapeutics 
of,  334  ;  diet  in,  399,  400 

Heat,  effects  of  great,  491  ;  sedative 
action  of,  344 

Heat-stroke,  see  Insolation,  491 

Helpless  persons,  feeding  of,  387  ;  nurs- 
ing of,  430 

Hemiplegia,  electric  treatment  of,  364 

Heredity  and  life  assurance.  483 

Hernia  and  life  assurance,  485 

Herpes  in  epidemic  c.-sp.  meningitis,  667 

Heterology,  202 

Hodgkin's  disease,  diet  in,  406 

Humoral  theory,  the,  88 

Hyaline  cells,  as  phagocytes,  91  ;  and 
leucocytes,  79;  and  fibroblasts,  118 

Hyaloplasm,  165 


INDEX 


973 


Hydrocephalus,  Chronic,  after  epidemic 
c.-sp.  meningitis,  668 

Hydrophobia,  feeding  in,  395 

Hydrotherapeutics,  action  and  physio- 
logical effects  of,  341  ;  bibliography, 
348;  cases  suitable  for,  345;  contra- 
indications to,  348  ;  definition,  339  ; 
history,  339  ;  modes  of  application,  340 

"  Hydrotherapeutic  reaction"  to  cold, 
341  ;  to  heat,  343 

Hyperplasia,  200 

Hyperplasia,  fibrous,  forms  of,  124  ;  and 
inflammation,  119;  non-inflammatory, 
124 

Hyperpyrexia,  154  ;  hydrotherapeutics, 
of,  348 

Hypertrophy,  197  ;  causes  of,  199  ;  com- 
pensatory, 198 

Hyphomycetes,  504 

Hypochondriasis,  climates  for,  294  ;  elec- 
tric treatment  of,  370 

Hypoplasia,  178 

Hysteria,  hydrotherapeutics  of,  .346  ;  diet 
in,  396 ;  electric  treatment  of,  369 ; 
massage  in,  383 

Ichthyosis,  44 

Idiosyncrasy,  44 

Immunity,  558  ;  definition  of,  663  ;  ac- 
quired, 558  ;  acquired,  Bouchard's 
hypothesis  of,  563 ;  acquired,  factors 
in  production  of,  573 ;  acquired  by 
feeding  with  living  organisms  or  prod- 
ucts, 565  ;  acquired  by  injections  of 
bacterial  products,  560  ;  acquired  by 
inoculation  with  attenuated  virus,  559  ; 
acquired  by  small  doses  of  virulent 
virus,  559 ;  acquired,  hypothesis  of 
retention,  568  ;  acquired,  natural,  after 
infection,  559 ;  acquired,  Pasteur's 
hypothesis  of  exhaustion,  566  ;  ac- 
quired, theories  of,  566 

Immunity,  active,  565,  572  ;  individual, 
575  ;  hereditary,  578  ;  natural,  575  ; 
natural  and  acquired  compared,  577  ; 
natural,  theories  of,  576  ;  passive,  565, 
572  ;  racial,  575 

Inanition,  discharge  of  nitrogen  in,  147  ; 
from  disease,  170 

Infants,  diet  of,  416 

"  Infants'  foods,"  415 

Infection,  537  ;  and  contagion,  540  ;  and 
intoxication,  538  ;  bibliography,  585  ; 
general  patliology,  503  ;  latent,  555 

Infection,  congenital,  556  ;  germinal, 
557  ;  placental,  557  ;  septic,  587 

Infection,  disposition  to,  congenital,  554  ; 
individual,  550  ;  racial,  550 

Infective  diseases,  definition  of,  538  ;  in- 
cubation of,  539  ;   propagation  of,  542 

Infiltration,  albuminous,  see  Cloudy 
Swelling,  192 


Infiltrations,  177 

Inflamed  areas,  increased  temperature 
of,  124 

Inflammation,  classification  of  forms  of, 
126;  comparative  pathology,  5t5;  defini- 
tion, 54,  134  ;  experimental  production 
of,  62,  66 ;  systemic  changes  conse- 
quent on,  131  ;  the  leucocytosis  of,  77 

Inflammation  of  the  cornea,  63 

Inflammation,  suppurative,  experimental 
production  of,  70  ;  processes  of,  72  ; 
septicseraic  extension  of,  73 

Inflammatory  exudation,  94  ;  dilution  of 
irritant  by,  96 ;  and  ordinary  lymph, 
96  ;  "  flushing  out"  action  of,  95 

Inflammatory  fever,  74 

Inflammatory  process,  factors  in,  77  ; 
phenomena  of,  75 

Influenza,  679  ;  getiology  of,  692  ;  bacteri- 
ology of,  694  ;  bibliography  of,  701  ; 
description  of,  679  ;  diagnosis  of,  698  ; 
diagnosis  of,  from  Dengue,  692  ;  diag- 
nosis of,  from  pertussis,  693 ;  dietary  in, 
394; history,  690;  incubation,  693;  mor- 
bid anatomy,  695 ;  nervous  phenomena, 
683  ;  prophylaxis,  700  ;  sequelge,  687  ; 
symptoms,  684  ;  types  of,  680 

Influenza,  typhoidal,  698 

Inhalation,  methods  of,  301  ;  of  carbonic 
acid,  302  ;  of  chlorine,  303  ;  of  iodine, 
303  ;  of  mercury,  304  ;  of  nitrous  oxide, 
302  ;  of  oxygen,  301  ;  of  steam,  304  ; 
of  sulphur,  304  ;  of  turpentine,  306 

Inheritance  in  disease,  laws  of,  39 

Insanity,  massage  in,  383 

Insolation,  491 ;  bibliography  of,  502  ; 
cases  of,  500  ;  forms  of,  495  ;  hyper- 
pyrexia in,  500 ;  morbid  anatomy, 
497  ;  prognosis,  496  ;  prophylaxis,  497  ; 
sequelse,  500;  statistics  of  (India), 
493,  494  ;  symptomatology  and  pathol- 
ogy, 494  ;  treatment,  498 

Insomnia,  electric  treatment  of,  370 ; 
massage  in,  379 

"  Insurance  heart,"  484 

Intemperance  and  life  assurance,  485 

Intestinal  obstruction,  feeding  in,  404 

Intoxication,  septic,  586 

Jaundice,   diet    in,   404 ;    in    relapsing 

fever,  943 
Junod  boot,  the,  307 

Kaposi's  disease,  inheritance  of,  44 
Keratinisation,  196 
Ketchum's  pneumatic  cabinet,  309 
Kidneys,  diseases  of,  climates  for,  294 
Kidneys,  lardaceous  d  isease  of,  diet  in,  407 
Koch's  comma  bacillus,  879  ;  chemistry 

of,    892  ;   pathogenetic   properties   of, 

889  ;  vitality  of,  894 
Kopf  tetanus,  780 


974 


SYSTEM  OF  MEDICINE 


Laryngeal  affections  in  enteric  fever, 
818 

Laryngitis,  feeding  in,  397 

Lead  poisoning,  diet  in,  409;  electric 
treatment  of,  o68 

Lecithin,  iuiportance  of,  in  nutrition, 
Kio  ;  in  fatty  degeneration  of  nervous 
system,  188 

Leprosy,  transmission  of,  42 

Leuchsemia,  diet  in,  405 

Leucocytes,  action  of  diffusible  irritants 
on,  10(5 ;  classification  of,  79  ;  diape- 
desis  of,  in  inflammation,  104  ;  mass- 
ing of,  08 

Leucocytopenia,  132 

Leucocytosis  in  diphtheria,  729 

Life  assurance,  476  ;  contingent  risks  in, 
477;  claims  in,  48G ;  endowment  as- 
surances, 477  ;  forms  of  application 
for,  479,  480 ;  issue  risks  in,  477  ; 
medical  examination  of  applicants, 
478,  4C1 ;  medical  officials,  duties  of, 
478  ;  r?.tin-  in,  481,  482 

Light,  effect:  of,  on  bacteria,  254  ;  effects 
of,  on  oridrlion  of  animal  cells,  253 

Lithsemir..,  dietary  in,  404 

Liver,  inlluence  of,  on  nutrition,  166 

Locomotor  ataxia,  massage  in,  382 

Longevity,  inherited,  169 

Lumbago,  electric  treatment  of,  369 

Lymphadenitis  in  diphtheritic  sore 
throat,  73-1 

Lymphatic  glands  in  plague,  929 

Lymphocytes,  79 

Malaria,  climatic  treatment  of,  294 

Map  of  cancer,  51  ;  comparison  of  cancer 
and  phthisis,  53  ;  heart  disease,  49  ; 
phthisis  among  females,  52 

Maps  of  diseases  of  Great  Britain,  48 

Massage,  373  ;  abdominal,  376  ;  bibliog- 
raphy of,  385  ;  contra-indications  to, 
384  ;  general,  376  ;  immediate  effect 
of,  377  ;  physiology,  377  ;  technique, 
374 

Measles,  distribution  of,  26 

Medical  statistics,  3 

Medication  by  mouth,  243  ;  by  rectum, 
243  ;  by  skin,  243 

Melancholia,  massage  in,  383 

Melanin,  197 

Mellin's  food  for  infants,  415 

Meningitis,  epidemic  cerebro-spinal,  659  ; 
SBtiology,  672  ;  complications  and  se- 
quelae, 6H8  ;  bacteriology,  673  ;  bibliog- 
raphy, 678;  diagnosis,  671;  features, 
cutaneous,  667  ;  general  features  of, 
664  ;  history,  660  ;  morbid  anatomy, 
661 ;  outbreaks  of,  in  United  Kingdom, 
676  ;  prognosis,  670  ;  symptoms  and 
course,  663 ;  treatment,  669 ;  types, 
various,  664 


Mental  alienation,  distribution  of,  33 

Mental  diseases  in  enteric  fever,  829 

Metamorphoses,  177 

Metamorphosis,  fatty,  185 

Metaplasia,  202 

Micrococci,  506 

Micro-organisms,  aerobic,  513 ;  anae- 
robic, 513  ;  atmospheric  pressure  on, 
515  ;  chromogenetic,  518  ;  classifica- 
tion, 516;  cultivation,  512,  515;  in 
infectious  diseases,  538 ;  interaction, 
534,  552  ;  latency,  555  ;  mechanical 
effects,  530  ;  pathogenetic,  535  ;  sun- 
light and,  514  ;  variability  of  virulence, 
530,  537,  643 

Micro-organisms,  involution  forms,  510  ; 
morphology,  504;  pleomorphism,  510 

Migraine,  dietary  in,  396  ;  massage  in, 
380 

Milk,  of  cow  and  human,  413  ;  sterilised 
for  infants,  414;  sterilised  or  boiled, 
393 

Mitosis  in  acute  inflammation,  101,  116 

Morphiomania,  massage  in,  384 

Motor  points,  diagi'ams  of,  357 

Moulds,  504 

Mucin  in  inflammatory  exudate,  97 

Murray's  pneumatic  instrument,  307 

Muscle,  atrophic  changes  of,  184 

"  Muscular  rheumatism,"  hydrothera- 
peutics  of,  345 

Myco-proteins,  527 

Myopia  and  dolichokephaly,  33 

Myxoedema,  diet  in,  406 

Nasal  feeding  apparatus  and  method,  387 
Necrosis   of   tissue,   by   disturbance   of 

circulation,  172 ;  causes  and  pathogeny, 

171,  172;  morbid  anatomy  and  pathol- 
ogy, 174. 
Necrosis  coagulation,  174 ;   colliquative, 

174  ;  fat,  175 ;   septic,  see  Gangrene, 

175 
Neoplasms  and  inflammation,  113 
Nephritis,  dietary  in,  406,  407 
Nerves,  injuries  of,  electric  treatment  of, 

366 
Nervous  system,  affections  of,  climates 

for,  294  ;  balneo-therapeutic  treatment 

of,  336 
Nervous  system  and  nutrition,  168  ;  and 

inflammation,  108 
Neuralgia,   climatic  treatment   of,  295  ; 

electric  ti-eatment  of,  369  ;  hydrother- 

apeutic   treatment   of,   345 ;   massage 

in,  380 
Neurasthenia,  climates  for,  294  ;  electric 

treatment  of,  370  ;  massage  in,  383 
Neuritis,  diet  in,  395  ;  electric  treatment 

of,  368  ;  massage  in,  380 
Neutropiiile    cells,   as   phagocytes,  91  ; 

classification,  79 


INDEX 


975 


New  growths,  attempts  to  cultivate  mi- 
crobe of,  214;  bibliography,  217;  en- 
demic location  of,  2U!t  ;  general  patliol- 

■  ogy,  201  ;  metastasis,  20o ;  parasitic 
theory,  2U(),  210;  pathogenesis,  204- 
206  ;  structure,  201  ;  treatment,  213- 
216 

Nitrification,  629 

Nuclein,  composition  of,  165 

Nurses,  age  for  training  of,  423  ;  duties  of, 
as  to  gyngecological  work,  439  ;  duties 
of,  as  to  hospital  ward  work,  424 

Nursing,  423 ;  district,  446 ;  medical, 
428  ;  of  children,  442  ;  of  children  in 
tra,cheotomy,  443  ;  of  helpless  patients, 
430  ;  private,  444 ;  puerperal,  450 ; 
surgical,  424 

Nystagmus  in  epidemic  c.-sp.  meningitis, 
666 

Obesity,  massage  in,  384 

Occupation  neuroses,  massage  in,  381 

Oertel's  steam  uebuliser,  305 

Optic  neuritis  in  epidemic  c.-sp.  menin- 
gitis, 666 

Osteomyelitis,  acute  suppurative,  in 
pyaemia,  605 

Oxyphile  cells,  classification,  79 

Pancrevs  and  nutrition,  167 

Paralysis  in  epidemic  c.-sp.  meningitis, 

666  ;  acute  atrophic,  massage  in,  382  ; 

bulbar,  feeding  in,  395  ;  facial,  electric 

treatment  of,  367  ;  in  diphtheria,  739  ; 

infantile,  electric  bath  for,  363  ;  electric 

treatment   of,   365 ;   pseudo-hypertro- 

phic,  massage  in,  382 
Parasitic  skin  diseases,  diet  in,  410 
Parotitis  in  enteric  fever,  820 
Peptones  in  inflammatory  exudate,  97 
Peptonised  foods,  393 
Perforation  in  entfric  fever,  823 
Pericarditis  in  Eright's  disease,  diet  in, 

400;  in  children,  treatment  of,  420 
Perichondritis  in  phthisis,  effect  of  Alps 

on,  287 
Periostitis  in  pyaemia,  605 
Periphei'al  neuritis  in  enteric  fever,  829 
Peritonitis,  diet  in,  404,  405 
Pestis  major,  928 
Pestis  minor,  928 

Phagocytosis,  81,  5G7  ;  theory  of,  86 
Pharmarmalke  rntionalis  (1674),  218 
Pharnmropceia  (London,  of  1618),  217  ; 

(of    1632),  217;    (of  1677),  219;    (of 

1788),  220 
Phary ngo-typhoid ,  82 1 
I'hosphorescence,  631 
Piithisis,  climatic  treatment  of,  273,  276, 

286  ;  compressefl  air  bath  in,  316  ;  flis- 

tribntion  of,  24  ;  heredity  of, 556  ;  rarity 

of,  in  Alps,  273  ;  and  life  assurance, 483 


Phthisis  pulmonalis,  dietary  in,  398 
Pigmentation,  195  ;  extrinsic,  197  ;  hsema- 

togenous,  196 
Pituitary  body,  in  nutrition,  168 
Plague  as  a  communicable  disease,  926  ; 
bacteriology,  921  ;  bibliography,  938  ; 
conditions  favourable  to,  925;  defini- 
tion,   917  ;    diagnosis,    934  ;    general 
pathology,  920  ;  history,  917;  morbid 
anatomy,  934  ;    mortality  from,  933  ; 
prognosis,  934  ;  prophylaxis  and  pre- 
vention, 936  ;  stages,  928  ;  symptoms, 
932  ;  treatment,  935 
Plague,  endemic,  922  ;  as  a  soil  disease, 

923 
Plasters,  mustard,  435 
Pleurisy  and  life  assurance,  484 
Poisoning,  chronic  metallic,  hydrothera- 

peutic  treatment  of,  346 
"  Poisson's  formula,"  4 
Polio-myelitis,  anterior,  faradism  in,  383  ; 

massage  in,  383 
Polio-myelitis  in  enteric  fever,  829 
Polyuria,  climatic  treatment  of,  295 
Pneumonia,    epidemic,    655 ;    aetiology, 
657  ;    bacteriology,    658  ;    occasional 
phenomena  of,   656  ;    relation   of,   to 
age,  table,  657  ;  symptoms,  656  ;  trans- 
mission, 659 
Pneumonia,  diet  in,  398  ;  in  connection 
with  malignant  endocarditis,  633 ;  in 
enteric  fever,  819 
Predisposition,  acquired,  548  ;   and  im- 
munity, 558;  hereditary,  554 ;  personal, 
547 
Pregnancy  and  life  assurance,  486 
Proliferation  of  connective  tissue  in  in- 
fiammation,  116  ;  of  fixed  cells  in  tuber- 
culosis, 117 
Protective  power  of  blood  serum,  570 
Proteids  in  inflammatory  exudate,  97 
Psoriasis,  diet  in,  411  ;  hydrotherapeutic 
treatment    of,    346 ;     inheritance    of, 
44 
Ptomaine  poisoning  in  children,  treat- 
ment of,  419 
Ptomaines,  519 

Puerperal  fever,  charts  of,  042  ;  in  con- 
nection with  sapraemia,  591 
Puerperal  septic  disease,  aetiology  of,  637  ; 
bacteriology  of,  638  ;  bibliography  of, 
651;  history  of,  635;  mortality  from, 
in  lying-in  hospitals,  636  ;  pathology 
of,  640  ;  paths  of  infection  in,  639  ; 
symptoms  of,  641  ;  theory  of  auto-in- 
fection in,  638  ;  treatment,  preventive, 
646  ;  remedial,  648 
Purpura,  diet  in,  405  ;  in  epidemic  c  -sp. 

meningitis,  667 
Putrefaction,  529 

Pyaimia,   age   in,   605;   diagnosis,  611; 
definition,   587  ;    experimental,   com- 


976 


SYSTEM  OF  MEDICINE 


pared  with  human,  590  ;  history,  601  ; 
joint  lesions  in,  604,  608  ;  morbid  anat- 
omy, 609  ;  patholoo:y,  602  ;  prognosis, 
612 ;  symptouis,  606  ;  tissue  clianges 
in,  605  ;  treatment,  612 

Pygemia,  chronic,  see  Abscesses,  multi- 
ple, 587  ;  idiopathic,  591  ;  portal,  see 
Pylephlebitis,  suppurative,  610  ;  puer- 
peral, 645 

Pyle-phlebitis,  suppurative,  591,  602,  610 

Pyloric  stenosis,  dietary  in,  403 

Pyrexia,  see  Fever,  139 

Pyrogen,  157 

Quarantine  for  cholera  Asiatica,  867  ; 
for  plague,  937 

Rainfall  in  different  regions,  252 

Ranvier's  cells  as  result  of  inflammation, 
81 

Rash  in  relapsing  fever,  943 

Rashes,  antitoxin,  584 

Raynaud's  disease,  electric  treatment  of, 
371 

Reaction  of  degeneration,  359 

Recruiting  statistics,  American,  27  ;  Bel- 
gium, 31  ;  French,  29  ;  French  table,  32 

Relapse  in  relapsing  fever,  944 ;  period 
of,  945 

Relapsing  fever,  940 ;  aetiology,  948  ; 
bibliography,  958;  contagion  in,  949; 
diagnosis,  955;  duration,  941;  inter- 
mission in,  945  ;  micro-organism,  950  ; 
morbid  anatomy,  950  ;  prognosis  in, 
956  ;  relation  of,  to  typhoid  fever,  953  ; 
sequelae,  956 ;  symptoms,  942 ;  syn- 
onyms for,  910  ;  treatment,  958 

Respirators,  305 

Respiratory  gymnastics,  316 

Respiratory  organs,  diseases  of,  balneo- 
therapeutic treatment  of,  333 

Response  to  injury  among  annelids,  60  ; 
metazoa,  58  ;  protozoa,  56  ;  vertebrata, 
62 

Retinitis  pigmentosa,  inheritance  of,  44 

Rheumatic  fever,  dietary  in,  409 

Rheumatism,  chronic,  balneo-therapeu- 
tic  treatment  of,  335 

Rheumatism,  hydrotherapeutics  of,  345 

Rickets,  dietary  in,  410  ;  hydrotherapeu- 
tics of,  346 

Rigors  in  influenza,  686 

Salivary  glands  in  diphtheria,  735 

Saprsemia,  setiology,  592  ;  definition,  586 
diagnosis,    595  ;    experimental,    588 
morbid  anatomy,  594  ;  pathology,  590  , 
prognosis,  595  ;  symptoms,  593  ;  treat- 
ment, 595 

Sapraemia  in  puerperal  disease,  638 

Sarcinse,  507 

.Sarcoma,  definition  of,  203 


Scarlatina,  distribution  of,  26 

Schizomycetes,  506 

Sciatica,  electric  treatment  of,  369  ;  hy- 
drothei'apeutic  treatment  of,  345 ;  mas- 
sage in,  380 

Scorbutus,  dietary  in,  405 

Scrofula,  climates  for,  293 ;  inheritance 
of,  42 

Scurvy,  infantile,  diet  in,  410 

Sea  voyages,  257,  291 

Senile  decay,  climatic  treatment  of, 
296 

Septicaemia,  contagiousness,  598  ;  defini- 
tion, 587  ;  diagnosis,  600  ;  experi- 
mental, 589  ;  morbid  anatomy,  599  ; 
pathology,  532,  596;  phlebitis,  591, 
602  ;  prognosis,  600  ;  symptoms,  599  ; 
treatment,  601 

Septicaemia,  puerperal,  639 

Serum,  antitoxic,  treatment,  579  ;  pro- 
tective value  of,  581,  585  ;  summary 
of  results  of,  583 

Serum,  curative,  administration  of,  584  ; 
dosage  of,  583  ;  rashes  due  to,  584  ; 
specificity  of,  569,  582 

Serum  therapeutics,  579  ;  bibliography, 
585  ;  limits,  580  ;  methods,  581 

Serum  treatment  in  diphtheria,  754  ;  in 
plague,  936;  in  tetanus,  771 

Serum-albumin  in  inflammatory  exu- 
date, 97 

Serum -globulin  in  inflammatory  exu- 
date,^97 

Sex  in  dosage  of  drugs,  244 

Sexual  organs,  affections  of  the  female, 
balneo-therapeutic  treatment  of,  336 

Shivering,  reflex  action  of,  159 

Sickness  in  various  armies,  table,  7 ; 
countries,  tables,  8-11 

Skin,  chronic  affections  of,  hydrothera- 
peutic  treatment  of,  346 

Small-pox,  distribution  of,  26 

Snow,  influence  of,  on  atmosphere,  252 

Soldiers,  liability  of,  to  cerebro-spinal 
meningitis,  672 

"  Soothing  syrups"  for  children,  422 

Specificity  of  disease,  535 ;  limitations 
of,  536 

"Spinal  irritation,"  massage  in,  379 

Spirilla,  507 

Spleen,  influence  of,  on  nutrition,  168  ; 
in  relapsing  fever,  952 

Spongioplasm,  165 

Spores,  508 

Staphylococci,  507 

Stature  in  connection  with  disease,  29 

Stigmata,  106 

Stomatitis,  dietary  in,  401 

Streptococci,  506 

Sunstroke,  see  Insolation,  491 

Suppuration  from  bacteria,  129  ;  from 
chemical  substances,  )29 


INDEX 


977 


Suprarenal   capsules,    influence  of,    on 

nutrition,  168 
Syncope  in  boys,  472  ;  in  insolation,  494 
Synovitis,  massage  in,  379 
Synovitis,  gonorrlioeal,  diet  in,  410 
Syphilis,    balneo-therapeutic    treatment 

in,  336  ;  diet  in,  395  ;  inheritance  of, 

40  ;  and  life  assurance,  486 
Syrups,  medicated,  422 

Teeth,  racial  characters  of,  34 

Temperament,  36  ;  suggestions  for  new 
system  of,  38  ;  types  of,  39 

Temperature,  atmosplieric,  influence  of, 
on  plague,  925 

Temperature  of  soil,  influence  of  drain- 
age on,  255  ;  vegetation  on,  255 

Tendon  reflexes  in  epidemic  c.-sp.  men- 
ingitis, 666 

Tetanus,  758  ;  accidental  traumatic,  766  ; 
artiticial   immunity   from,   770 ;    bac- 
teriological  diagnosis,    767  ;    bibliog- 
raphy,   790  ;    diagnosis,    780  ;    experi- 
mental, 764;  "idiopathic,"  764,  778 
incubation,  reference  to  severity,  773 
morbid  anatomy,  788  ;  pathology,  759 
statistics,    in    American    war,    789 
symptoms,  776  ;  treatment,  783 

Tetanus  antitoxin,  772 

Tetanus  bacillus,  the,  760  ;  culture  of, 
762  ;  inoculation  of,  763 

Tetanus,  feeding  in,  395 

Tetanus,  infantile,  789 

Tetanus  neonatorum,  789 

Tetanus  poison,  the,  766 

Tetanus,  serum  treatment  in,  771  ;  re- 
sults of,  compared  with  diphtheria,  775 

Tetany,  782 

Tetracocci,  507 

Thermogenesis,  148,  159 

Thermolysis,  159 

Thermotactic  centre,  the,  151 

Thermotaxis,  159 

Thrombo-phlebitis  in  carbuncles,  655 

Thrombosis,  food  in,  395,  401  ;  in  enteric 
fever,  817  ;  in  influenza,  683;  in  pyae- 
mia, 591,  603 

Thyroid  body,  influence  of,  on  nutrition, 
167 

Tinnitus  aurium,  electric  treatment  of, 
370 

Tissue,  calciftcation  of,  193  ;  associated 
with  fatty  degeneration,  195 

Tissue  cells,  degeneration  of,  in  inflam- 
mation, 113;  "reversionary"  degen- 
eration of,  in  inflammation,  114  ;  re- 
generation of,  115;  in  inflammation, 
113 

Tissues,  interdependence  of,  166 

Tonics  in  disi-ases  of  children,  421 

Tonsillitis,  diet  in,  401      * 

'I'orticollis,  massage  in,  382 

VOL.    1 


Toxalbumins,  519 

Toxic  proteins,  523 

Toxins,  517  ;  intravascular  and  extra- 
vascular,  effect  of,  on  diapedesis,  106 

Tracheotomy  in  diphtheritic  croup,  751 

"Transmutation  in  transmission,"  46 

Trophotropism,  58 

Trousseau's  cigarettes,  304 

Tuberculosis,  inheritance  of,  41 

Tuberculosis  of  lymph  glands,  diet  in, 
406 

Tufnell's  diet,  400 

Tumours,  innocent,  202 ;  growth  of,  by 
inflammation,  203  ;  malignant,  202  ; 
multiplicity  of,  302 

Tympanites  in  enteric  fever,  823,  855 

Typhilitis,  diet  in,  403 

Typhoid  bacillus,  character  and  biology 
of,  793 ;  diagnosis  of,  from  B.  coll 
commune,  796 ;  inoculation  on  ani- 
mals of,  801;  pathogenetic  nature  of, 
799  ;  portals  of  entrance  into  human 
body,  808 

Typhoid  spine,  829 

Typhus,  relapsing,  and  other  fevers, 
dietary  in,  392 

Tyrosis,  175 

Ulcer,  gastric,  dietary  in,  402 

Uraemia,  feeding  in,  407 

Urinary  organs,  diseases  of,  dietary  in, 

406 
Urine,  incontinence  of,  electric  treatment 

of,  372 
Urticaria,  diet  in,  411 
Uterine  fibroma,  electric  treatment  of, 

372 

Vaso-motoe  paralysis  and  inflammation, 

111 
Venosity,  abdominal,  balneo-therapeutic 

treatment  in,  333 
Ventilation  of  medical  wards,  428  ;  of 

surgical  wards,  424 
Virchow's  theory  of  inflammation,  114 
Vomiting,  hysterical,  diet  in,  396 
Vomiting,  in  diphtheria,  738 ;  in  epidemic 

c.-sp.  meningitis,  Q^^ 

Waldenburg's    pneumatic    apparatus, 

307 
Wasting  in  children,  treatment  of,  422 
Water-beds,  431 

Water  boiled,  use  of,  in  dietetics,  393 
Water,  internal  use  of,  344  ;  cold,  local 

application  of,   343  ;   cold  treatment, 

341;    hot,   local  application  of,   344; 

warm,  treatment,  343 
Waters,  alkaline,  323  ;    action  of,  324  ; 

enumeration    of   spas,   324 ;   uses   of, 

32") ;  varieties  of,  324 
Waters,  arsenic,  327 

3  R 


978 


SYSTEM   OF  MEDICINE 


Waters,  common  salt,  or  muriated  sa- 
line, 321  ;  action  of,  322  ;  enumeration 
of,  321  ;  uses  of,  323 

Waters,  earthy  or  calcareous,  329  ;  action 
of,  330  ;  enumeration  of,  329  ;  uses  of, 
330 

Waters,  iron  or  chalybeate,  326  ;  action 
of,  327  ;  enumeration  of,  32(3 ;  uses  of, 
327 

Waters,  mineral,  carbonic  acid  in,  323  ; 
choice  of,  in  individual  case,  332  ; 
classification  of,  319  ;  description  of, 
318  ;  therapeutic  employment  of,  330 

Waters,  simple  thermal,  819  ;  action  of, 
320  ;  enumeration  of,  320  ;  uses  of,  321 

Waters,  sulphated  or  bitter,  325  ;  action 


of,  325  ;  enumeration  of,  325  ;  uses  of, 
325 

Waters,  sulphur,  328  ;    action  of,  329  ; 

enumeration  of,  328  ;  uses  of,  329 
Weir    Mitchell's    rest    treatment,   382 ; 

treatment  of  hysteria,  397 
Work-hypertrophy,  198 
Writer's  cramp,  massage  in,  381 

Xanthochroi,  36 
Xeroderma,  inheritance  of,  44 
Xeroderma  pigmentosum,  44 

Yaws,  27 

Yellow  fever,  distribution  of,  25 

Youth,  the  hygiene  of,  457 


END    OF   VOL.    I 


I 


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DATE  DUE 


DEMCO  38-296 


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